What shall it be, NHIF?

nhif, national health insurance fund, medical cover

The NHIF building in Nairobi.

What you need to know:

  • Whispers of favouritism persist, where some private hospitals get their patients’ approvals in record time and with decent sums paid out because of collusion between these facilities and some NHIF staff, with kickbacks exchanging hands.
  • Yet some of these facilities are death traps that make you wonder how they were even approved as NHIF service providers in the first place.

Freyda* saw me 18 months ago. She walked into my office seeking a second opinion. Deep down she knew I wasn’t going to tell her anything different than she already knew,  but she came anyway. 

Seven years ago, Freyda had surgery for uterine fibroids. She had suffered severe period pains accompanied by torrential menses every month and going under the knife was her only respite. Being in formal employment, she had the benefit of a private medical insurance from her employer, which easily paid for her care. 

Her healing was uneventful and Freyda went right back to her life. Her gynaecologist informed her that uterine fibroids were likely to recur over the years and may require repeat surgery in future, especially since she still had a long reproductive life ahead. Freyda tucked that piece of information right back at the back of her mind and focused on other things. 

Seven years later, she was back to her doctor with recurrence of her symptoms. She knew exactly what he would say but she was also clutching at straws regarding the diagnosis. This visit was really just to reaffirm that the diagnosis was correct and treatment was necessary. We discussed her treatment options and she still settled for repeat surgery. 

The next consideration was regarding treatment costs. Freyda was no longer in formal employment. She had set up a small business that was greatly affected by the Covid-19 pandemic but it was finally beginning to pick up. Though she hadn’t taken a private medical cover, she had dutifully paid her annual the National Health Insurance Fund (NHIF) subscriptions every April and was a beneficiary of the NHIF Supa Cover. 

I informed Freyda that she was eligible for NHIF claims for at least part of her bills for the surgery. She settled for one of the middle level hospitals for the procedure and we filled in the requisite pre-authorisation forms. The hospital submitted the forms to NHIF and Freyda went home to await confirmation.
 
On the very same week, Monique, a Supa Cover beneficiary just like Freyda, was also going through the same pre-authorisation process to undergo the same surgery. She too had been a faithful contributor to NHIF for the past five years. She had postponed her surgery because of her grandmother’s funeral the month before. I was hoping to schedule their surgeries on the same day for convenience on my part. 

Two days later, Monique calls to confirm approval for the procedure. NHIF had authorised credit for Sh80,000. Meanwhile, a disappointed Freyda had been awarded a measly Sh20,000! I was taken aback. Why the discrimination? 

NHIF has been a roller-coaster since the introduction of the expanded coverage. The initial season started with great benefits for users, especially those with enhanced packages like the civil servants. For the first time, the poor rural folk, the unemployed low-income earners and the retired elderly folk had unrestricted access to life-saving medical care such as dialysis, organ transplant, chronic disease prescriptions, complex surgeries and of course the maternity services. 

As NHIF struggled to find a balance between what can be paid for and how much collection came in, there was need for drastic policy shift, resulting in the revised NHIF Act (Cap.255). What remains untamed though are the unfair practices in the institution regarding claims that have facilitated fraud, injustice to patients and outright denial of services to the very needy. 

There is absolutely no explanation as to why two patients undergoing the same procedure under the same circumstances should have a variance in how much NHIF commits to pay for. It has become a case of “Whom do you know?” for one to get a decent amount paid out. A hip replacement surgery is a hip replacement surgery. Why should a patient have to change hospitals to get a better preauthorisation? Why is a patient forced to pay their premiums at least two years forward for them to even be considered for coverage yet they have never defaulted an instalment for the past several years? 

Whispers of favouritism persist, where some private hospitals get their patients’ approvals in record time and with decent sums paid out because of collusion between these facilities and some NHIF staff, with kickbacks exchanging hands. Yet some of these facilities are death traps that make you wonder how they were even approved as NHIF service providers in the first place.

As an aggrieved service provider, I want my patients to get equal benefits for the Supa Cover without discrimination and intimidation from some unscrupulous NHIF staff! I want to have a publicly gazette price list for my patients to refer to when they need information on how much they expect NHIF to pay for them for specific services. It should never be at the whim of the person seated on the other side of the computer. That way they can plan and know how much more they will require to top up for treatment. And dear NHIF CEO, kindly conduct a customer relations training for your staff!

Dr Bosire is an obstetrician/gynaecologist
 

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