Elijah Wachira, CEO of NHIF

Elijah Wachira, CEO of NHIF during an interview at his offices at the National Health Insurance Fund (NHIF) headquarters, Nairobi on November 22, 2023. 

| Wilfred Nyangaresi | Nation Media Group

New-look NHIF: How State will assess your ability to contribute to SHIF

What you need to know:

  • The fund will set a limit to how much hospitals can charge for certain medicines or procedures.
  • All employed Kenyans, the Act stipulates, will be deducted 2.75pc of their income on a monthly basis.

The government will assess your life with a fine toothcomb to determine whether you are, indeed, too poor to pay for the State health insurance plan, and will only pay for those deemed completely incapable, with the rest, employed or not, expected to contribute to the fund.

These are some of the recommendations of the team implementing the rollout of the Social Health Insurance Fund (SHIF), which will replace the National Health Insurance Fund (NHIF), with a body called the Social Health Authority (SHA).

The State envisages the authority as the bearer of its dream of the Universal Health Coverage (UHC) with every adult Kenyan, and all foreigners living in Kenya, expected to pay a monthly contribution to the fund. Those that do not have the card will be denied government services at the national and county government level.

In the new plan, hustlers who are not in gainful employment will be subjected to a means testing tool that will determine how much they are supposed to pay to the fund monthly.

In an exclusive interview with the Nation, NHIF chief executive Elijah Wachira said that they have categorised hustlers, the unemployed mostly in small businesses, into two categories, with the assessment determining whether they will pay or be supported by government.

NHIF boss Elijah Wachira: How State will assess your ability to contribute to new health fund

“We have two levels of hustlers. Level 1 is that mama mboga (green grocer) who runs a small business and makes money but the inflows of the money is irregular. For her, we shall use the means testing tool to establish their income cycle and how much premium they can be able to pay. After this is established, then premium financing arrangements will be made so that they can be able to pay in advance and then the balance is paid to the aggregator on a monthly basis or in whatever frequency depending on how regularly their money comes through,” said Mr Wachira.

The assessment will be done by Community health promoters (CHPs), who will go to Kenyans in informal settlements and other low income areas, and using the input they have in devices the government has given them will arrive at what is payable.

“The only one thing that is for sure, nobody will pay less than Sh300, which means the minimum has been moved from Sh 500 to Sh 300,” said Mr Wachira.

The Level 2 Hustler, according to Mr Wachira, is the one that does not have any income at all.

“You are over 18, you could be having a family but your income status defined by that means testing tool says that you cannot raise money. For these hustlers, the Act has recognised them as indigent, and the plan is for the government to pay the premium on their behalf...the money will come from the exchequer. Both the national and county governments will sponsor indigents,” said Mr Wachira.

All employed Kenyans, the Act stipulates, will be deducted 2.75 per cent of their income on a monthly basis.

The State is to present regulations to Parliament that will determine whether there will be a cap to the contributions. With initial proposals suggesting it be capped at Sh5,000.

Besides the SHIF, other funds established by the Act repealing the current NHIF are Primary Healthcare Fund and the Emergency, Chronic and Critical Illness Fund in what is a significant structural change to the healthcare funding system in the country.

“For those of us in employment, cash flows are available monthly, but for those who are unemployed, cash flows are available in an irregular manner and so the Act envisioned that and has arranged with various aggregators, for example the Kenya Tea Development Authority(KTDA) among other cooperatives whose role will be to ensure that they look at the income patterns of a number of these unemployed people, give them the money in advance and then the monies will be deducted from them on a monthly basis or when their funds are available,” said Mr Wachira.

The contributions, Mr Wachira said, will be determined per household, and premiums calculated by breaking down the income averages.

“For now we shall use averages as we are doing our computations for premiums for households, but it does not matter how many dependents one has and as long as they are legal dependents, they will be covered under household. Kenyan households are irregular, that we know, but a household will remain a house hold and will ordinarily comprise of a mother, father, children who are biological or adopted who are either below 18 or below 25 if there is evidence they are college going,” added Mr Wachira.

For Kenyans who would wish to seek treatment abroad, the CEO discloses that the fund may not come in to assist you if you do not follow the proper channels of referrals.

“You must use the normal referral systems where you will go to Level 2,3,4,5 and 6 (and if)after level 5 and 6 feel you require specialised treatment abroad, the fund participates as long as the referral system is following protocol as defined in the Act.”

The authority, Mr Wachira says, will register any Kenyan in the emergency, Chronic and Critical Illness Fund if in the course of treatment, one exhausts their SHIF limit.

“When a Kenyan or a beneficiary exhausts their limit in SHIF, then they will automatically go into the Emergency, Chronic and Critical Illness Fund. We are envisioning a situation where people will not lack treatment because of (lack of) funds anymore because after exhausting the limit in fund one, they automatically move to fund two,” he explains.

The Emergency, Chronic and Critical Illness Fund is supposed to fund chronic conditions which are conditions that last more than a year, according to Mr Wachira.

The CEO says the fund will also set a limit to how much hospitals can charge for certain medicines or procedures, seeking to cure discrepancies in fees.

“When the regulations are published, they will have something called an essential benefits package where we shall agree with providers how much SHA will pay per condition or disease and to that extent we are guiding the hospital on what medicine to give you for what disease and how much to charge SHA for it,” says Mr Wachira.

This, he adds, will go along with the ‘digital superhighway’ that will see all hospitals in the country interlinked.

“This means all records of treatment will be available on a dashboard to everybody and so no hospital will say I gave medicine X when they indeed administered medicine Y because all the data and records will be available on the digital superhighway,” says the CEO.

Mr Dennis Nkarichia, an associate at Mohammed Muigai LLP in Nairobi and an expert in digital and health law, however, faults the requirement to have a card to access government services as well as failure to acknowledge Kenyans with dual citizenships. He also faults the law in that it requires even those Kenyans who will be out of the country for a year or more to still pay up.

“How can you make payments to a scheme without consummate benefits from that scheme? The statute must recognise the operational parameters of the country,” says Mr Nkarichia.

He is, however, happy to note that tourists will now be required to have insurance.

“Unlike other countries where you are compelled to get health insurance while traveling, Kenya did not have this, and it’s good to see this is now happening,” he told the the Nation.