Chronically ill patients locked out in costly NHIF rules

Chronically ill patients using the National Hospital Insurance Fund (NHIF) are unable to use the cover after the fund imposed a more costly requirement for upfront payment of premiums.

Lately, patients seeking minor and major surgeries, diagnostic tests, chemotherapy and radiotherapy services have been forced to pay two-year premiums in advance as a pre-condition for the national insurer to foot their bills.

Those unable to meet this condition have been turned away by the State insurer, forcing them to make out-of-pocket payments despite having an active medical cover.

Not defaulted

Interestingly, all the patients the Nation spoke to had not defaulted in paying the required premium of Sh500 for non-employed Kenyans, meaning that their NHIF covers were active.

Ms Margaret Waweru is one such patient who, despite being a long time contributor to NHIF, has recently faced challenges accessing treatment.

Since she was diagnosed with breast cancer 24 years ago, Ms Waweru has been undergoing frequent treatments.

"Initially when I sought treatment in India and came back NHIF refunded me Sh70,000 of the Sh1.2million I had spent. They have also been settling three-quarters of the amount I spend on chemotherapy and drugs," said Ms Waweru.

Rude shock

That was until Saturday last week when she got a rude shock after the insurer asked her to pay premiums covering until 2022 if she was to use the cover.

"I put in my request as usual but I got a response that it was declined. On enquiring, someone from NHIF Monday told me that I need to top up my premiums to cover up to 2022 which we did. The person then told us to go back to the doctor and get another pre-authorisation request,” she explained.

As of Tuesday afternoon she was still unsure whether the medical insurer was going to cover her seventh cycle of chemotherapy slated for Thursday.

Should they fail to cover, Ms Waweru, who does not have any other insurance cover, is left with only one choice: to go for chemotherapy but stop taking her daily drugs until such a time she’s able to buy them.

“As a sick person, when you get a declined approval from the cover you solely depend on, you start worrying,” she said.

For Jacinta Wakanyi, when the fund prematurely stopped paying, she had to default on her treatment.

Ms Wakanyi is among women with a rare form of early stage breast cancer medically known as human epidermal growth factor receptor 2-positive (or HER2+).

Sh100,000 per dose

To treat her, she requires injections of the drugs, which the NHIF has been paying for, at Sh100,000 per dose.

To complete the treatment, she needs to have at least Sh1.8 million to acquire the recommended 18 doses. But the Fund only covered the first four shots.

"They stopped paying after the fourth cycle. I wrote to appeal and plead with them but my requests fell on deaf ears," she said.

Without money to pay for the remaining 14 injections, Jacinta defaulted on medication in 2019. Last year, the disease came back more aggressively and she had to start the jabs a fresh.

Meanwhile, Dr Lillian Mbau, needed to get her grandmother to undergo a CT scan.

Pay advance premium

Like the other patients, she too had an up-to-date cover but when they got to the imaging centre where the scan was to be taken, they were asked to pay the advance premium.

“That was coming to Sh12,000 and when I compared it to the cost of the scan vis-a-vis what the insurance would pay even after updating the cover, it made more sense to pay for the scan,” Dr Mbau said.

In 2019, NHIF denied forcing patients to pay premiums in advance, saying it only “advises” them to do so to reduce the risk of defaulting.

“Informal sector members who pay Sh500 per month are usually encouraged to pay for three, six months or even full year to avoid defaulting, which then would block them from accessing benefits at the hour of need. There is no policy to pay in advance,” said the then CEO Nicodemus Odongo.

No response from NHIF

Wednesday, the fund had not responded to the Nation’s enquiry by the time of going to press despite acknowledging receipt of our email.

CEO Peter Kamunyo also acknowledged receiving a text message from this writer, but did not respond to the questions posed.

"Thank you for reaching out, will give you a concise response," read his SMS feedback.

Mr David Makumi, the chairman of the Kenya Network of Cancer Organisations (Kenco) said although there have been rising complaints of the regulation, nothing has been shared in writing.

“Why are they punishing patients with upfront premiums and why didn’t they communicate it. At first I thought it was a one-off situation but many patients and caregivers have come up and it’s now turning into a systemic problem,” Makumi said.

NHIF is a State-supported health insurer into which all formally employed workers are supposed to contribute as a way of subsidising insurance coverage for the poor.

Contribution revenue

According to its website, total contribution revenue has increased from Sh3.1 billion in 2006/07 to around Sh55 billion in 2019/2020.

Kenya continues to bear the biggest burden of non-communicable diseases and significant costs of treatment which is seeing more households pushed into poverty.

According to the Institute of Economic Affairs, for every Sh100 that a Kenyan spends on health, Sh28 is out of their pocket.

Ms Sarah Igobwa, a peasant farmer whose ailing parents were denied treatment despite having active NHIF cover, is among those paying out of pocket.

The first was Ms Igobwa’s father who needed surgery for hernia.

“My siblings used to pay for his cover one year in advance without defaulting but when we went to hospital, we were told we needed to pay for an extra year if NHIF was to cater for the bills,” she narrated.

It was the same story with her mother who has cancer. For five years, she had been getting her medication using NHIF at Kakamega General Hospital.

“One day we went to the hospital as usual but we were asked to top up the cover premiums. Since then, we have been buying mom’s medicines out-of-pocket.”

Financial burden

Out-of-pocket payments are spending on health made directly by households which introduce financial burden or risk to the household, by eating into household budgets.

“In our support group, many women have stopped paying that Sh500. After all, if it’s not going to cover you when you need it, then why pay for it in the first place,” asked Ms Igobwa.

Kenya’s out-of-pocket ratio was found to be above the average of the five select countries (Uganda, Tanzania, South Africa and Rwanda) by 4.1 per cent.

“In the advent of increased non-communicable diseases such as cancer that require long time treatment, reduction of the out-of-pocket payments is key in sustaining affordability and access to healthcare services,” says the IEA in its 2020 analysis.

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