The National Health Insurance Fund (NHIF) recorded a 43 percent income growth to Sh82.6 billion in the financial year ended June 2022, buoyed by enhanced schemes and sponsored programmes, with private hospitals taking the bulk of claims.
This was, however, below an actual target of Sh90.5 billion for the period and compared to the Sh60 billion realised in the 2020/21 fiscal year.
NHIF’s results for the period show that contribution for the year to June 2022 stood at Sh41 billion, up from Sh37.4 billion the previous year, with the national scheme raking in Sh34.4 billion as collections from statutory contribution schemes netted Sh6.9 billion. “However, this performance was below target by 15 per cent (Sh6.97 billion). Net contributions received was an achievement of 82 per cent at Sh34.37 billion (excluding statutory contributions for members with enhanced cover),” the NHIF said.
The national scheme dubbed ‘supacover’ is the primary health insurance cover for all members and their declared dependants as provided in the amended NHIF Act, 2022. Members enjoy inpatient and outpatient services and special packages.
The supercover comes in three segments, including one in which employed or salaried members from the private and public sectors make a monthly contribution between Sh150 and Sh1,700 based on their monthly income. This cover also caters to the self-employed who pay a monthly contribution of Sh500. Additionally, it covers members in the informal sector who are paid for by sponsors or donors.
In the year to June 2022, there were 15.45 million registered members in the supercover, an improvement from 13.94 million in a similar period last year. The total benefits paid out for beneficiaries for the 2021-22 financial year were Sh27.94 billion, against a budget of Sh35.33 billion.
“Utilisation for national scheme members was 79 per cent, with a special benefits package at a high of 114 per cent. Inpatient and outpatient utilisation rate was 55 per cent and 60 per cent respectively. Of the Sh27.94 billion paid out as benefits, Sh27.51 billion was paid to hospitals as claim reimbursement, while Sh426.93 million was paid for evacuation services,” the NHIF said.
Claims received from private facilities accounted for 67 per cent (Sh13 billion) of the total, while those from government facilities were 15 per cent (Sh4 billion). Faith-based facilities were at 17 per cent (Sh4.7 billion).
Of the Sh27.94 billion in claims and other benefits, Sh17.43 billion (62 per cent) were for members of the informal sector, while Sh10.51 billion (38 per cent) were paid for formal sector members. The total number of claims paid for formal sector members stood at 542,601 in the year to June 2022, while the informal sector was 715,956. The informal sector had a prevalence of 64 per cent compared to an active membership of 1,113,823, while the formal sector’s population of 3,939,054 active members translated into 14 per cent.
The NHIF data showed that the claims loss ratio was highest among informal sector members. Compared to contributions received from members, the informal sector loss ratio was 265 per cent whereas the formal sector loss was 38 per cent.
“This shows an adverse effect in the informal sector where only 14 per cent of the members are actively paying for the cover when in need to access benefits,” the NHIF said.
The number of claims received for payment has reduced by eight percent from 1,353,036 in 2020-21 to 1,257,714 this year. In the period under review, Kenyatta National Hospital was paid the highest amount in claims totalling Sh1.62 billion, closely followed by Moi Teaching and Referral Hospital and Nairobi Hospital at Sh864.5 million and Sh541.9 million respectively.
Renal failure condition
A total of 406 medical occurrences were reported during the 2021-22 financial year, with renal failure being the most frequent, accounting for 22 per cent of the total notifications, followed by child delivery at seven per cent. The top highest spend is the renal failure condition with a total claim amount of Sh2.74 billion followed by delivery at Sh1.45 billion.
As of June 30, 2022, the NHIF national cover had made Sh5.2 billion in capitation payments for outpatient services—an equivalent of 60 per cent utilisation, against an annual budget of Sh8.6 billion. The Fund applies a capitation model to reimburse health facilities for outpatient services under the national cover.
The NHIF report showed that in the year to June 30, 2022, the Fund paid out Sh33.92 billion in benefits under its enhanced scheme, which covers civil servants, the police, the prison service, county staff, Edu-Afya and parastatals, among others.
Under the Linda Mama programme, the Fund paid more than Sh3.8 billion to over 600 health facilities in the country offering the services. This financial year, over Sh8.1 billion from the Health ministry was sent to NHIF for Linda Mama.
No allocation was made to the programme in 2021. The ministry has transferred about Sh19.6 billion to NHIF in the last four financial years to support pregnant women and infants in accessing health services under the Linda Mama initiative.