What will happen once the Social Health Authority is fully launched on July 1? Who will determine what premiums Kenyans in the informal sector will pay? These are some of the concerns Kenyans are raising in the ongoing public participation forums on the benefits package under SHA. Mass registration for the new health insurance begins this week on Friday. The Star's John Muchangi sat down with the Acting SHA Chief Executive Officer ELIJAH WACHIRA, who explained what Kenyans can expect.
Let’s start with the benefits package published last week. How was it arrived at?
We looked at the consumption habits of Kenyans. NHIF has been in existence from 1966 so we have data of what conditions Kenyans suffer from, which parts of Kenya they come from, and what would most address their needs.
Based on that analysis, we came up with a listing of conditions they suffer from, and that was the genesis of forming a benefit package. We have gone ahead and studied modern disease trends. We have seen increases in cancers, increase in a number of preventable lifestyle diseases. And that informed the creation of this third fund called Emergency, Chronic and Critical Illness Fund.
Are patients tied to one facility for outpatient services?
The patient will be linked to a primary care network, so people will have opportunity of moving from one provider to another depending on quality of care, the availability of commodities and even their location when they need the service.
People are tired of being tied to a facility, is also not very good. That is the feedback we got. So right now, we plan to tie them to a primary care network instead of tying them to one facility.
The mass registration of Kenyans to Social Health Authority begins Friday this week. What should Kenyans know and expect?
The law says everybody must register. We have a bit of clean data with NHIF, and the national registration bureau. So what will happen is easy. You'll be told to tap your mobile phone, and confirm your details and the registration process will be complete. Kenyans aged above 18 could take less than three minutes to register from the comfort of their phones, whether smartphones or the other phones.
So we're not going to go to a facility to register or confirm details?
As long as you are literate, it will be rare that you will have to go to a facility or Huduma Centre. I foresee a situation where a lot of registration will happen at the comfort of your home or office. Only the biometrics or the fingerprints will be taken at a facility or a SHA branch.
In the meantime, should Kenyans on the voluntary Sh500 cover continue paying the same to NHIF?
The law says that NHIF can only accept the Sh500 up to end of June 2024 so the last month that the Sh500 will be acceptable will be the current month of June 2024. Thereafter, we shall now go into the regime of means testing for those in the informal sector. People will fill in a questionnaire, and then out of that questionnaire, some algorithm in the backend will calculate their income, and the 2.75 per cent of that income.
What happens to Kenyans who already paid Sh6,000 upfront for the entire year?
Not a problem at all. Again, the law says that any monies that you will have pre-paid to NHIF will automatically go into SHA. The law says that on the appointed date, which is November 22, 2023, all assets and liabilities and contractual obligations of NHIF reverted to SHA. So if there is any prepayment into NHIF, this prepayment is already a liability of SHA, and SHA has to make sure that it is utilised to the last cent.
We had so many defaulters in the Sh500 voluntary scheme. Once they begin payments under SHA, will they pay penalties as usual to access services?
No, this is a new establishment. There'll be no penalty. And the other good thing with this one, we want to make it easier for the people in the non-employment, the informal sector. We have talked with a number of financial institutions. When you register as a person in informal sector, and we settle on the premium, financial plans like the Hustler Fund or others, will pay upfront for you. Then you will be left paying the Hustler Fund, or whichever programme supported you.
Can you explain Means Testing and how it will be conducted?
This is a test to measure how much income a person has in order to decide how much they should pay in premiums and if they should get assistance from the government.
In our case, a number of scientifically researched questions have been put in the registration system. So when you correctly answer those questions in the portal, those questions are supposed to determine how much income you make per month, per annum. It is that income that you make per annum after answering those questions, that is used to make a determination. Do you have a roof? Do you have wall to wall carpet? Again, I'm just giving examples, these are not necessarily the questions. Where do you access your water? Do you have water inside your house? So when you answer all these questions, then they will be able to, with a fair degree of accuracy, estimate the income. And after they estimate this income, then 2.75 per cent of this income is what will be payable to SHA.
How long will this Means Testing exercise take across the country?
Nobody will take more than 10 minutes on a good device. And it is not residence alone that will be used to determine what you pay. We have people in the informal sector who make a lot of money. I've seen somebody living in the informal sector who makes Sh2 million a month, but he prefers living down there.
So we are using science, and only the least earning Kenyans will pay Sh300. Many other people in the informal sector will pay depending on their income, and this is what means testing is. So you will answer questions on your phone, your computer or somewhere else, and then the system will quickly compile and within a short time, come back to you, telling you on the same day that what you are supposed to pay is not Sh300 but we have looked at you and we think you can afford Sh700 or Sh326 or Sh20,000 every month. This will all depend on the income you make and how you answer those questions.
Does SHA carry a limit on the number of children or wives that can be on one cover?
We do not have a limit of the number of children or spouses, as long as they are fairly official. To that extent, we shall make sure that everybody, as long as you are in a recognisable household, then you pay based on the household income.
Can you explain how the three funds inside SHA are related?
The best way of explaining is to give the history of SHA. On October 19, 2023, the President assented into law four bills. One of the laws was the Social Health Insurance Act, or the SHA Act. The organisation that was formed by the SHA Act is called Social Health Authority. SHA will manage three funds. The first fund is called Primary Healthcare Fund. This fund will finance the treatment in Level Two and Level Three hospitals – that is, dispensaries and health centres.
The Primary Healthcare Fund will be fully funded by government and as long as you are registered with SHA, you do not have to be paid up to access service in Level Two and Level three.
All of us will be required to go into this Primary Healthcare Fund first, before we can go to any other fund. So for all of us, the first level of treatment will be dispensary and healthcentres. Here we expect many communicable diseases, diarrhoea, flu, to be treated and people discharged.
Then the second fund is called Social Health Insurance Fund (SHIF). SHIF is a contributory fund. This is where the 2.75 per cent of our incomes go. Those who cannot pay anything the government will pay for them up to Sh300.
SHIF will pay for services at Levels 3, 4, 5 and 6 hospitals. To access this, a patient will have to have been referred from Level 2 and Level 3, where you will go first. The main objective here is to decongest the Levels 4,5,6 hospitals. So you don't have somebody with a simple cold holding a queue for somebody who suffering from stroke or a condition that could lead to death or permanent disability.
The third fund is the Emergency, Critical and Chronic Illness Fund (ECCIF). This is for emergencies and for people who exhaust their limits in SHIF.
Looking at the benefits package I see copayment. I mean, for some conditions, SHA will cover hospitalisation for up to 50 days.
There are some limits, but we have worked hard not to have financial limits. We have limits based on the mode of treatment, number of dialysis sessions, number of days admitted. Again, this has scientifically been arrived at based on the data and the experience we have over time.
Are health facilities going to be contracted and empanelled again?
We are going to empanel afresh, because that's what the law says. In actual fact, even for those we had empaneled in NHIF, the contracts are coming to an end on June 30. So we need new contracts.
Number one, the law says that as long as you are accredited by the accrediting authorities, such as the KMPDC, then that accreditation in itself is equal to empanelment.
So all we shall do is to interest them in our contract terms and conditions and our tariffs, which we shall advertise. If they are keen to do it, we shall go through a process called E-contracting, where they will review our terms and conditions, agree with them, sign their end, we sign our end, and we shall have a contract in the shortest time possible. The one thing you realise about SHA is that we are heavily, digital. So we shall be able to empanel about 9,000 providers within a maximum of three days,
Do we have different terms for the private and public hospitals?
The terms are all the same. In actual fact, Universal Health Coverage means everybody. So everybody is being exposed to the same contract. They will sign for the services they're able to offer, and everybody will get the same amount of money for the same service.
To be clear, from July 1, can Kenyans access benefit listed under SHA?
Yes. SHA promises Kenyans a big benefits package. It promises Kenyans good health. My expectation is healthier, more productive Kenyans, happier employees and some good automation of processes.