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February 21, 2019

EXPERT COMMENT: Tame private clinics eating up NHIF cash

NHIF logo /
NHIF logo /

The National Hospital Insurance Fund (NHIF) money should go towards improving public hospitals for everyone because it is social insurance that is statutory by law. NHIF contributions should never have been treated as a cash cow for the private sector.

The way NHIF pays up to 80% of collections to private health profiteers and only 16% to public facilities, it has to go bankrupt. This happened in Ghana too.

NHIF should also stop cushioning private sector insurance companies by paying a part of the bill called rebates or bed charges.

At the same time, UHC pilot as is designed has very little to do with NHIF. But in the bigger scheme, NHIF may play an important role if the country decides to adopt an insurance-based UHC model.

Even so, NHIF must reform to be a strategic purchaser of services and not an insurer that private sector leeches on at the expense of contributing workers.

NHIF is a workers' fund, it would also be important to have less government in it and more workers representatives ensuring better stewardship.

The Kenya Medical Practitioners and Dentists Union is ready to guide other workers' organisations into what reforms should be pursued at NHIF.

There is a lot of interference at the insurer owing to the fact that it has been captured by the private medical services providers. The said entities are profit-oriented and present or raise claims which are not sustainable.

The aspect of advance purchase of insurance, where many people apply for cover at the time they are sick, also needs a relook. Such persons take insurance for the sole purpose of getting treated for the particular ailment and then default after they get well.

The default rates are so high to a point that of the six million users, only about 3.5 million are regular hence burdening the rest who also depend on the fund. Those who pay or contribute also have dozens of dependants.

With the fact that the cost of care in the health sector is not regulated, the claims mechanism employed by NHIF at the moment is likely to make the insurer bankrupt and susceptible to fraud.

NHIF makes an approximate Sh51 billion annually in revenue from contributors. This is enough to ensure specific hospitals, especially public referral facilities, have the capacity in terms of enough specialised workers, medical equipment, medicine and other commodities to attend to contributors. The model has worked before so the ministry of health should reform the insurer to this sustainable strategy. False claims, fraud within the fund, fraud between the fund and providers and fraud between the fund and contributors must be dealt with and minimised. There have been cases of contributors being listed in facilities that they know nothing about so that the facilities can claim money from NHIF.

NHIF can be a saviour for healthcare financing. If it is reformed to work for all Kenyans as a social insurance fund.

Read: NHIF boss arrested in Sh1.5b graft probe

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