HEALTHCARE

To implement UHC, reform NHIF, get rid of institutionalised corruption

Given health is rightfully a devolved function, national government input into supporting UHC implementation in counties should not be supply driven but demand driven.

In Summary

• When we entered Parliament in 1993 as opposition members, one of the things we started fighting for was the introduction of Universal Health Coverage.

• We argued that health insurance, or health coverage, had to be extended to ALL Kenyans for both in-patient and out-patient care.

President Uhuru Kenyatta unveils the UHC logo during the launch of the pilot programme in Kisumu on December 13 last year
BIG FOUR AGENDA: President Uhuru Kenyatta unveils the UHC logo during the launch of the pilot programme in Kisumu on December 13 last year
Image: PSCU

When Kenya initiated a health insurance scheme in 1967, it was the first of its kind in sub-Saharan Africa. It was called the National Hospital Insurance Fund.

It focused on giving civil servants insurance cover when admitted to hospitals. It assumed that the rest of Kenyans were fully catered for by other means when admitted.

The Europeans, for example, as a reasonably well to do community, had the Princess Elizabeth Hospital (now The Nairobi Hospital), to cater for their interests as private patients. They had their wealth, as well as their own private insurance arrangements, to pay for the cost. The Asians equally had the MP Shah and other hospitals under similar circumstances. The Africans had access to various missionary and government hospitals across the country whose in-patient and out-patient care was offered at reasonable rates, making access less problematic than it is today.

 

It must be remembered that Kenya's population was then just slightly less than 10 million people. Catastrophic diseases like HIV-Aids were not there. Chronic illnesses such as hypertension, diabetes, cancer, etc were also scarce due to a more healthy diet and less stressful lifestyles.

By 1990, almost 30 years after independence, the demographic and health architecture of Kenya had changed radically. Aids/HIV was rampant, killing our people left, right and centre. Non-communicable diseases such as cancer and diabetes had been growing at geometric progression over time, and malnutrition and its associated health hazards among children was a major problem. Seventy-five per cent of those seeking healthcare were outpatients, civil servants included.

In government health facilities, outpatient care was reasonably affordable except for diagnostic services and pharmaceuticals. Quite frequently, due to the pressure of numbers seeking service, the medical personnel were not adequate to provide needed care, thereby compromising the quality and timeliness of services rendered.

When we entered Parliament in 1993 as opposition members (the party I belonged to was Ford Kenya led by Jaramogi Oginga Odinga) one of the things we started fighting for was the introduction of Universal Health Coverage. The Hansard of the 1990s will bear evidence to this. Further, I remember participating in the writing of various manifestos of the many opposition parties and groups we formed where the issue of access to quality and affordable healthcare for "the common wananchi" was always our major concern.

It was obviously ironical that NHIF catered only for a class of people, a minority at that, who could afford to pay for healthcare. Elsewhere the private sector and parastatals had more elaborate arrangements for looking after the health needs of their employees. Why were the workers and peasants of Kenya left out yet without them the civil servant could not have access to the "unga" he needed for his "ugali"? We argued that health insurance, or health coverage, had to be extended to ALL Kenyans for both in-patient and out-patient care.

When the reformist Narc government, led by Mwai Kibaki, came to power in 2003, our manifesto entitled "Democracy and Popular Empowerment" had two very important proposals in the Social Pillar. These were free primary school education and universal access to affordable and quality healthcare for all Kenyans. I was privileged to serve on this government as the Minister for Planning and National Development charged with transforming our manifesto into an implementable reform agenda to rescue our economy from total collapse after many years of decay. 

We immediately embarked on transforming our manifesto into a development agenda led by a core team comprising my PS Joe Kinyua, the director of the Central Bureau of Statistics the late David Nallo, and Harry Mule, David Ndii and Sam Mwale as my advisers. Professor Michael Chege joined us later in the year. The end result was the formulation of the "Economic Recovery Strategy for Wealth and Employment Creation" (ERS in short), the precursor of Vision 2030.

 

The Social Pillar of the ERS included free primary education and UHC. Even before the ERS was launched by the President in June 2003, the Narc government had gone ahead to implement free primary education, notwithstanding opposition from the usual naysayers. In the Ministry of Health, with Charity Ngilu at the helm, we were on top gear pushing for UHC. A bill was presented to Parliament and passed but was never implemented because the President declined to give his ascent due, no doubt, to pressure excreted by the powerful health insurance moguls. The official reason for the decline was that, as proposed then, the government could not afford to finance UHC.

I was again privileged to serve as Minister for Medical Services in the Coalition Government in 2008 to 2013. This time, I decided to approach the issue in stages. My argument was that since 75 per cent of Kenyans seek healthcare as out-patients, it did not make sense for NHIF to cater for only a fraction of the remaining 25 per cent and only as in-patients. We needed to expand NHIF coverage to cater for all Kenyans seeking out-patient care before we cover in-patient care. Once this first step succeeded then we could move on to cover in-patient as well.

But this policy would mean enhancing NHIF contribution in terms of contributors going beyond formally employed persons. Contributions would also be calculated in a graduated manner in terms of "from each according to his earnings."

We engaged the services of the International Finance Corporation and the Rockefeller Foundation to undertake a study on how NHIF coverage could be upscaled to cover in-patient and out-patient care for all contributors. The government would cater for indigents--or those who could not pay for themselves. The end result was that NHIF opened its doors to out-patient coverage. Various programmes were introduced to cover indigents with user fees being abolished at the dispensary and health centre levels for out-patient care.

But all these steps, while advancing the journey towards full UHC, still left us without the "full thing". I was, therefore, very encouraged when President Uhuru Kenyatta announced that this time, we want to implement UHC "in full".

We need to do the following. First, build on our experience. Where are we now and where do we intend to go? Second, learn from passed studies like the IFC/Rockefeller study. How much of it was implemented and what was left undone, and why?

Third, take a good look at NHIF, not simply as a HOSPITAL insurance fund, but as a HEALTH  insurance fund. I think this institution is our best bet and provides the best insurance architecture for building an insurance-based UHC in Kenya. But it needs serious reforms to improve governance, get rid of institutionalised corruption as well as control by a lobby of "employers" who resist contributions by employers on ILO principles.

Finally, given that health is rightfully a devolved function, national government input into supporting UHC implementation in counties should not be supply driven but demand driven.