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EA nations' hurdles in providing cheap healthcare
A surgery in progress. For Universal Health Care to work, hospitals must be equipped with personnel. PHOTO | NMG
What you need to know:
- Every Kenyan household will be expected to pay 2.75 percent of their income to pump in a projected$357.4 million annually to the Social Health Insurance Fund.
- In Tanzania, President Samia Suluhu Hassan is demanding quick implementation of the revised National Health Insurance Fund rates.
- Uganda has the highest out-of-pocket health expenditure in the region, compared with Kenya’s 24.06 percent, Tanzania’s 23.10 percent and Rwanda’s 11.7 percent.
States have put into motion programmes and legislation to facilitate Universal Health Care (UHC), but legal and political challenges have seen some of the efforts hit a snag.
Take Kenya for example, President William Ruto last October assented to four new Health Bills that set the legal framework for the overhaul of the country’s UHC programme.
This gave way to the formation of the Social Health Authority (SHA), which enshrines regulatory frameworks for the creation of a new public health scheme, Social Health Insurance Fund to replace the National Health Insurance Fund (NHIF), which experts say favoured a social class that could afford to remit payments to the Fund.
But the scheme ran into legal headwinds. A week after Health Cabinet Secretary Susan Nakhumicha issued a Gazette notice operationalising the new Social Health Insurance (SHI) Fund Act, 2023, the Kenya Medical Practitioners, Pharmacists and Dentists Union obtained court orders stopping the planned rollout. The government moved to Court of Appeal to lift the order and will know its fate on January 19.
But, even if the appellate court lifts the orders, the government is grappling with the transition from the 57-year-old NHIF to the new scheme.
A Harvard University study that explored social health insurance for developing nations defines SHI as a healthcare financing model that allows mobilisation of funds and pooling risks so that the poor and near-poor can access healthcare.
“SHI may be a solution for a critical part of a nation’s systemic health care problem, but is not necessarily a solution for the whole problem,” they explain.
Every Kenyan household will be expected to pay 2.75 percent of their income to pump in a projected Ksh57 billion ($357.4 million) annually to the Social Health Insurance Fund.
A Primary Healthcare Fund will solely be government sponsored and the Emergency and Chronic Illness Fund is meant to help people who get into accidents and those living with chronic illnesses. But the people who will access it will have exhausted their SHIF first.
The transition period to the new scheme is, however, marred by confusion, and is hurting some Kenyans. High school students, for instance, who previously depended on the NHIF-backed EduAfya Medical Scheme, have no cover, as the scheme was phased out at the end of last year.
Some students with chronic illnesses who travelled abroad under EduAfya now have to foot their bills.
A letter seen by The EastAfrican addressed to Kenya’s Ministry of Education details the agony of one student who is currently in a critical condition and is being treated in India. The letter from Manipal Hospitals in India shows that the patient still needs medical management but cannot pay.
“The patient’s mother… Does not have money to bear the expenses for medical treatment as well as accommodation and our hospital is ready to support her to some extent but we cannot waive the complete medical bills amount,” the letter reads.
The EastAfrican has learnt that some remittances for key services such as dialysis have not been done.
Private medical service providers say they have begun feeling the pinch of the shift. Three dialysis centres in Mombasa have been closed down, reportedly because the owner is owed about Ksh20 million ($125,391) by NHIF.
Dr Jonathan Wala, chairperson of the Kenya Renal Association supports the shift, but wants the government to use the transition period “to house-clean.”
“At the moment, dialysis units are running with the hope that they are ultimately going to be paid by NHIF. But, when dialysis units start closing down or work with cash-paying patients, then that will not be a good place to be in,” he said.
Dr Wala said the transition period is confusing because there are two people at the helm; chief executive of NHIF and board chair of the SHA. Service providers are therefore confused about where file their claims.
“Ultimately, the ministry (Health) has to be concerned that the financial implications of the new programme needs to be addressed,” he said.
Dr Davji Atella, Secretary-General of the Kenya Medical Practitioners Pharmacists and Dentists Union (KMPDU), said while the union rallies support for UHC, some sections of the new legislation leave out key issues that would steer the UHC agenda forward.
“Medical workers, for instance, relinquished their medical allowance in 2011 so that they could enjoy the benefits of a comprehensive cover but, with the transition, they are likely to lose that,” he said. “Civil servants may not fully access care and will likely have out-of-pocket expenditure. It would have been better if all Kenyans had the privilege of accessing services under a replica of the former comprehensive cover,” he added.
Dr Atella said that for UHC to work, hospitals must be equipped with personnel, because it beats logic to have facilities with no one to attend to patients.
Edwine Barasa, a health economist who teaches at the University of Oxford, says some of the new proposals are impractical. Making the Social Health Insurance compulsory for everyone will be problematic to enforce.
“The proposal to provide health insurance subsidies for the poor could address some of the anticipated inequities. The plan means testing to identify the poor will face globally documented challenges that will likely attenuate any potential benefit. Administering means testing is costly,” he said.
“This money would be better spent on healthcare. It is also error-prone, with some undeserving individuals being classified as poor, while some deserving poor are excluded.”
Then there is corruption, which the new administrators have to deal with. Just recently, Ms Nakhumicha acknowledged the loss of over a million dollars in a fraudulent claims, featuring hospitals and NHIF.
“Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Ksh171 million ($1.07 million),” she said.
Citizens feel that they are contributing to a larger kitty for officials to steal from.
In Tanzania, President Samia Suluhu Hassan is demanding quick implementation of the revised National Health Insurance Fund (NHIF) rates, which is stuck due to opposition by private service providers.
Parliament passed the Universal Health Coverage (UHC) Bill on November 1, 2023 and President Samia signed it into a law on December 4, 2023.
President Samia said in Zanzibar on Wednesday that health insurance was inevitable and every citizen should be covered. She was reacting to the suspension of the new NHIF package by Health minister Ummy Mwalimu after discussions with the Association of Private Health Facilities Tanzania (Aphfta), the Tanzania Muslim Supreme Council and the Christian Social Services Commission on January 4.
Aphfta said lower rates recommended by the new law would cause huge losses to their facilities and force them out of business. Tanzania’s Lutheran church is the leading institution providing basic and referral health services, managing referral and specialised hospitals in Tanzania, including the Kilimanjaro Christian Medical Centre and Kibong’oto Infections Disease Hospital, all in Kilimanjaro region, northern Tanzania.
The Catholic Church in Tanzania manages a number of referral hospitals, dispensaries and other health centres providing general and specialised medical services. Bugando Referral Hospital in Mwanza is the biggest Catholic Church-owned hospital in Tanzania.
About 20 million people in Tanzania are registered with the NHIF scheme, most of them being government employees. Data from the Ministry of Health indicates that out of about 60 million Tanzanians, only 15 percent have health insurance.
But NHIF has been trapped in price disputes with private hospitals with a number complaining of non-payment and delayed payments.
Aphfta said that NHIF needed to avoid unilateral price setting and engage in genuine and transparent dialogue with private health facilities on charges.
In Uganda, although the Bill for the national health insurance scheme was passed by parliament in March 2021 after many years of back-and-forth discussions between the Health Ministry and its partners, the implementation remains a far cry, as Ugandans remain burdened by the heavy medical bills.
President Yoweri Museveni sent the Bill back to parliament, requiring the ministry officials to return to the drawing board and consider some of the issues he raised, such as the vague implementation framework. It is two years since.
State Minister for Primary Health Care Margret Muhanga, says the Bill will be re-tabled soon and believes the National Health Insurance Scheme will address issues of medical bills among financially distressed people and make it easier for the country to attain the universal health coverage.
Apart from the president’s concerns about implementation, there have been concerns over the lack of a regulatory framework governing health insurance in the country and disagreements on whether the poor should be asked to pay.
The Bill had proposed an annual fee of sh15,000 ($6) per household member, but the government has no framework for getting this money from the informal sector, and proposes to transfer the burden to the formal sector by having employers contribute 50 percent of their employees’ total contribution.
“We appreciate parliament for its continued interest in national health insurance. “ However, only 30, 000 Ugandans are organised in Community Health Insurance Schemes, and about 39 percent of Ugandans are not in the money economy,” said Dr Leticia Nakimuli of Save for Health Uganda, an NGO.
The formal sector is already burdened by the taxes and many contributions, including the National Social Security Fund (NSSF), and workers feel that this comes as another form of taxation amid a beaten economy, high cost of living and increasing inflation rate.
The safety of the money contributed is also in question, given that government officials have a history of misuse or abuse of public funds
According to Dr Elisa Rutahigwa, a member of the Parliamentary Health Committee, the scheme may not work because most government health facilities lack essential medicines to treat the people.
Uganda has the highest out-of-pocket health expenditure in the region, compared with Kenya’s 24.06 percent, Tanzania’s 23.10 percent and Rwanda’s 11.7 percent. An estimated 38 percent of Uganda’s health expenditure is paid by individuals through out-of-pocket costs, followed by development partners (41 per cent), the government (16 per cent), and others (5 per cent). The country’s current health insurance options include employer or community-based schemes, which are covering less than 2 percent of the population.
Insurance Regulatory Authority of Uganda CEO Kaddunabbi Ibrahim Lubega says they want to partner with government to ensure effective implementation and supervision of this scheme, adding that they expect health care professionals from both the public and private sector to offer services to address the issue of shortage of personnel in the country, especially after both public and private health care providers have been accredited to provide services under the NHIS scheme.
Uganda has about 6,940 health facilities, 45 percent of which are government-owned, 15 percent are private not-for-profits, and 40 percent are private for profit. But the health worker population ratio remains low, at 1.87 per 1,000 population, compared with the WHO recommended ratio of 2.5 per 1,000 population.
