Q&A With NHIF Boss Peter Kamunyo Gathenge

June 14, 2021

The National Hospital Insurance Fund CEO Peter Kamunyo Gathenge answers questions from the public via Sunday Nation.

The opposition to the NHIF Act (Amendment) Bill, 2021 that we are seeing is largely based on NHIF’s not-so-rosy past. The criticism has been about the capacity of NHIF to run the UHC when it has had numerous cases of funds embezzlement and poor services. The sentiments against the Bill also question the different services a person would get from the Sh500 they will be paying. What is your response to these? Joy Karambu, Maua

In terms of capacity, there are deliberate efforts being made by the Government to ensure quality service delivery to the people of Kenya in the national UHC scale-up. In this regard, the Cabinet Secretary for Health appointed a Health Financing Reforms Experts Panel (HEFREP) for the transformation and repositioning of NHIF as Strategic Purchaser of Healthcare Services.

The implementation of the reforms is at advanced stages; the amendment of the NHIF Act is currently in parliament, the restructuring of Human Resource, introduction of biometric registration and electronic claims management system. These reforms are expected to enhance efficiency in service delivery and improve access.

The boost in contribution where members will be expected to pay Sh500 per month (Sh17 per day or Sh6,000 annually) will enable NHIF to broaden the spectrum of services offered to the members. Currently, members have access to inpatient & outpatient services and packages such as surgical, oncology, radiology, maternity, renal dialysis & kidney transplant cover among others.

Sir, the insurance sector has warned that there is the prospect of raising the cost of labour and therefore lay-offs if the proposal contained in the Bill that the employer will match the employee contribution to NHIF is adopted. Therefore, in as much as Kenyans want quality healthcare, they are also mindful of retaining their jobs. How can NHIF strike a balance here? Angela Mbugua, Riverside Nairobi

Good health is an important aspect of any workplace as it impacts directly on their productivity and the economy. As a social health insurer, the key focus is to ensure sustainability and inclusion of everybody where the one who are able support those who are unable. The assurance of access to quality healthcare for all employees will be a big saving for the employer in the long run. NHIF is in communication with stakeholders to explore if there are other options to achieve this goal.

My question concerns the non-payment by NHIF of certain services contrary to what the national insurer says in its policies, eg MRI under the radiological services package; prostate cancer diagnosis/testing and presumably treatment under the oncology package. I have been denied both services and had to fundraise to afford the same. Why is this so? Ernest Mungai

It is true, the cost of cancer management is high and this goes for all other Non-Communicable Diseases which have been on the rise in the recent past. NHIF pays for treatment for all cancers though chemotherapy, radiotherapy, brachytherapy and other related treatment.

For chemotherapy, payments are made based on the treatment regimen with a capped limit of Sh25,000 per cycle for first line treatment and Sh150,000 per cycle for second and third line treatment.

For radiotherapy and/or brachytherapy, NHIF pays a maximum of Sh72,000. For treatment planning, NHIF pays for MRI, CT Scans and PET CT scans. You will find that in facilities with comprehensive contract, this amount is sufficient for treatment.

An increased safety net mechanism for the indigents is one of the key components of Universal Health Care. What programmes have been implemented by the Fund to support this group? Hope Kalekye, Nairobi County 

The guiding principle for the attainment of UHC is that those who can pay for their health insurance are encouraged to pay and those who cannot pay are identified and supported.

The Government of Kenya has been cushioning vulnerable segments of populations from health care-related out of pocket expenses by targeting vulnerable groups to ensure that those who need healthcare and financial protection the most get it.

Currently, collaboration among the Ministry of Health, the Ministry of Labour and Social Protection has seen vulnerable members supported as NHIF members.

The Health Insurance Subsidy Programmes for the Orphaned & Vulnerable Children (HISP-OVC) and that for the Elderly and Persons Living with Severe Disabilities (HISP-OP&SD) cover 181,968 and 42,000 indigent households respectively. The government is funding, through NHIF, the Free Maternity Program dubbed Linda Mama Program for the all mothers in their reproductive age.

Additionally, NHIF has engaged various County Governments, Members of Parliament and Members of County Assemblies to sponsor indigents in their jurisdictions from the funds allocated for development. Currently, an additional one million households have been identified for sponsorship by the Government and pay for them NHIF.

I call upon well-wishers to come forth and adopt a village, a family, a child and pay for their health insurance. We shall have collectively taken a step towards bridging the gap of poverty by making strides towards UHC.

What is your position in regards to the funds the NHIF was supposed to refund to the Interior Ministry at the lapse of the medical cover for police and prison officers? Antony Mulatya, Syokimau

NHIF signed a contract to offer a comprehensive medical cover for the National Police and Kenya Prisons officers for the period 2017/2019. Besides the premiums payable of Sh4.5 billion annually, an additional Excess of Loss fund of Sh200 million annually was paid to the Fund. These additional funds were meant to cushion the officers who exceed their medical limits.

Reconciliation of the funds is ongoing between NHIF and the Ministry of Interior to establish funds to be rolled over to the next contract period.

It is a reality that cancer diagnosis, treatment and follow-up, especially in Kenya, is very expensive bearing in mind that majority of cases are diagnosed late and therefore cost more to treat. This doesn’t always have to be the case give advances in science in screening tests. What is the current NHIF plans on covering at least a one-in-a-lifetime screening test for each of the above cancers? When can we expect NHIF to offer women aged 40 and above at least a one-in-a-lifetime screening mammography? What about at least a one off colonoscopy for anyone at or above 45 years? Dr Alex Muturi, GI Surgeon KU Hospital

NHIF takes cognizance of the importance of diagnosis, treatment and follow up as aspects of preventive and promotive healthcare services. Currently, we cater for oncology treatment including radiotherapy, chemotherapy and screening through our radiology packages which include MRI, CT Scans and PET CT scans.

We are hopeful that with the UHC scale up and the adoption of the NHIF Act (Amendment) Bill, we will be able to have conversations with partners to include these services in the benefits the members can access.

Sir, are the changes envisaged in the NHIF Act (Amendment) Bill, 2021 achievable and sustainable in a contracting economy like ours? Ivy Odhiambo, Nairobi

Ivy, Yes! Health is wealth! The changes envisaged in the NHIF Act Bill follow the recommendations contained in the HEFREP report. In the report, there were 55 recommendations and out of these, to date we have already completed 31 and 24 are in progress, of which the Bill is one of them.

There were reports a few years ago that the government would meet the NHIF contributions for the aged, even as it continued giving them a monthly stipend. Instead, we now have the NHIF Act (Amendment) Bill, 2021 which is silent on the proposal for covering the aged and vulnerable. What became of this noble idea? Githuku Mungai, Nairobi

This spirit of the proposed NHIF Act amendment Bill is to ensure that all Kenyans are covered and have access to affordable healthcare services without suffering financial hardship. The Government has taken the first step to sponsor indigent population through various programmes such as the UHC scale up where a million households that cannot afford basic necessities including healthcare have been identified to be supported.

To strengthen support for indigent population, the Ministry of Health, Social Protection Department and NHIF on Wednesday, June 10, 2021, signed a Memorandum of Understanding (MOU) to put in place structures that will guide the implementation of such programmes.

NHIF has been mandated by the government of Kenya to be the driver of Universal Health Coverage (UHC) scale up. How ready and aligned is the Fund bearing in mind the dynamics in the health sector? Lydia Mwangi, Kikuyu 

NHIF is ready! First, the organisation is carrying out reforms that will place the institution as a strategic purchaser of healthcare services. For example, the re-engineering of the ICT systems to allow for a full digitization of its core operations, restructuring of its human resource and amendment of NHIF Act among others.

It is noteworthy that NHIF as the public health insurer is best positioned to provide health insurance to all Kenyans due to its vast experience and capacity in providing social health insurance for the last 55 years.

The other aspects that make NHIF best suited to deliver on UHC is the wide network of contracted healthcare providers which currently stands at over 8,000 across the country and the well-established NHIF Services Points (70 fully fledged branches, 33 satellite offices and 54 Huduma Centres) and Self-care Platforms (USSD *155#, mobile App and Online platforms).

Furthermore, NHIF has established a dedicated customer experience centre that operates 24 hours to handle customer queries in real time. The diversified Benefits Package gives NHIF a competitive edge when it comes to quality of services accessed by members.

You have joined NHIF at a period that it is undergoing transformation and reforms. What are you doing differently? Mickey Mburu, Kirinyaga County

I joined NHIF when the institution was undergoing structural and operational reforms in alignment to the National Agenda of achieving UHC. I set out five focus areas as a basis for actualizing the NHIF’s Mandate.

First, actively listening to both the internal and external stakeholders has enabled me to have a better understanding of diverse ideas, as a result, enabled informed decisions making.

Secondly, I have learnt that an organization is only as great as its team! I am focused more on relying on the heart count as opposed to the headcount. With the understanding that health is an emotive issue, I strive to ensure that issues to do with our members are dealt with in a timely and efficient manner and with the empathy it deserves.

Restoration of trust is crucial to develop pertinent best practices in stakeholder management for transparency and accountability. Fourthly, prudent utilization of resources and cost containment is vital in delivering an organization’s mandate and beyond. Finally, adding value to the stakeholders is a passion that focuses on innovative health care solutions to strengthen efficiency and improve health outcomes. It is nothing less than working towards putting a smile on the faces of those my work impacts.

The proposed NHIF Act (Amendment) Bill, 2021 that recommends a mandatory Sh500 contribution by every household towards a medical cover is facing stiff opposition from many quarters. Is the opposition based on facts? Why or why not? Virginia Nthenya, Nairobi

Universal Health Coverage (UHC) is a state where all people have access to affordable health services they need without financial hardship. To ensure that no one is left behind, the Government is rolling out UHC on an insurance model using NHIF as a vehicle for delivery of the services. To build a solid financial base for sustenance of UHC, it will therefore require every Kenyan to be enrolled to NHIF.

Currently, NHIF has a membership of 10.4 million registered principal members drawn from both the employed (formal sector) and voluntary contributors (informal sector). Out of the 10.4 million plus members, active members are only about five million principal members.

This is attributed to the fact that most members of the informal sector only pay for their medical insurance when they have a healthcare need and will often drop off once their health need has been met. Those who remain consistent contributors are mostly those with chronic illnesses or requiring major treatment. This puts a financial strain on the system.

The proposed amendments suggest ways to secure the sustainability of the institution through member retention and revenue flow that includes mandatory contribution for the informal sector to reduce the adverse selection. The proposed bill ensures sustainability of NHIF and ability to continue offering improved benefits.

A number of NHIF members who have sought medication in both public and private hospitals during this pandemic period have noticed medical bills are unnecessarily exaggerated. In fact one raised questions about some bills and the same were revised downwards without much explanations. Sir, how rampant are such incidents? What is the Fund doing to mitigate against such unethical practices? Komen Moris, Eldoret  

To be honest, such incidences are common place in the insurance industry the world over. Medical insurance fraud comes in many forms: impersonation where someone uses a card that does not belong to them or a neighbour giving a card to their friend, hospital and insurance personnel colluding to defraud the organization and such cases as you have raised where a healthcare facility inflates bills or claims for services not rendered.

To deal with this issue, NHIF has instituted mitigation measures, for example, use of biometric registration and identification, deployment of the e-claim system in all contracted healthcare facilities, and establishment of Compliance & Enforcement Division, which is working in collaboration with the Directorate of Criminal Investigations (DCI).

To demonstrate how serious we are against such vices, we have suspended some healthcare facilities that have been found committing fraudulent activities and have taken others to court. We are also not excusing employee-induced fraud and staff that have been found culpable have been dealt with accordingly.

Hospitals are caught in a cash crisis. They are having great difficulty in paying their bills, due to the late payment of the money owed by NHIF for patients treated in 2020. When do you expect to clear this backlog? Graham Girvan, Bungoma

Currently, the organization is carrying out major reconciliation of accounts with a commitment to pay all valid claims promptly. However, there are certain benefits that rely on third party funding which is occasionally delayed. Delay sometimes would also mean that the documents were returned for correction or attachment of requisite documents.

With the expected increase in the volume of claims on full rollout of the UHC, NHIF has adopted an electronic claim processing system. The system has already been piloted successfully and is now on implementation in a phased approach. Healthcare facilities in over 14 counties have already been deployed with the e-claim system. This exercise is currently ongoing in different parts of the country and will be completed by July 2021.

If the proposed Bill was adopted as it is what substantive reforms can we expect from NHIF once it comes into effect? How does the proposed amendments anchor Universal Health Coverage? Dylan Armani, Nairobi

The ongoing reforms are geared towards transforming NHIF to a strategic purchaser of healthcare services for the people of Kenya. This is meant to align all the functions of NHIF to the scale up for UHC that we are currently undergoing and it is dependent and supported by the Bill.

Over the years the Fund has been hesitant to cater for expensive specialized treatments like surgeries and organ transplants surprisingly even in public health facilities. How can this be addressed to ensure that Kenyans freely access all medical services in the context of Universal Health Care? Dan Murugu, Nakuru

As a matter of fact, Mr Murugu, NHIF does cater for specialised surgeries and organ transplants to a maximum of Sh500,000. In April 2015, the NHIF contribution rates were revised, to account for increased cost of healthcare services and to expand the benefit package.

This led to the expansion of the NHIF Benefit package from the previous only one benefit (inpatient rebate) to the current 10 benefits such as surgical package, oncology package, radiology services, and renal dialysis and kidney transplant package among others. The kidney transplant package for example has seen over 60 transplantations done in both local and international healthcare facilities since 2019. Patients on renal dialysis access a benefit of Sh972,000 annually for the cost of weekly dialysis.

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