I love my bartender. He hands me stuff. I pay for it. Then boom! My worldview shifts, flirting with the uncanny as my troubles scamper from sight. They melt into the darkness, to surface only at a distance just far enough that I barely make the glow of their eyes. They whimper, lost in the pit of pitch-black hell that is bliss from alcohol induced obliviousness. From America to Kenya, such a mindset steeped in the simplistic route to hedonism of the ease of a bar transaction muddles the straight thinking needed to deliver universal health care (UHC).
America’s love-hate swing-song with Obamacare is a matter of fact. For Kenyan’s there is NHIF Supa Cover and its overselling as the holy grail path to UHC.
Universal Health Care : At The Mercy of Political Rhetoric Christened Political Goodwill
Just like Trump, Kenyan politicians are obsessive about a national health insurance scheme. Infatuated they are, but in all the wrong ways, court her. In this pursuit, they are guilty of child-like mistakes. Mistakes boys inexperienced at the chase are damned to make in their uncultured pursuits.
Key among them is the cardinal sin of not calling her by her name. Just like an unseasoned boy in the game of love, these politicians err by christening her the name of the other maiden they are obligated to : UHC. Sadly so, as the peoples representatives tasked with delivering universal health care, calling her by any other name but shifts the mirage of universal health care once more.
Borrowing from Greek mythology, this Eros (love/ sexual attraction) follows such a pattern like that of Greek gods. In Greek mythology, Eros comes after Chaos (nothingness) of unresponsive health systems. On the campaign trail, politicians will sell this tainted love with the graft and craft of a snake oil salesman. Once again, good intentions, bad moves.
Good because their actions signify an acknowledgement of the dire state of their peoples health. More so under the spirit of the constitution of Kenya 2010, where health is a universal human right. Bad moves as just like the boy who gets Nanjala’s and Wanjiku’s birthdays all mixed up, they end up gifting the wrong girl with the right gift.
How Political Rhetoric Ill-Shapes The Universal Health Care Agenda
NHIF Supa Cover has been fronted as the power that will save Gaia (the Earth – Kenya) form Tartarus. Tartarus is an abyss – in our case, a world bereft of universal health care. Right gift, wrong girl. As Trump “repealed” Obamacare, the Kenyan president recently launched a scheme to cover students under NHIF. The Star reported Uhuru Kenyatta as saying:
The cover which is a negotiated initiative between Ministry of Health and Education ministry is unique as it caters only for students as opposed to the entire family. This will also encourage other family members and guardians to these students enroll for NHIF as we forge ahead to achieving a universal health care
The president seems to be following precedence set by devolved units. As envisioned by constitution of Kenya 2010, Counties share in the task of ensuring Kenyans access the highest standard of health. The president, Muranga, Kirinyanga, Homabay, Kitui counties ( and others ) are guilty of the one mistake all double-dealing lovers know of too well. Never confuse Mary for Miriam.
Debunking The Myth That Government Footing NHIF Bills Leads To Universal Health Care for Kenyans
On the surface, more money in health care seems a honorable thing. But as the American case informs, in delivering social goods like health, throwing money at it cannot correct ills about its eventual distribution. It is a lose-lose situation. First money is lost. Then budgetary constraints kill any other worthy investment in social goods like health. Finally, the resultant inefficiency bursts any dreams of UHC. Indeed Kenyan eminent thinkers on the path to universal health care have called out the president on this move.
This opinion piece by a leader in Kenya’s private health sector identified opacity in health care costs, insufficient regulation, insurance fraud, a crippled public health sector etc as pressing concerns to be addressed in Kenya’s UHC journey.
Recently, a union official from the umbrella body that safeguards doctors, pharmacists and dentists interests, KMPDU, called out the president on duplication. Children under the age of 22 are covered by NHIF by way of them being dependents, he argued.
Moreover, scholars from countries with comparable health challenges and economic profiles to Kenya front less mainstream solutions such as national accreditation systems as tools to deliver universal health care. Kenya, you better listen.
Getting There
In light of such concerns, the magic bullet that slays the UHC dragon appears to be an informed mix. A cocktail made to taste that includes avant-garde subtleties such as design thinking and continuous quality improvement (QI) in health. Such approaches to health delivery aim at improving the efficiency of health systems. They fortify any efforts at strengthening fragile health systems as they avail funds by bringing down the cost of health care.
The intermediate outcomes from both of these modern approaches additionally form the basis of the two key qualities of UHC: accessibility to quality health care and negation of financial ruin.
They achieve that by embracing a patient-focus prism to health care. In the new world of value-based health, they offer more plausible routes to universal healthcare than simply ‘throwing money at it’. NHIF’s inadequacy as a vehicle to UHC begins at this structural point. NHIF is a capitation based health insurance. It rewards absolute numbers rather than patient outcomes. The structure of NHIF therefore flies in the face of these modern trends informing health care delivery.
However, it can be conversely argued that efficiency metrics borne out of such strategies like QI lean unduly on intermediate outputs ( numbers treated, waiting time, etc). This raises the risk of sub optimal recommendations that nee sub optimal outputs of the health system. Given this risk, we are obligated to additionally view actions by government to foot NHIF premiums for sections of Kenya’s demographic as a UHC strategy from a macro level.
Big 4 Agenda – Universal Health Care : With NHIF, Do The National and County Governments Have Their Priorities All Mixed Up?
In health care, policy aimed at addressing the seven pillars of a responsive health system could be interpreted as acting at the macro level. Given the cost of inputs at this level, through investments such things as PET scans and nationwide health information systems, the huge outlay involved makes it prohibitive for private players in health care or even county governments.
The actions of national government towards UHC can then only be weighed against their fidelity to investments in the pillars of a responsive health system. Context for this analysis is set by the framework of constitution 2010 of Kenya and GoK health policy documents. Any other activity outside these boundaries is likely to reek of political gamesmanship aimed at hoodwinking the pubic of government commitment to UHC.
Hoodwinked
It is our opinion that investments in health workforce, health technologies and any of the other five pillars of a responsive health system are better taken care of by the national government. Measures like NHIF premium payments appear to serve politics more than any public good.
First, the majority of payments under NHIF come from premiums paid by the insured, you and me. The four billion students scheme isn’t even 10% of total premiums collected by NHIF per year. Purely on these proportions, the government is a minor shareholder in Kenya’s UHC journey.
Still, some might argue that this allocation opens a path to differentiated care for adolescents.Maybe, but only until the realization that the students cover leaves out pregnant teens.
In our view, their vulnerability, as teens and pregnant, should serve as impetus for differentiated care, but in this case, it doesn’t. The cited article points out that pregnant teens could be better served by the Linda Mama program. Not so we contend.
Pregnant, Scared, Alone and Left Out
First, timely enrollment by this demographic is likely to limited. Their access to a mobile phone, lack of national ID and even actionable information my limit their ability to enroll in advance, thus missing out on the free service. Principally, this creation of another level of eligibility might deter access, negating universal health care.
The layering of bureaucracy, as in this example, is our primary contention to the view that governments (county or national) paying NHIF premiums leads to UHC. Bureaucracy breeds inefficiency manifest as corruption, poor management, wastage of resource and ballooning of administrative costs . Every additional layer of bureaucracy raises the risk of sub-optimal health system outputs.
Thus, in the paradigm of allocation efficiency, we have to ask: Would have the national government better served by incremental increases in financing its functions as envisioned in schedule four of the constitution? This question also bedevils the actions of county governments in paying NHIF premiums.
Why County Governments Have Universal Health Care All Wrong With NHIF Premium Payments
Would county governments better realize their goals by dropping this populist policy? The me-too bug has more county governments allocate scare shillings fulfilling a role that they can’t see to its logical conclusion. Maybe county health departments should emulate a model from a county in central Kenya county.
In this county , mobile health technology is being utilized to encourage NHIF enrollment. Add no additional cost, community health workers encourage households to enroll into NHIF. This happens alongside collection of routine household health data during their monthly visits.
This innovative approach avails funds for the county government to fulfill its obligations as per schedule 4 of the Kenyan constitution 2010. Moreover, it also nudges the population towards involvement in achieving UHC by encouraging part payments of premiums.
More Solutions on How County Governments Can Better Contribute to UHC Agenda
Given our justifications on why the national government should hold the preserve for macro investments in healthcare, would it be prudent for county governments to bear the cost of intermediate concerns? Like ensuring policy framed by the national government on what we’ve termed as avant-garde intermediary concepts is implemeneted? Approaches that oil the wheels of UHC such as the Kenya Quality Model for Health.
We opine that such an approach would be feasible within county government budgets. Moreover, it would see county health departments improve the state of public facilities from monies saved.
What if Kenya’s Private Health Sector Was Facilitated to Fill Gaps in WHO Pillars of a Responsive Health System?
In such a scenario, however tempting, engaging the Kenya private health sector could stymie the spirit of universal health care. This is because the need to recover costs and make gains on capital would be at cross-hairs with delivering health care to all, whilst preventing financial ruin, as envisioned by UHC.
You only have to look at the telecommunications sector to appreciate the inherent risk of private players owning and developing key infrastructure. A long standing feud that pits the country’s leading telecommunications companies on monopolistic tendencies by the leading provider can be traced to such moves. A good example is the long drawn battle over deployment of 4G LTE network in Kenya.
In health, the Kenyan government has been accused of encouraging monopolistic ambitions by private health care providers through skewed payments of NHIF premiums. A KMPDU official was once quoted offering numbers that point at inequitable payment of NHIF premiums. The private sector which serves less than 10% of the population receives more than 50% of NHIF reimbursements. India, a popular destination for medical tourism for Kenyans, gets half of what remains. Public sector hospitals, burdened by inadequacies whilst treating the majority, have to deal with the scraps.
You then have to ask, will mass NHIF payments lead to universal health care? Some have labeled NHIF the difficult path to UHC. Others have called an alternative, the popularly termed Ngilu Health Bill as a more plausible path. Meanwhile, Kenyans continue to suffer from the double jeopardy where more money results in dwarf improvements in their health.
It must appreciated also that even satisfactory NHIF enrollment would not automatically mean attainment of UHC. While health financing is a key driver of UHC, lessons from around the world urge tailoring of solutions as there is no one fits all solution.
Universal Health Insurance is Not Universal Health Care
Obamacare sought to deliver UHC by bridging the gap between insured and uninsured Americans. Its key innovation was the introduction of a regulated market place for health insurance. In this regulated space, Americans without employer health insurance could purchase affordable plans. Through this market place,the health of tens of millions of Americans who didn’t qualify for Medicaid or Medicare was secured.
Once again politics got in the way and confusion reigned. Nonetheless, even amidst the confusion, consensus continues to builds that such a strategy aimed at diversifying the pool of financiers of health towards a multiplayer system may be beneficial to UHC in some contexts.
The Case For A Kenyan Health Insurance Market Place Inspired By The Obamacare Model
By all measures, NHIF is being sold in a market with other health insurance plans distinct from it. Given this, observers, propose the design of a health financing model, fit for Kenya’s UHC ambitions, should echo Obamacare.
The national government could sponsor laws and policy to create such a market place. NHIF would have to make better use of the 15% of premiums set aside for administrative costs. Manage these costs and allocate more to sell itself as the ideal health insurance product. The resultant competition could lead to better offerings of health insurance products for Kenyans. County governments would use their collective power through the Council of Governors to negotiate for better deals for their workers.
Beyond that we must acknowledge that “national” does not mean “universal”. Neither is universal insurance equal to universal health care. Burke, Normand, Barry and Thomas in their paper posit the three dimensions of UHC as:
- Breadth: coverage for the entire population.
- Scope: coverage of the full spectrum of quality health services according to need; and
- Depth: coverage of the full costs of health services.
How does NHIF Supa Cover perform against these yardsticks?
What is NHIF Supa Cover? + Why It Should Not Be Confused For Universal Health Care
On the 21st of November 2016, NHIF’s twitter handle carried a leading question in a poll on NHIF Supa Cover. The question hinted at what Supa Cover entailed. It was explicit in directing those who chose to partake the poll, on their experience with Supa Cover. Telling it was then, that the most popular response was : What is NHIF Supa Cover?
NHIF SUPA COVER entails our new and improved benefits package for both IN and OUT patient medical cover. What is your experience?
— NHIF Kenya (@nhifkenya) November 21, 2016
That exactly six months later, on 20th April of 2017, the NHIF CEO Geoffrey Mwangi, in what appeared to be bought media time, took the trouble to answer a lot of scripted questions on prime time TV, might have been a direct response to the Twitter poll. Kenyans, here is what the CEO had to say:
In politest of terms, NHIF Supa Cover is brand differentiation. On the other end of the scale, it’s a marketing gimmick. Though comprehensive through its offerings on inpatient, out patient, evacuation and referral health coverage, it is easy to pick ‘colorful language’ meant to mask the depth of its benefit package.
Before you label this position as an unfair, we have to consider the nuances. Like what does universal health care entail? From the Burke et, al. paper above, NHIF does deepen Kenya’s universal health care offerings, but grossly falls short.
Beyond NHIF Supa Cover
For instance, a surgical cover of half a million Kenyan shillings can afford one only so much protection from financial ruin from ill health. It can only offer access to full spectrum of quality health services to a point in public health facilities. Our public facilities, where most of us are served, are ill equipped in terms of health inputs. Most are yet to embrace health care delivery approaches (QI, design thinking , etc). With thee two handicaps, it is wishful thinking to expect them to offer the highest attainable standard of care.
The following TV report does well to highlight NHIF Supa Cover failures and successes. We can only wonder on the allocation, production and technical efficiency of the government’s zeal in fronting Supa Cover as UHC. It is clear that Kenya’s UHC quest would require much more in inputs than a national cover.