The National Health Insurance Fund (NHIF) has rolled out a set of changes that have taken effect starting July 1. 

NHIF has increased hospital refunds by 12 per cent. It will also pay for 549 surgical procedures up from 292.

The new benefits take effect after the commencement of the NHIF benefits package for the 2022/2024 contracting cycle, effective from 1st July 2022.

The new contract includes features that accommodate the recommendations of members and contracted healthcare providers.

They include;

1. Standardisation of reimbursement rates across all healthcare providers as per the Kenya Essential Package for Health (KEPH) levels of care.
2. The contracts have been categorised into two: Comprehensive (walk in and walk out) within the scope of cover and non-comprehensive.
3. Expanded scope that covers medical outpatient, inpatient, cancer cenefits, surgical benefits, early diagnosis and early optimised management.
4. Additional benefits package, the mental and behavioural health benefits package, has been enhanced due to the population-based survey on the increasing need for specialised mental and behavioural health services.
5. NHIF Members will access services in over 7,800 healthcare providers across the country.

The Government initiated a raft of reforms that would transition and position the Fund as a strategic purchaser of healthcare services to ensure sustainability and affordability of NHIF.

The new changes included the digitalization of NHIF processes, restructuring and realignment of the structure, benefits design, and amendment of the NHIF Act.

The state has also put in place some strategies to ensure that this objective is realised. Among these strategies is ensuring that all Kenyans have the NHIF.

 According to recent data from NHIF, the current membership is 14.3 million principal members, and 18.6 million dependents, totaling 32.9 million beneficiaries. This is 69 per cent of the total population of 47 million Kenyans.

However, only 44.6 percent (6.3 million members) are active. The active ones mostly need sustained treatment as others come in on a need basis.

NHIF CEO Peter Kamunyo said the trend has put a strain on available resources  and is thus unsustainable.

According to the amended NHIF Act, all Kenyans above 18 years should be registered as NHIF members.

The Act has provided for mandatory contributions by all those who can afford to pay for their health insurance while the National Government will identify and support indigents and vulnerable households.

Further, Dr. Kamunyo urged the government to ensure that there are sufficient healthcare services.

The amended Act offers NHIF an opportunity to be creative in terms of engagement for strategic purchasing of healthcare services.

“With the change of name, from National Hospital Insurance Fund to National Health Insurance Fund, the Fund can now contract different healthcare providers besides hospitals. They include laboratories, consultants, pharmacies, hospices, and healthcare professionals,” Mr. Kamunyo said.

Further, he said that plans are underway to bring forth a pharmacy benefit package that aims at bringing the cost of medicines lower and accessible in contracted facilities.

According to the CEO, the major reasons why the medical bills hike are diagnostics and medication parts.

“A long-term strategy to control and lower the costs especially related to non-communicable diseases is by partnering with pharmaceutical manufacturers and distributors to ensure strategic purchasing for efficiency and value for money for NHIF beneficiaries,” Mr. Kamunyo said.

He said that this can be done by ensuring that the prices of drugs are slashed, especially those that fit within the NHIF benefit packages.

Further, he said the partnership between the pharmaceutical manufacturers and distributors will support the development and establishment of a tailored pricing and reimbursement system that will enable efficient resource utilisation.

Engagement with counties is also key in ensuring that the UHC is attained, he said.

“There is a need to look at how to increase capacity in public facilities as this will ensure access to most beneficiaries,” Mr. Kamunyo said.

“NHIF has contracted 7,666 healthcare providers (HCPs), 72 percent of which are public facilities. Providing incentives to county facilities such as the current plan by NHIF to standardise reimbursement across all HCPs will go a long way in attaining UHC.”

The ripple effect is improved quality and continuation of care that will impact the country’s pricing of healthcare services. But most importantly, data harvesting will play a key role in decision-making.