The NHIF nightmare in Kenya

Like most government operated services, the NHIF insurance cover doesn’t fail to disappoint.  It’s the most advertised. The most heard of. The cheapest for some. The most expensive for others. 

Despite endeavoring to bridge the gap in access to quality healthcare between the haves and the have-nots in Kenya, this insurance scheme falls miles short of this goal. The gap in the quality of healthcare enjoyed by the low premium contributors and the “comprehensive cover” contributors can be seen from the moon.  The reason for this, is a secret both NHIF and contracted hospitals have guarded, beyond the ear of the unsuspecting patient.

The NHIF Nightmare

How NHIF Works

Collection of Premiums

First, we need to delve into how the National Health Insurance Fund ( NHIF) works. Premiums are collected from basically all government employees, the amounts being approximately proportional to how much you earn or job group. For example, employees earning salaries above ksh.  100, 000 are deducted ksh. 1700 towards the fund.  

Thousands of private institutions and businesses also remit contributions for their employees to the fund, mostly, directly from the salaries. The amounts deducted from these employees range mostly between ksh 500 to ksh 1000. The last group belongs to the self-employed citizen who contributes ksh. 500 per month.  Various amendments are made from time to time in the contribution amounts from different groups of Kenyans.

Insurance Schemes Provided

NHIF then offers different covers for different groups according to how much they contribute towards the scheme. At least, mostly. The Two most common covers are Free For Service (FFS), commonly called the comprehensive cover, and The National scheme mostly assigned to the “last group” we mentioned above, majority of the teachers and most employees remitting less than ksh 1500 also belong to the national scheme. Most employees paying beyond this get the FFS cover.

Teachers are also covered by other insurance companies which explains why NHIF drops them down on the floor.

The National Police Service and the Kenya Police Service receive a unique kind of cover. A kind of small brother to the FFS. NHIF assures them that they have a comprehensive cover, and they would easily receive a massage for free if hospitals offered it. The truth is, their outpatient limits are fixed depending on the contract made with the hospital visited. These outpatient limits are capped at as low as Ksh. 2000 in some level  4 hospitals, an amount that may not cover a Thyroid Function Test alone.  

Ownership of NHIF

NHIF is owned and run by the Goverment of Kenya as one of the Govermenment parastatals to provide health coverage to all registered Kenyans.

Categories of NHIF Facilities

NHIF facilities are divided into three categories:

  • Contract A :Government Facilities
  • Contract B: Faith Based and medium sized private facilities
  • Contract C: High-cost Private facilities

How long it takes for NHIF to be active after Registration

For Employed citizens, it takes 1 month for the NHIF cover to become active. It takes 2 months for unemployed Citizines’ cover to be active as per the time of writing of this.

How long it takes for NHIF dependants to be active or covered

It takes 28 days for the dependants to be covered for NHIF services after they are added by a member. Its always best to add dependants immediately after registration for the service.

Disadvantages of NHIF

Why NHIF patients are asked to buy drugs or pay for tests

For the National Scheme patients, NHIF has contracts with some hospitals that allow it to pay a fixed amount per month for outpatient visits, for example, ksh 100 (a real amount paid to certain hospitals) per month for a contributor as at 2023. This amount is supposed to pay for services for the contributor and the dependents regardless of how many times they visit the hospital. This is the reason why such patients are asked to buy drugs by various private facilities and are denied basic tests or asked to pay for them from their own pockets.

For public facilities, the tests and the drugs are simply not available or in shortage despite getting additional funds from governments and other organizations. This is because the amounts remitted by NHIF for these patients cannot even cover a third of the cost of services offered to them on average, making the hospitals unable to purchase supplies for their next visit.

This, is also the reason why National Scheme patients hop from one hospital to another every few months hoping that at least they will get a test, drugs or better services without success.  Because the next hospital receives the same peanuts for their cover. 

Why NHIF remits inadequate funds for National Scheme Patients

NHIF assumes, when contracting hospitals, that by paying a fixed amount for every “national scheme” card registered to a hospital, the hospital will use the amounts from those who don’t visit during the year to cover for those who do. In truth almost all card holders or their dependents find a reason to visit the hospital during the year. In the end, the scheme is a massive loss to any facility that doesn’t ask the patients to top up in cash or buy drugs outside the facility.

The reason for low NHIF cash payouts to hospitals for National Scheme Patients emanates from the amounts these clients pay to NHIF. Ksh 500 per month (Ksh 6,000 per year) cannot buy any sensible insurance cover on this planet. Not even double that. It’s even surprising that NHIF can pay for admissions and surgeries from the pool of funds, thanks to its non-profit nature and the large number of contributors

Why NHIF patients are more frequently admitted unnecessarily

Other private facilities have found a workaround, by admitting the card holder for sneezing twice in order to cover for the cetirizine. This is because the amounts remitted by NHIF for admitted patients is slightly higher, approximately ksh. 3000 every 24 hours for level 4 facilities as observed at the time of writing this. This is also among the lowest of all medical insurance companies.

Other than the numerous rumors of NHIF scandals, disappearing funds and billionaire cleaners at the institution, the customer service here is the most notorious.  They know no emergency. Approvals even for emergency procedures, tests and imaging can find the patient long buried and forgotten. These procedures if done by a hospital before the approval may not be approved and therefore, may not be paid for, counting as a loss.

To give credit where it is due, the NHIF has enabled a good number of patients to access procedures they would never have afforded in their lifetime. It is one of the greatest ideas from the Kenyan government, just executed the Kenyan way.

Other Reads: Here are the most affordable alternatives to the NHIF

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