Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage

Examining national health insurance fund members' preferences and trade-offs for the attributes of contracted outpatient facilities in Kenya: A discrete choice experiment

Patient choice of health facilities is increasingly gaining recognition for potentially enhancing the attainment of health system goals globally. In Kenya, National Health Insurance Fund (NHIF) members are required to choose an NHIF-contracted outpatient facility before accessing care. Understanding their preferences could support resource allocation decisions, enhance the provision of patient-centered care, and deepen NHIF's purchasing decisions. We employed a discrete choice experiment to examine NHIF members' preferences for attributes of NHIF-contracted outpatient facilities in Kenya. We developed a d-efficient experimental design with six attributes, namely availability of drugs, distance from household to facility, waiting time at the facility until consultation, cleanliness of the facility, attitude of health worker, and cadre of health workers seen during consultation. Data were then collected from 402 NHIF members in six out of 47 counties. Choice data were analysed using panel mixed multinomial logit and latent class models. NHIF members preferred NHIF-contracted outpatient facilities that always had drugs [β=1.572], were closer to their households [β=-0.082], had shorter waiting times [β=-0.195], had respectful staff [β=1.249] and had either clinical officers [β=0.478] or medical doctors [β=1.525] for consultation. NHIF members indicated a willingness to accept travel 17.8km if drugs were always available, 17.7km to see a medical doctor for consultation, and 14.6km to see respectful health workers. Furthermore, NHIF members indicated a willingness to wait at a facility for 8.9 hours to ensure the availability of drugs, 8.8 hours to see a doctor for consultation, and 7.2 hours to see respectful health workers. Understanding NHIF member preferences and trade-offs can inform resource allocation at counties, service provision across providers, and purchasing decisions of purchasers such as the recently formed social health insurance authority in Kenya as a move towards UHC.

"If We Manage Early, We Can Get It Right": A Descriptive Study of Healthcare Workers' Experiences Managing Sepsis at a Kenyan Referral Hospital

Background and objectives Sepsis and septic shock are conditions of high mortality across the globe. Despite the efforts of the Surviving Sepsis Campaign, improvements in outcomes for patients with sepsis and septic shock have been mostly seen in high-income countries (HICs), leaving low- and middle-income countries (LMICs) to bear most of the global disease burden. This paper utilizes a socio-ecological model to describe the lived experiences of local healthcare workers treating sepsis and septic shock at a large referral hospital in Western Kenya. These perspectives shed light on barriers and strengths in care, gaps in knowledge, and areas of high-yield improvement. Materials and methods This is a descriptive analysis focused on providers caring for patients with sepsis and septic shock. Twenty-seven interviews with a wide variety of purposively sampled patient-facing and ancillary medical staff were performed. Concurrent thematic analysis took place as interviews were being conducted. The concept presented was inductively and deductively reasoned and analyzed using a socio-ecological framework. We chose to present three levels of influence on the individual provider. Results We present our results using a socio-ecological model. At the health system level, we found that most patients do not have healthcare coverage, which drives up out-of-pocket expenses for individuals. At the hospital level, capacity limits, particularly personnel shortages and small intensive care unit (ICU) spaces, influence care. At the interdisciplinary level, relationships between providers and other members of the healthcare team can present challenges. Lastly, these system-, hospital-, and interdisciplinary-level challenges make guideline adherence difficult and not always feasible for individual providers. Conclusions To our knowledge, this is the first study to give voice to local providers treating patients with sepsis at a referral center in Western Kenya. By presenting findings in the socio-ecological model, we are able to organize potential interventions for the improvement of care at various levels. We found high-yield areas for improving care including establishing clear protocols for task assignments and communication, increasing the number of trained personnel both in the general wards and in the ICU, and, on a broader scale, advocating for expanded healthcare coverage for all Kenyans. This work provides a framework for further investigation into elements of sepsis care and the creation of locally relevant treatment guidelines in sub-Saharan Africa and across LMICs.

Challenges and Opportunities of Universal Health Coverage in Africa: A Scoping Review

BACKGROUND

Universal health coverage (UHC) is a global priority, with the goal of ensuring that everyone has access to high-quality healthcare without suffering financial hardship. In Africa, most governments have prioritized UHC over the last two decades. Despite this, the transition to UHC in Africa is seen to be sluggish, with certain countries facing inertia. This study sought to examine the progress of UHC-focused health reform implementation in Africa, investigating the approaches utilized, the challenges faced, and potential solutions.

METHOD

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, we scoped the literature to map out the evidence on UHC adoption, roll out, implementation, challenges, and opportunities in the African countries. Literature searches of the Cochrane database of systematic reviews, PUBMED, EBSCO, Eldis, SCOPUS, CINHAL, TRIP, and Google Scholar were conducted in 2023. Using predefined inclusion criteria, we focused on UHC adoption, rollout, implementation, and challenges and opportunities in African countries. Primary qualitative, quantitative, and mixed-methods evidence was included, as well as original analyses of secondary data. We employed thematic analysis to synthesize the evidence.

RESULTS

We found 9633 documents published between May 2005 and December 2023, of which 167 papers were included for analysis. A significant portion of UHC implementation in Africa has focused on establishing social health protection schemes, while others have focused on strengthening primary healthcare systems, and a few have taken integrated approaches. While progress has been made in some areas, considerable obstacles still exist. Financial constraints and supply-side challenges, such as a shortage of healthcare workers, limited infrastructure, and insufficient medical supplies, remain significant barriers to UHC implementation throughout Africa. Some of the promising solutions include boosting public funding for healthcare systems, strengthening public health systems, ensuring equity and inclusion in access to healthcare services, and strengthening governance and community engagement mechanisms.

CONCLUSION

Successful UHC implementation in Africa will require a multifaceted approach. This includes strengthening public health systems in addition to the health insurance schemes and exploring innovative financing mechanisms. Additionally, addressing the challenges of the informal sector, inequity in healthcare access, and ensuring political commitment and community engagement will be crucial in achieving sustainable and comprehensive healthcare coverage for all African citizens.

Moving toward universal health coverage with a national health insurance program: A scoping review and narrative synthesis of experiences in eleven low- and lower-middle income countries

Universal Health Coverage (UHC) aims to provide access to quality health services to all while avoiding financial hardship. Strategies can include establishing a national health insurance scheme (NHIS). However, variations in the progress exist among countries with an NHIS. This study assesses strategies adopted in low- and lower-middle-income countries (LLMICs) with an NHIS to expand UHC. The research entailed a descriptive, qualitative review of the literature on LLMICs that have implemented an NHIS. PRISMA guidelines were used to identify studies and reports. A total of 569 texts were identified from 4 databases. A total of 78 texts were included, spanning 7 countries from Sub-Saharan Africa and 4 from Asia. The search was conducted in March 2023 and updated in April 2024. An analytical framework was used to systematically collect, analyze, and synthesize key features to review healthcare financing mechanisms and coverage dimensions. Countries generate revenue through various public and private means, including taxes, premiums, and out-of-pocket payments. Some have consolidated revenue streams into a single pool for efficiency, while others maintain separate pools. Healthcare services are procured from public and private providers, differing by country. Fee-for-service is the prevalent payment method, but capitation systems have been attempted to control expenses. Population coverage depends on whether enrollment in an NHIS is mandatory or voluntary and on its enforcement. Service provision can be comprehensive and universal or can vary with specific schemes. Mechanisms to avoid financial hardship can involve premium exemptions or subsidies. Progressing toward UHC requires addressing issues of financial sustainability, cost-containment, enrollment expansion, financial protection, and health equity. While policy options are context-specific, this review showcased experiences for other LLMICs committed to UHC with an NHIS. Recommendations on health financing include increasing the allocation of tax revenues to the insurance scheme, merging risk pools, and adopting strategic purchasing.

Policy Options for Contributory Health Insurance Schemes in Low and Lower-Middle Income Countries to Enable Progress Towards Universal Health Coverage

The promise of contributory health insurance to generate additional, self-sustaining funding for the health sector has not been achieved in many low- and lower-middle-income countries. Instead, contributory health insurance has been found to exacerbate inequities in access to health care because entitlements are linked to contributions. For these countries with contributory health insurance schemes, with separate institutional arrangements for revenue collection and purchasing, that operate alongside budget-funded and other health financing schemes, it is usually not politically or technically feasible to reverse or eliminate these arrangements even when they fragment the health system. We propose three complementary policy options for countries in this difficult position to enable progress towards UHC: (1) Merge existing schemes into a single scheme (or fewer schemes) to consolidate pooling and purchasing functions. (2) Build on what they have by: reducing reliance on contributions by increasing budget transfers; using existing revenue collection mechanisms to allow the insurance agency to focus on the purchasing function; and strengthening insurance agencies' operational capacity for purchasing. (3) Reframe the insurance agency's role within the overall health system, rather than treating it as a distinct system by: unifying data collection and analysis for all patient visits irrespective of scheme membership, and universalizing core benefits across the population. We urge countries to review the patchwork of schemes and avoid worsening fragmentation that compromises health system performance. Countries can then create a strategy to expand coverage more equitably in a sequential manner, while consolidating institutional capacity for purchasing and unifying data systems.

Health Reforms in Pursuit of Universal Health Coverage: Lessons from Kenyan Bureaucrats

In this commentary, two members of the technical teams that led Kenyan health reforms reflect on progress made in the country's journey toward universal health coverage during President Uhuru Kenyatta's second term (2017 to 2022). The authors discuss how key decisions were made while balancing multiple considerations such as: maintaining the technical fidelity of the reforms to achieve objectives, accounting for the context of previous reforms, and making necessary trade-offs between technical and political pressures. They share three lessons, contextualized with African proverbs, for others implementing health reforms. First: "The person who does not seize today's opportunity will also be unable to seize tomorrow's opportunity"-that is, act quickly when opportunities arise. Second: "The person who cannot dance will say, 'The drum is bad!'" This implies that naysayers, especially those who are not part of technical teams, may not understand the reasons behind certain decisions or trade-offs. Reformers must balance different needs, including responding to varied opinions, taking urgent action, generating timely results, making technically sound decisions, and getting the design right. And third: "A bird that flies from the ground onto an anthill does not know that it is still on the ground." This proverb reminds us to not mistake short-term gains for the achievement of long-term goals. Kenya continues to enjoy unprecedented political will to pursue health reforms. For other reformers lucky enough to have political support, the final advice to the technical teams in the driver's seat is to design for delivery … and then start!

Social Health Insurance for Universal Health Coverage in Low and Middle-Income Countries (LMICs): a retrospective policy analysis of attainments, setbacks and equity implications of Kenya's social health insurance model

OBJECTIVES

To analyse the potential of the Social Health Insurance (SHI) model to support the achievement of Universal Health Coverage (UHC) in Low and Middle-Income Countries (LMICs) through a policy analysis case study of Kenya's National Health Insurance Fund (NHIF).

DESIGN

We used an adaptation of the policy triangle framework to perform a retrospective policy analysis of Kenya's NHIF, drawing from semistructured interviews and analysis of published documents and grey literature.

SETTING

We focused on Kenya's NHIF as a case study.

PARTICIPANTS

We conducted 21 interviews with key stakeholders including policy experts, healthcare providers and formal and informal sector workers. We then triangulated the interview findings with document analysis.

RESULTS

Only 17% of Kenya's population are currently covered by the SHI as of 2023. Only 27% of the informal economy is covered by the NHIF, implying very low uptake and/or retention rates. We found little stakeholder engagement in the policy implementation process and minimum adoption of expert advice. Our analysis suggest that political affiliations and positions of power heavily influence health financing policies in Kenya. Purchasing and payment of healthcare was found to be riddled with inefficiencies, including slow bureaucratic reimbursement procedures, little expertise by rural hospital clerks, misappropriations and favouritism of specific private healthcare providers. We also found that group-based parallel schemes and penalty payments for defaulted premiums widened the existing inequity gap in healthcare access.

CONCLUSION

Although the SHI system is perceived to increase coverage and the quality of health services in Kenya, substantial structural and contextual challenges appear to deter its suitability to finance the attainment of Universal Health Coverage. From Kenya's experience, we identify little informal sector participation, inefficiencies in purchasing and payment of healthcare services, as well lack of political goodwill, as key bottlenecks for the implementation of SHI schemes in LMICs. LMICs adopting SHI need to also implement co-financing arrangements that do not impose on the population to co-finance, strategic purchasing systems, political goodwill and good governance for the SHI systems to be beneficial.

Seeking and receiving hypertension and diabetes mellitus care in Tanzania

The rapid increase in chronic non-communicable diseases (NCDs) poses a major challenge to already strained health systems in sub-Saharan Africa. This study investigates the factors associated with seeking and receiving NCD services in Tanzania, using a household survey and client exit interview data from Kilombero and Same districts. Both districts are predominantly rural, with one semi-urban area called Ifakara town and Same town. Of the 784 household survey respondents, 317 (40.4%), 37 (4.7%), and 20 (2.5%) were diagnosed with hypertension, diabetes mellitus, and other NCDs, respectively, of whom 69% had sought care in the past six months. After controlling for covariates, those enrolled in the National Health Insurance Fund (NHIF) and those who received a user fees waiver were more likely to use health services. However, even when NCD patients managed to access the care they needed, they were likely to receive incomplete services. The main reason for not receiving all services at the health facility visited on the day of the survey was drug stock-outs. Among health care users, those registered with the improved Community Health Funds (iCHF) were less likely to receive all prescribed services at the health facility visited than uninsured patients. The findings of this study highlight the need to strengthen both primary care and social health protection systems to improve access to needed care for NCD patients.

Evaluating the effectiveness of the National Health Insurance Subsidy Programme within Kenya's universal health coverage initiative: a study protocol

BACKGROUND

Low-income and middle-income countries, including Kenya, are pursuing universal health coverage (UHC) through the establishment of Social Health Insurance programmes. As Kenya rolls out the recently unveiled UHC strategy that includes a national indigent cover programme, the goal of this study is to evaluate the impact of health insurance subsidy on poor households' healthcare costs and utilisation. We will also assess the effectiveness and equity in the beneficiary identification approach employed.

METHODOLOGY AND ANALYSIS

Using a quantitative design with quasi-experimental and cross-sectional methods, our matched cohort study will recruit 1350 households across three purposively selected counties. The 'exposure' arm, enrolled in the UHC indigent programme, will be compared with a control arm of eligible but unenrolled households over 12 months. Coarsened exact matching will be used to pair households based on baseline characteristics, analysing differences in expenses and catastrophic health expenditure. A cross-sectional design will be employed to evaluate the effectiveness and equity in beneficiary identification, estimating inclusion errors associated with the subsidy programme while assessing gender equity.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Scientific and Ethics Review Unit at Kenya Medical Research Institute, with additional permissions sought from County Health Departments. Participants will provide written informed consent. Dissemination strategies include peer-reviewed publications, conference presentations and policy-maker engagement for broad accessibility and impact.

Re-envisioning contributory health schemes to achieve equity in the design of financial protection mechanisms in low- and middle-income countries

Universal health coverage has emerged as a global health priority, requiring that financing strategies that ensure low-income and medically and financially at-risk individuals can access health services without the threat of financial catastrophe. Contributory financing schemes and social health insurance (SHI) schemes, in particular, predominate in low- and middle-income countries (LMICs), despite evidence that suggests the most vulnerable remain excluded from such schemes. In this commentary, we discuss the need to re-envision schemes to prioritize equity, offering 3 concrete recommendations: adopt participatory designs for the co-design of schemes with beneficiaries, establish linkages between contributory financial protection schemes with economic empowerment initiatives, and prioritize the needs and preferences of beneficiaries over political expediency. Co-design alone does not necessarily translate into more equitable schemes, underscoring the need for greater monitoring and evaluation of these schemes that consider differential impacts across contexts and subgroups. In doing so, SHI schemes can be both attractive and accessible to populations that have long been excluded from financial protections in LMICs, acting as 1 channel in a broader financing strategy to achieve universal health coverage.

The path to universal health coverage in five African and Asian countries: examining the association between insurance status and health-care use

Despite major efforts to achieve universal health coverage (UHC), progress has lagged in many African and Asian countries. A key strategy pursued by many countries is the use of health insurance to increase access and affordability. However, evidence on insurance coverage and on the association between insurance and UHC is mixed. We analysed nationally representative cross-sectional data collected between 2022 and 2023 in Ethiopia, Kenya, South Africa, India, and Laos. We described public and private insurance coverage by sociodemographic factors and used logistic regression to examine the associations between insurance status and seven health-care use outcomes. Health insurance coverage ranged from 25% in India to 100% in Laos. The share of private insurance ranged from 1% in Ethiopia to 13% in South Africa. Relative to the population with private insurance, the uninsured population had reduced odds of health-care use (adjusted odds ratio 0·68, 95% CI 0·50-0·94), cardiovascular examinations (0·63, 0·47-0·85), eye and dental examinations (0·54, 0·42-0·70), and ability to get or afford care (0·64, 0·48-0·86); private insurance was not associated with unmet need, mental health care, and cancer screening. Relative to private insurance, public insurance was associated with reduced odds of health-care use (0·60, 0·43-0·82), mental health care (0·50, 0·31-0·80), cardiovascular examinations (0·62, 0·46-0·84), and eye and dental examinations (0·50, 0·38-0·65). Results were highly heterogeneous across countries. Public health insurance appears to be only weakly associated with access to health services in the countries studied. Further research is needed to improve understanding of these associations and to identify the most effective financing strategies to achieve UHC.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

The impact of COVID-19 on health financing in Kenya

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Effects of healthcare financing policy tools on health system efficiency: Evidence from sub-Saharan Africa

Background

Evidence shows high levels of catastrophic and impoverishing healthcare expenditure among households in sub-Saharan Africa (SSA). The way healthcare is financed has an impact on how well a health system performs its functions and achieves its objectives. This study aims to examine the effect of healthcare financing policy tools on health system efficiency.

Method

The study classifies 46 sub-Saharan African (SSA) countries into four groups of health systems sharing similar healthcare financing strategies. A two-stage and one-stage stochastic frontier analysis (SFA) and Tobit regression techniques were employed to assess the impact of healthcare financing policy variables on health system efficiency. Data from the selected 46 SSA countries from 2000 to 2019 was investigated.

Results

The results revealed that prepayment healthcare financing arrangements, social health insurance, mixed- and external-financing healthcare systems significantly enhance health system efficiency. Reliance on a single source for financing healthcare, particularly private out-of-pocket payment reduces health system efficiency.

Conclusion

For policy-making purposes, health care systems financed through a mix of financing arrangements comprising social health insurance, private, and public funding improve health system efficiency in delivering better health outcomes as opposed to depending on one major source of financing, particularly, private out-of-pocket payments.

The impact of health insurance enrollment on health outcomes in Kenya

BACKGROUND

The achievement of the global agenda on universal health coverage (UHC) is pivotal in ensuring healthy lives and promoting the well-being of all. However, achieving healthy lives and wellbeing of all has been hampered by the challenge of health care financing. As such, healthcare financing, through health insurance is gaining popularity in developing countries such as Kenya, in their pursuit to achieve universal health coverage. The primary purpose of health insurance and delivery is to improve health. However, there is a paucity of evidence on the effectiveness of health insurance in improving the health outcomes and health status of the Kenyan population. Therefore, this study aimed to analyze the impact of health insurance on health outcomes in Kenya.

METHODS

The study utilized the most recent nationally representative Kenya Integrated Household Budget Survey (KIHBS) 2015/16 dataset in order to analyze the impact of health insurance on health outcomes. The instrumental variable 2-stage least squares (IV 2SLS) and control function approach (CFA) estimation techniques were used to cater for potential endogeneity and heterogeneity biases present in ordinary least squares (OLS) estimators.

RESULTS

Health insurance enrolment leads to a reduction in mortality, thereby improving the health status of the Kenyan population, despite low levels of insurance uptake. However, the insured population experienced higher chronic illnesses and out-of-pocket (OOP) expenditures raising concerns about financial risk protection. The fact that health insurance is linked to chronic illnesses not only reinforces the reverse causality of health insurance and health status, but also that the effects of potential adverse selection strongly drive the strength and direction of this impact.

CONCLUSIONS

We conclude that health insurance enrolment reduces mortality and hence has a beneficial impact in promoting health. Health insurance coverage therefore, should be promoted through the restructuring of the National Hospital Insurance Fund (NHIF) fragmented schemes and by consolidating the different insurance schemes to serve different population groups more effectively and equitably. The government should revisit the implementation of a universal social health insurance scheme, as a necessary step towards UHC, while continuing to offer subsidies in the form of health insurance to the marginalized, vulnerable and poor populations.

Preferences of healthcare workers for provider payment systems in The Gambia's National Health Insurance Scheme

BACKGROUND

The Government of The Gambia introduced a national health insurance scheme (NHIS) in 2021 to promote universal health coverage (UHC). Provider payment systems (PPS) are strategic purchasing arrangements that can enhance provider performance, accountability, and efficiency in the NHIS. This study assessed healthcare workers' (HCWs') preferences for PPS across major service areas in the NHIS.

METHODS

A facility-based cross-sectional study was conducted using a probability proportionate to size sampling technique to select an appropriate sample size. Health care workers were presented with options for PPS to choose from across major service areas. Descriptive statistics explored HCW socio-demographic and health service characteristics. Multinomial logistic regressions were used to assess the association between these characteristics and choices of PPS.

RESULTS

The majority of HCW did not have insurance coverage, but more than 60% of them were willing to join and pay for the NHIS. Gender, professional cadre, facility level, and region influenced HCW's preference for PPS across the major service areas. The preferred PPS varied among HCW depending on the service area, with capitation being the least preferred PPS across all service areas.

CONCLUSION

The National Health Insurance Authority (NHIA) needs to consider HCW's preference for PPS and factors that influence their preferences when choosing various payment systems. Strategic purchasing decisions should consider the incentives these payment systems may create to align incentives to guide provider behaviour towards UHC. The findings of this study can inform policy and decision-makers on the right mix of PPS to spur provider performance and value for money in The Gambia's NHIS.

Medical debt during epidemics: A case for resolving the situation in low- and middle-income countries such as Kenya

This paper evaluates the problem of medical debt in Kenya during the COVID-19 pandemic. The medical debt problem is compounded during pandemics such as COVID-19 when patients seek treatment and end up in insurmountable debt because illnesses related to the pandemic are not covered by the Kenyan National Health Insurance Fund (NHIF), the public health coverage body under government control. As a result, discharged patients may be detained in hospitals and dead bodies are locked away in mortuaries, until relatives and friends fundraise and clear the bills. Apart from causing vulnerability, fear, and emotional stress among the poor, this practice leads to a growing lack of trust in the healthcare system, with patients deliberately avoiding hospitals whenever they suspect they have COVID-19. The resulting vicious cycle makes healthcare more inaccessible by limiting the choices that people may have. User fees, which were introduced in all public health facilities by the Kenyan government as part of a World Bank prescription for cost-sharing, normally affect more women than men. Although Kenya has implemented a general waiver system in public hospitals for those who cannot pay their medical bills, the process of obtaining this waiver can be burdensome, demeaning, and dangerous for the health of the patients. This undermines the government's commitment to the provision of equitable and affordable health care for the citizens. In this article, the problem of medical debt in Kenya is addressed as a multi-faceted problem drawing on issues of justice and fairness, human dignity, good governance, the interplay between global and local policies, as well as politics and law. It argues that it is in the best interest of Kenya and other African countries to ensure that public health coverage covers pandemics so that the majority poor can afford and access healthcare.

Examining the responsiveness of the National Health Insurance Fund to people living with hypertension and diabetes in Kenya: a qualitative study

OBJECTIVES

To assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya.

DESIGN, SETTING AND PARTICIPANTS

We carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach.

RESULTS

Study participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered.

CONCLUSION

Whereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF's benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened.

A health systems approach to critical care delivery in low-resource settings: a narrative review

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya

BACKGROUND

Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya.

METHODS

We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices.

RESULTS

We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%.

CONCLUSION

We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market.

Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

"It is like an umbrella covering you, yet it does not protect you from the rain": a mixed methods study of insurance affordability, coverage, and financial protection in rural western Kenya

Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage, affordability and financial risk protection provided by health insurance, especially for rural informal households, is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya.Methods We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 focus group discussions (FGDs) with community stakeholders in rural western Kenya. Health insurance status was self-reported and households were categorized into insured and uninsured. Using survey data, we calculated the affordability of health insurance (unaffordability was defined as the monthly premium being > 5% of total household expenditures), out of pocket expenditures (OOP) on healthcare and its impact on impoverishment, and incidence of catastrophic health expenditures (CHE). Logistic regression was used to assess household characteristics associated with CHE.Results Only 12% of households reported having health insurance and was unaffordable for the majority of households, both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP, with both insured and uninsured households reporting high OOP spending and similar levels of impoverishment due to OOP. Overall, 12% of households experienced CHE, with uninsured households more likely to experience CHE. Participants expressed concerns about value of health insurance given its cost, availability and quality of services, and financial protection relative to other social and economic household needs. Households resulted to borrowing, fundraising, taking short term loans and selling family assets to meet healthcare costs.Conclusion Health insurance coverage was low among rural informal sector households in western Kenya, with health insurance premiums being unaffordable to most households. Even among insured households, we found high levels of OOP and CHE. Our results suggest that significant reforms of NHIF and health system are required to provide adequate health services and financial risk protection for rural informal households in Kenya.

A new universalism? Universal health coverage and debates about rights, solidarity and inequality in Kenya

The rise of universal health coverage (UHC) as a global policy endorsed in the Sustainable Development Goals (SGDs) appears to signal new directions in global health as it introduces a progressive language of inclusion, solidarity and social justice and advocates the right of 'everyone' to access the healthcare they need 'without financial hardship'. Since 2018 the Kenyan government has attempted to widen access to healthcare by experimenting with free health care services and expanding health insurance coverage. Such progressive moves are, however, layered onto histories of healthcare, citizenship and state responsibility that in Kenya have been dominated by forms of exclusion, differentiation, a politics of patronage, and class inequality, all of which work against universal access. In this paper, we follow recent attempts to increase access to healthcare, paying particular attention to how a language of rights and inclusion circulated among "ordinary citizens" as well as among the health workers and government officials tasked with implementing reforms. Despite being clothed in a language of universalism, solidarity and inclusion, Kenya's UHC reforms feed into an already fragmented and struggling healthcare system, reinforcing differentiated, limited and uneven access to healthcare services and reproducing inequity and exclusions. In this context, reforms for universal health coverage that promise a form of substantial citizenship are in tension with Kenyans' experiences of accessing healthcare. We explore how, amid vocal concerns about healthcare costs and state neglect, the promises and expectations surrounding universal health coverage reforms shaped the claims people made to accessing care. While our informants were cynical about these promises, they were also hopeful. The language of universality and inclusion drew people's attention to entrenched forms of inequality and difference, the limits of solidarity and the gaps between promises and realities, but it also generated expectations and a sense of new possibilities.

Out-of-pocket payments during childbirth in Kenya under the free maternity services: Perspectives of mothers, healthcare workers and county officials

Background: This study seeks to determine the extent of women's out-of-pocket (OOP) payments for delivery under the free maternity policy (FMP).  Methods: We conducted a convergent parallel mixed-methods study using quantitative and qualitative data collection. The study was set in three facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved exit interview (EI) surveys with mothers (n = 553) who utilised FMP delivery services and focus group discussions (FGDs) with mothers who returned for postnatal visits (6, 10, and 14 weeks). There were 21 in-depth interviews (IDIs) with county officials and healthcare workers (HCWs). Quantitative data were analysed using descriptive statistics, while qualitative data were audio-recorded, transcribed and analysed using thematic analysis.  Results: Despite the FMP being free on paper, mothers incurred OOP payments in practice. The overall mean OOP payments incurred by mothers who underwent normal delivery was 9.50 USD (SD 8.20 USD), and caesarean section (CS) was 10.88 USD (SD 15.16 USD). The main cost drivers were transport, lack of adequate supply and medications, lack of policy clarity by health workers, failure to notify the NHIF office of available clients, and ultrasound scan services. While the OOP payments were not deemed catastrophic, some women perceived it as a barrier to care as they ended up using savings or selling their assets to meet the costs. There were no patient characteristics associated with OOP payments.  Conclusions: OOP payments during childbirth in Kenya place a considerable economic burden on mothers and their households. There is need to promote awareness of the policy and provide a sustainable form of transport, especially during emergencies, through collaboration with partners. Prioritising the supply of required medication used in maternal services in the universal health care benefits package to which Kenyan citizens are entitled, or sustainably financing the FMP is crucial.

Impact of community-based health insurance on healthcare utilisation and out-of-pocket expenditures for the poor in Senegal

OBJECTIVES

This study aims to assess the impact of the subsidised community health insurance scheme in Senegal particularly on the poor.

DESIGN AND SETTING

The study used data from a household survey conducted in 2019 in three regions, representing 29.3% of the total population. Inverse probability of treatment weighting approach was applied for the analysis.

PARTICIPANTS

1766 households with 15 584 individuals selected through a stratified random sampling with two draws.

MAIN OUTCOME MEASURES

The impact of community-based health insurance (CBHI) was evaluated on poor people's access to care and on their financial protection. For the measurement of access to care, we were interested in the use of health services and non-withdrawal from care in case of illness. To assess financial protection, we looked at out-of-pocket expenditure by type of provider and by type of service, the weight of out-of-pocket expenditure on household income, non-exposure to impoverishing health expenditure and non-exposure to catastrophic health expenditure.

RESULTS

The results indicate that the CBHI increases primary healthcare utilisation for non-poor (OR 1.36 (CI90 1.02-1.8) for the general scheme and 1.37 (CI90 1.06-1.77) for the special scheme for indigent recipients of social cash transfers), protect them against catastrophic (OR 1.63 (CI90 1.12-2.39)) or impoverishing (OR 2.4 (CI90 1.27-4.5)) health expenditures. However, CBHI has no impact on the poor's healthcare utilisation (OR 0.61 (CI90 0.4-0.94)) and do not protect them from the burden related to healthcare expenditures (OR: 0.27 (CI90 0.13-0.54)).

CONCLUSION

Our study found that CBHI has an impact on the non-poor but does not sufficiently protect the poor. This leads us to conclude that a health insurance programme designed for the general population may not be appropriate for the poor. A qualitative study should be conducted to better understand the non-financial barriers to accessing care that may disproportionately affect the poorest.

Acceptability of prepayment, social solidarity and cross-subsidies in national health insurance: A mixed methods study in Western Kenya

Introduction

Many low- and middle-income countries are attempting to finance healthcare through voluntary membership of insurance schemes. This study examined willingness to prepay for health care, social solidarity as well as the acceptability of subsidies for the poor as factors that determine enrolment in western Kenya.

Methods

This study employed a sequential mixed method design. We conducted a cross-sectional household survey (n = 1,746), in-depth household interviews (n = 36), 6 FGDs with community stakeholders and key informant interviews (n = 11) with policy makers and implementers in a single county in western Kenya. Social solidarity was defined by willingness to make contributions that would benefit people who were sicker ("risk cross-subsidization") and poorer ("income cross-subsidization"). We also explored participants' preferences related to contribution cost structure - e.g., flat, proportional, progressive, and exemptions for the poor.

Results

Our study found high willingness to prepay for healthcare among those without insurance (87.1%) with competing priorities, low incomes, poor access, and quality of health services, lack of awareness of flexible payment options cited as barriers to enrolment. More than half of respondents expressed willingness to tolerate risk and income cross-subsidization suggesting strong social solidarity, which increased with socio-economic status (SES). Higher SES was also associated with preference for a proportional payment while lower SES with a progressive payment. Few participants, even the poor themselves, felt the poor should be exempt from any payment, due to stigma (being accused of laziness) and fear of losing power in the process of receiving care (having the right to demand care).

Conclusion

Although there was a high willingness to prepay for healthcare, numerous barriers hindered voluntary health insurance enrolment in Kenya. Our findings highlight the importance of fostering and leveraging existing social solidarity to move away from flat rate contributions to allow for fairer risk and income cross-subsidization. Finally, governments should invest in robust strategies to effectively identify subsidy beneficiaries.

Medical debt during epidemics: A case for resolving the situation in low- and middle-income countries such as Kenya

This paper evaluates the problem of medical debt in Kenya during the COVID-19 pandemic. The medical debt problem is compounded during pandemics such as COVID-19 when patients seek treatment and end up in insurmountable debt because illnesses related to the pandemic are not covered by the Kenyan National Health Insurance Fund (NHIF), the public health coverage body under government control. As a result, discharged patients may be detained in hospitals and dead bodies are locked away in mortuaries, until relatives and friends fundraise and clear the bills. Apart from causing vulnerability, fear, and emotional stress among the poor, this practice leads to a growing lack of trust in the healthcare system, with patients deliberately avoiding hospitals whenever they suspect they have COVID-19. The resulting vicious cycle makes healthcare more inaccessible by limiting the choices that people may have. User fees, which were introduced in all public health facilities by the Kenyan government as part of a World Bank prescription for cost-sharing, normally affect more women than men. Although Kenya has implemented a general waiver system in public hospitals for those who cannot pay their medical bills, the process of obtaining this waiver can be burdensome, demeaning, and dangerous for the health of the patients. This undermines the government’s commitment to the provision of equitable and affordable health care for the citizens. In this article, the problem of medical debt in Kenya is addressed as a multi-faceted problem drawing on issues of justice and fairness, human dignity, good governance, the interplay between global and local policies, as well as politics and law. It argues that it is in the best interest of Kenya and other African countries to ensure that public health coverage covers pandemics so that the majority poor can afford and access healthcare.

The costs of complications after emergency gastrointestinal surgery in Kenya

BACKGROUND

The financial burden of surgery is substantial worldwide. Postoperative complications increase costs in high-resource settings, but this is not well studied in other settings. Our objective was to review the financial impact of postoperative complications.

METHOD

Patients undergoing emergency gastrointestinal operations at a center in Kenya were reviewed between January 2017 and June 2019. In a cost analysis, we ascertained the outcome of total hospital costs, adjusted for inflation, and converted to international dollars using purchasing power parities. Costs were analyzed for their association with a postoperative complication, defined using standardized criteria. We calculated the Africa Surgical Outcomes Study surgical risk scores and clustered for discharge diagnosis in a mixed-effects generalized linear model accounting for confounding factors related to costs and complications.

RESULTS

A total of 361 individuals had cost data available. The cohort had 251 men (69.5%) and 110 women (30.5%) with a median age of 41 years (interquartile range: 29-57 years). A total of 122 (33.8%) patients experienced a postoperative complication with an overall all-cause mortality rate of 10.5%. The median total cost of hospitalization was 1,949 (interquartile range: 1,516-2,788) international dollar purchasing power parities. When controlling for patient factors and diagnoses, patients who did not develop complications had costs of 2,119 (95% confidence interval 1,898-2,340) compared to costs of 3,747 (95% confidence interval 3,327-4,167) for patients who developed a postoperative complication, leading to a 77% increase of 1,628 international dollar purchasing power parities for patients with complications.

CONCLUSION

Our findings demonstrated a substantial financial burden generated by postoperative complications in patients undergoing emergency gastrointestinal operations. Reducing complications could allow cost savings, an important consideration in variable-resource settings.

Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi’s sarcoma in Kenya: a qualitative study

Background

Kaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal.

Methods

57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care.

Results

Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy.

Conclusion

Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.

Household access to non-communicable disease medicines during universal health care roll-out in Kenya: A time series analysis

Objectives

This study aims to describe trends and estimate impact of county-level universal health coverage expansion in Kenya on household availability of non-communicable disease medicines, medicine obtainment at public hospitals and proportion of medicines obtained free of charge.

Methods

Data from phone surveillance of households in eight Kenyan counties between December 2016 and September 2019 were used. Three primary outcomes related to access were assessed based on patient report: availability of non-communicable disease medicines at the household; non-communicable disease medicine obtainment at a public hospital versus a different outlet; and non-communicable disease medicine obtainment free of cost versus at a non-zero price. Mixed models adjusting for fixed and random effects were used to estimate associations between outcomes of interest and UHC exposure.

Results

The 197 respondents with universal health coverage were similar on all demographic factors to the 415 respondents with no universal health coverage. Private chemists were the most popular place of purchase throughout the study. Adjusting for demographic factors, county and time fixed effects, there was a significant increase in free medicines (aOR 2.55, 95% CI 1.73, 3.76), significant decrease in medicine obtainment at public hospitals (aOR 0.68, 95% CI 0.47, 0.97), and no impact on the availability of non-communicable disease medicines in households (aβ -0.004, 95% CI -0.058, 0.050) with universal health coverage.

Conclusions

Access to universal health coverage caused a significant increase in free non-communicable disease medicines, indicating financial risk protection. Interestingly, this is not accompanied with increases in public hospitals purchases or household availability of non-communicable disease medicines, with public health centers playing a greater role in supply of free medicines. This raises the question as to the status of supply-side investments at the public hospitals, to facilitate availability of quality-assured medicines.

Universal health insurance in Africa: a narrative review of the literature on institutional models

Introduction

Several African countries have introduced universal health insurance (UHI) programmes. These programmes aim to extend health insurance to groups that are usually excluded, namely informal workers and the indigent. Countries use different approaches. The purpose of this article is to study their institutional characteristics and their contribution to the achievement of universal health coverage (UHC) goals.

Method

This study is a narrative review. It focused on African countries with a UHI programme for at least 4 years. We identified 16 countries. We then compared how these UHI schemes mobilise, pool and use funds to purchase healthcare. Finally, we synthesised how all these aspects contribute to achieving the main objectives of UHC (access to care and financial protection).

Results

Ninety-two studies were selected. They found that government-run health insurance was the dominant model in Africa and that it produced better results than community-based health insurance (CBHI). They also showed that private health insurance was marginal. In a context with a large informal sector and a substantial number of people with low contributory capacity, the review also confirmed the limitations of contribution-based financing and the need to strengthen tax-based financing. It also showed that high fragmentation and voluntary enrolment, which are considered irreconcilable with universal insurance, characterise most UHI systems in Africa.

Conclusion

Public health insurance is more likely to contribute to the achievement of UHC goals than CBHI, as it ensures better management and promotes the pooling of resources on a larger scale.

Scaling up the primary health integrated care project for chronic conditions in Kenya: study protocol for an implementation research project

INTRODUCTION

Amid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya.

METHODS AND ANALYSIS

The study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) in-depth interviews with health workers and decision-makers to explore experiences of delivering PIC4C; (2) a cross-sectional survey of patients with diabetes or hypertension and in-depth interviews to understand how well PIC4C meets patients' needs; (3) a cohort study with an interrupted time series analysis to evaluate the degree to which PIC4C leads to health benefits such as improved management of hypertension or diabetes; and (4) a cohort study of households to examine the extent to which the national hospital insurance chronic care package provides financial risk protection to people with hypertension or diabetes within PIC4C.

ETHICS AND DISSEMINATION

The study has received approvals from Moi University Institutional Research and Ethics Committee (FAN:0003586) and the London School of Hygiene & Tropical Medicine (17940). Workshops with key stakeholders at local, county, national and international levels will ensure early and wide dissemination of our findings to inform scale up of this model of care. We will also publish findings in peer-reviewed journals.

Patients Access to Medicines - A Critical Review of the Healthcare System in Kenya

Access to affordable, safe, effective, and quality-assured medicines by a patient is important for good health outcomes. Unfortunately, there is sparse literature published on the pharmaceutical enablers that may increase the sale of a substandard and falsified (SF) medicine to a patient in Kenya. The review highlights some of the factors that may facilitate the entry of SF medicines into the legitimate pharmaceutical supply chain and discusses their impact on patient access to medicines. Lack of essential medicines in public health facilities is an important factor that may contribute to increased demand for medicine-related out-of-pocket expenses from private health facilities, thus a likelihood for a patient purchasing SF medicine from unlicensed and illegal medicine outlets or unregulated websites. The need to increase medicine availability in the public sector by the Ministry of Health (MOH) is emphasized in addition to the strengthening of public procurement to cushion it from corruption and mismanagement. In addition, the MOH should promote local pharmaceutical manufacturing and implement a medicine pricing containment policy to avoid abuse and prevent overexploitation of patients, increase medicine price transparency, and reduce pharmaceutical supply chain distortion. Recommended regulatory reviews include accreditation of unlicensed illegal medicine outlets to facilitate accountability, regulatory oversight, and active surveillance. The national post-market surveillance regulatory capacity should be strengthened to improve rational medicine use. A 3-year diploma course should be replaced with a shorter 1- or 2-year pharmaceutical support staff training not eligible to superintend a pharmacy. The recommended legislative review includes a mandatory clause to enforce generic prescribing and the implementation of generic substitution by health workers. Unethical manipulative pharmaceutical marketing practices should carry stiffer penalties to deter malpractice. Future research areas include investigation of medicine prescribing and dispensing practices, medicine consumption studies, medicine price differences within different health sub-sectors, and between licensed pharmacies and unlicensed illegal medicine outlets.

The Effects of Health Purchasing Reforms on Equity, Access, Quality of Care, and Financial Protection in Kenya: A Narrative Review

Kenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities' access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate.

The status and future of emergency care in the Republic of Kenya

Kenya is a rapidly developing country with a growing economy and evolving health care system. In the decade since the last publication on the state of emergency care in Kenya, significant developments have occurred in the country's approach to emergency care. Importantly, the country decentralized most health care functions to county governments in 2013. Despite the triple burden of traumatic, communicable, and non-communicable diseases, the structure of the health care system in the Republic of Kenya is evolving to adapt to the important role for the care of emergent medical conditions. This report provides a ten-year interval update on the current state of the development of emergency medical care and training in Kenya, and looks ahead towards areas for growth and development. Of particular focus is the role emergency care plays in Universal Health Coverage, and adapting to challenges from the devolution of health care.

A multi-step approach to managing missing data in time and patient variant electronic health records

OBJECTIVE

Electronic health records (EHR) hold promise for conducting large-scale analyses linking individual characteristics to health outcomes. However, these data often contain a large number of missing values at both the patient and visit level due to variation in data collection across facilities, providers, and clinical need. This study proposes a stepwise framework for imputing missing values within a visit-level EHR dataset that combines informative missingness and conditional imputation in a scalable manner that may be parallelized for efficiency.

RESULTS

For this study we use a subset of data from AMPATH representing information from 530,812 clinic visits from 16,316 Human Immunodeficiency Virus (HIV) positive women across Western Kenya who have given birth. We apply this process to a set of 84 clinical, social and economic variables and are able to impute values for 84.6% of variables with missing data with an average reduction in missing data of approximately 35.6%. We validate the use of this imputed dataset by predicting National Hospital Insurance Fund (NHIF) enrollment with 94.8% accuracy.

Improving access to diabetes care for children: An evaluation of the changing diabetes in children project in Kenya and Bangladesh

BACKGROUND

The changing diabetes in children (CDiC) project is a public-private partnership implemented by Novo Nordisk, to improve access to diabetes care for children with type 1 diabetes. This paper outlines the findings from an evaluation of CDiC in Bangladesh and Kenya, assessing whether CDiC has achieved its objectives in each of six core program components.

RESEARCH DESIGN AND METHODS

The Rapid Assessment Protocol for Insulin Access (RAPIA) framework was used to analyze the path of insulin provision and the healthcare infrastructure in place for diagnosis and treatment of diabetes. The RAPIA facilitates a mixed-methods approach to multiple levels of data collection and systems analysis. Information is collected through questionnaires, in-depth interviews and focus group discussions, site visits, and document reviews, engaging a wide range of stakeholders (N = 127). All transcripts were analyzed thematically.

RESULTS

The CDiC scheme provides a stable supply of free insulin to children in implementing facilities in Kenya and Bangladesh, and offers a comprehensive package of pediatric diabetes care. However, some elements of the CDiC program were not functioning as originally intended. Transitions away from donor funding and toward government ownership are a particular concern, as patients may incur additional treatment costs, while services offered may be reduced. Additionally, despite subsidized treatment costs, indirect costs remain a substantial barrier to care.

CONCLUSION

Public-private partnerships such as the CDiC program can improve access to life-saving medicines. However, our analysis found several limitations, including concerns over the sustainability of the project in both countries. Any program reliant on external funding and delivered in a high-turnover staffing environment will be vulnerable to sustainability concerns.

Best Practices in Achieving Universal Health Coverage: A Scoping Review

Background: The Universal Health Coverage (UHC) is a very important and effective policy in the health system of countries worldwide. Using the experiences and learning from the best practices of successful countries in the UHC can be very helpful. Therefore, the aim of the present study is to provide a scoping review of successful global interventions and practices in achieving UHC. Methods: This is a scoping review study that has been conducted using the Arkesy and O'Malley framework. To gather information, Embase, PubMed, The Cochrane Library, Scopus, Scientific Information Database, and MagIran were searched using relevant keywords from 2000 to 2019. Studies about different reforms in health systems and case studies, which have examined successful interventions and reforms on the path to UHC, were included. Articles and abstracts presented at conferences and congresses were excluded. Framework Analysis was also used to analyze the data. Results: Out of 4257 articles, 57 finally included in the study. The results showed that of the 40 countries that had successful interventions, most were Asian. The interventions were financial protection (40 interventions that were categorized into 14 items), service coverage (31 interventions categorized into 7 items), population coverage (36 interventions categorized into 9 items), and quality (18 interventions categorized into 7 items), respectively. Also, the positive results of interventions on the way to achieving UHC were financial protection (14 interventions), service coverage (7 interventions), population coverage (9 interventions), and quality (7 interventions), respectively. Conclusion: This study provides a comprehensive and clear view of successful interventions in achieving the UHC. Therefore, with consideration to lessons learned from successful interventions, policymakers can design appropriate interventions for their country.

Acceptability and Feasibility of Pharmacy-Based Delivery of Pre-Exposure Prophylaxis in Kenya: A Qualitative Study of Client and Provider Perspectives

As countries scale up pre-exposure prophylaxis (PrEP) for HIV prevention, diverse PrEP delivery models are needed to expand access to populations at HIV risk that are unwilling or unable to access clinic-based PrEP care. To identify factors that may influence implementation of retail pharmacy-based PrEP delivery in Kenya, we conducted in-depth interviews with 40 pharmacy clients, 16 pharmacy providers, 16 PrEP clients, and 10 PrEP providers from two provinces. Most participants expressed strong support for expanding PrEP to retail pharmacies, though conditioned their acceptance on assurances that care would be private, respectful, safe, and affordable. Participant-reported determinants of feasibility centered primarily on ensuring that the intervention is compatible with retail pharmacy operations (e.g., staffing levels, documentation requirements). Future research is needed to develop and test tailored packages of implementation strategies that are most effective at integrating PrEP delivery into routine pharmacy practice in Kenya and other high HIV prevalence settings.

Understanding the Performance of County Health Service Delivery in Kenya: A Mixed Method Analysis

To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county’s commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems

Probability and amount of medicines expenditure according to health insurance status in Kenya: A household survey in eight counties

Background

National and county governments in Kenya have introduced various health insurance schemes to protect households against financial hardship as a result of large health expenditure. This study examines the relationship between health insurance and medicine expenditure in eight counties in Kenya.

Methods

A cross‐sectional study of collected primary data via household survey in eight counties was performed. Three measures of medicine expenditure were analysed: the probability of any out‐of‐pocket expenditure (OOPE) on medicines in the last 4 weeks; amount of OOPE on medicines; and OOPE on medicines as a proportion of total OOPE on health.

Results

Out of the 452 individuals, those with health insurance (n = 225) were significantly different from individuals without health insurance (n = 227): overall, they were older, had a higher level of educational attainment and possessed more assets. Adjusting for covariates, individuals with health insurance had a reduced probability of OOPE on medicines (0.40, CI95% 0.197–0.827) and spent proportionally less on medicines out of total health expenditure (0.50, CI95% 0.301–0.926).

Conclusions

Kenya has made great strides to scale up Universal Health Coverage including access to medicines. Prioritising enrollment of low‐income individuals with non‐communicable diseases can accelerate access to medicines and financial protection.

What Drives Outpatient Care Costs in Kenya? An Analysis With Generalized Estimating Equations

Objective: This study aimed to identify the factors associated with outpatient expenses incurred by households in Kenya.

Background: The problem of outpatient healthcare expenses incurred by citizens in countries with limited resources has received little attention. Thus, this study aimed to determine the predictors of household spending on outpatient expenses in Kenya.

Method: We conducted a cross-sectional analysis on households in Kenya using data from the 2018 Kenya Household Health Expenditure and Utilization Survey. We applied the generalized estimating equations method to determine the best subset of predictors of outpatient care cost.

Findings: The best predictors of outpatient care expenses in Kenya are age, wealth index, and education level of the household head.

Conclusions: There were no differences regarding age in the mean spending on outpatient care. Moreover, we found that the cost of outpatient care changes with age in a sinusoidal manner. We observed that rich households spent more on outpatient care, mostly owing to their financial ability. Households whose heads reported primary or secondary school education level spent less on outpatient costs than households headed by those who never went to school.

Impact of household shocks on access to healthcare services in Kenya: a propensity score matching analysis

OBJECTIVE

This study examines the effects of household shocks on access to healthcare services in Kenya. Shocks are adverse events that lead to loss of household income and/or assets.

DESIGN AND SETTING

The study used data from the Kenya Integrated Household Budget Survey 2015/2016, a nationally representative cross-sectional survey. A propensity score matching approach was applied for the analysis.

PARTICIPANTS

The study sample included 16 297 individuals from households that had experienced shocks (intervention) and those that had not experienced shocks (control) within the last 12 months preceding the survey.

OUTCOME MEASURES

The outcome of interest was access to healthcare services based on an individual's perceived need for health intervention.

RESULTS

The results indicate that shocks reduce access to healthcare services when household members are confronted with an illness. We observed that multiple shocks in a household exacerbate the risk of not accessing healthcare services. Asset shocks had a significant negative effect on access to healthcare services, whereas the effect of income shocks was not statistically significant. This is presumably due to the smoothing out of income shocks through the sale of assets or borrowing. However, considering the time when the shock occurred, we observed mixed results that varied according to the type of shock.

CONCLUSIONS

The findings suggest that shocks can limit the capacity of households to invest in healthcare services, emphasising their vulnerability to risks and inability to cope with the consequences. These results provoke a debate on the causal pathway of household economic shocks and health-seeking behaviour. The results suggest a need for social protection programmes to integrate mechanisms that enable households to build resilience to shocks. A more viable approach would be to expedite universal health insurance to cushion households from forgoing needed healthcare when confronted with unanticipated risks.

Gender Differences in Insurance, Surgical Admissions and Outcomes at a Kenyan Referral Hospital

INTRODUCTION

Gender is an important factor in determining access to healthcare resources. Women face additional barriers, especially in low- and middle-income countries. Surgical costs can be devastating, which can exacerbate engendered disparities. Kenya's National Hospital Insurance Fund (NHIF) aims to achieve universal coverage and protect beneficiaries from catastrophic health expenditures. We examine gender differences in NHIF coverage, health-seeking behavior, and surgical outcomes at a tertiary care hospital in Eldoret, Kenya.

MATERIALS AND METHODS

All patients ≥13 years admitted to the general surgery service at Moi Teaching and Referral Hospital from January 2018-July 2018 were enrolled. Health records were retrospectively reviewed for demographic data, clinical parameters, NHIF enrollment, and cost information. Descriptive analyses utilized Wilcoxon Rank Sum, Pearson's Chi-square, and Fisher's Exact tests.

RESULTS

366 patients were included for analysis. 48.6% were enrolled in NHIF with significant female predominance (64.8% versus 37.9%, P < 0.0001). Despite differing coverage rates, male and female patients underwent surgery and suffered in-hospital mortality at similar rates. However, women only comprised 39.6% of admissions and were significantly more likely to delay care (median 60 versus 7 days, P < 0.0001), be diagnosed with cancer (26.6% versus 13.2%, P = 0.0024), and require a palliative procedure for cancer (44.1% versus 13.0%, P = 0.013).

CONCLUSION

Many financial and cultural barriers exist in Kenya that prevent women from accessing healthcare as readily as men, persisting despite higher rates of NHIF coverage amongst female patients. Investigation into extra-hospital costs and social disempowerment for women may elucidate key needs for achieving health equity.

Framing universal health coverage in Kenya: an interpretive analysis of the 2004 Bill on National Social Health Insurance

In 2004, President Mwai Kibaki of Kenya refused to sign a popular Bill on National Social Health Insurance into law. Drawing on innovations in framing theory, this research provides a social explanation for this decision. In addition to document review, this study involved interpretive analysis of transcripts from 50 semi-structured interviews with leading actors involved in the health financing policy process in Kenya, 2014-15. The frame-critical analysis focused on how actors engaged in (1) sensemaking, (2) naming, which includes selecting and categorizing and (3) storytelling. We demonstrated that actors' abilities to make sense of the Bill were largely influenced by their own understandings of the finer features of the Bill and the array of interest groups privy to the debate. This was reinforced by a process of naming, which selects and categorizes aspects of the Bill, including the public persona of its primary sponsor, its affordability, sustainability, technical dimensions and linkages to notions of economic liberalism. Actors used these understandings and names to tell stories of ideational warfare, which involved narrative accounts of policy resistance and betrayal. This analysis illustrates the difficulty in enacting sweeping reform measures and thus provides a basis for understanding incrementalism in Kenyan health policy.

WITHDRAWN: Impact of basic medical insurance fund risk on the health risk assessment of urban residents

Ahead of Print article withdrawn by publisher.

Financing employee healthcare: fusing the preferences of employees in decision-making

Purpose

Good health is important for the happiness and productivity of employees of any organization and a nation. With the declining government funding for public Universities in Kenya, providing health cover for employees is a real challenge. Thus, the universities have to explore widely acceptable and sustainable options. This study aims to explore the correlations of employee preferences for health care schemes and evaluated the cost implications of each of the available Schemes.

Design/methodology/approach

The study applied a multinomial probit analysis on cross-sectional data from Taita Taveta University (TTU) in Kenya's coastal region. Cost-benefit analysis was used to rank alternative healthcare schemes. For triangulation of information, individual interviews were supplemented with key informant interviews.

Findings

Two sets of factors, personal attributes of employees and the attributes of the health care provider, were found to drive employee preferences for health care schemes. Thus, the universities need to consider these attributes in their choice sets of health care schemes to gain employee support.

Research limitations/implications

The study was based on a cross-sectional survey that may not capture the dynamic elements in institutional management. Thus, future research may build panel data on the current one for further analysis.

Practical implications

The study found that household characteristics and the perceived attributes of the healthcare providers are key drivers of the preferences. Thus, it is important to consider the characteristics of the employees (for example, age, family sizes, etc.) and attributes of healthcare providers before selecting a healthcare scheme for the workers

Originality/value

This is a pioneer study on the choice of healthcare scheme for institutions of higher learning in Kenya. Universities are made aware of what informs employee's preferences for health schemes. This is important for tailoring health care schemes to match employee preferences for greater satisfaction.

Association of SHI coverage and level of healthcare utilization and costs in the Philippines: a 10-year pooled analysis

BACKGROUND

The Philippine Health Insurance Corporation (PhilHealth), which manages the Philippine national health insurance program, is a critical actor in the country's strategy for universal health coverage. Over the past decade, PhilHealth has passed significant coverage, benefits and payment reforms to contain costs and improve the affordability care for high-cost diseases, inpatient care and select outpatient services.

METHODS

We studied the association of PhilHealth with health care utilization and health care costs using three rounds of the Philippine Demographic and Health Survey with data on individual outpatient and inpatient visits from 2008 to 2017.

RESULTS

PhilHealth membership was associated with 42% greater odds of outpatient utilization and 47-100% greater odds inpatient utilization depending on survey year. Depending on facility type, use of PhilHealth to pay for care was associated with higher average health care costs of 244-865% for outpatient care and 135-206% for inpatient care.

CONCLUSIONS

PhilHealth has likely decreased barriers to health care utilization but may have inadvertently driven up health care costs in the country. Results align with past studies that suggest that reforms in the prior decade have done little to contain health care costs for Filipinos.