Historical account of the national health insurance formulation in Kenya: experiences from the past decade

A critical review of literature on health financing reforms in Uganda - progress, challenges and opportunities for achieving UHC

Background

Universal health coverage (UHC) is one of the sustainable development goals (SDG) targets. Progress towards UHC necessitates health financing reforms in many countries. Uganda has had reforms in its health financing, however, there has been no examination of how the reforms align with the principles of financing for UHC.

Objective

This review examines how health financing reforms in Uganda align with UHC principles and contribute to ongoing discussions on financing UHC.

Methods

We conducted a critical review of literature and utilized thematic framework for analysis. Results are presented narratively. The analysis focused on health financing during four health sector strategic plan (HSSP) periods.

Results

In HSSP I, the focus of health financing was on equity, while in HSSP II the focus was on mobilizing more funding. In HSSP III & IV the focus was on financial risk protection and UHC. The changes in focus in health financing objectives have been informed by low per capita expenditures, global level discussions on SDGs and UHC, and the ongoing health financing reform discussions. User fees was abolished in 2001, sector-wide approach was implemented during HSSP I&II, and pilots with results-based financing have occurred. These financing initiatives have not led to significant improvements in financial risk protection as indicated by the high out-of-pocket payments.

Conclusion

Health financing policy intentions were aligned with WHO guidance on reforms towards UHC, however actual outputs and outcomes in terms of improvement in health financing functions and financial risk protections remain far from the intentions.

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.

Developing and implementing National Health Insurance: learnings from the first try in Benin

In 2008, Benin government launched a national health insurance scheme, but this had been suspended in 2017. We aim to understand how existing ideas and institutions, stakeholders' behaviour and their interests shaped policy-making process and policy content, from its launch to its suspension.

METHODS

We used a case study design, framed by the policy triangle of Walt and Gilson. We collected data through document review, quantitative data extraction from routine information, and interviews with 20 key informants. We performed a content analysis using both complementarily deductive and inductive analysis.

RESULTS

This study confirms the keen interest for national health insurance scheme in Benin among various stakeholders. Compared with user fee exemption policies, it is considered as more sustainable, with a more reliable financing, and a greater likelihood to facilitate population's access to quality healthcare without financial hardships.Exempting the poor from paying health insurance premiums was however considered as an equitable mean to facilitate the extension of the health insurance to informal sector workers.The whole arrangements failed to deliver appropriate skills, tools, coordination and incentives to drive the policy implementers to make individual and organisational changes necessary to adjust to the objectives and values of the reform. These deficiencies compromised the implementation fidelity with unintended effects such as low subscription rate, low services utilisation and sustainability threats.

CONCLUSION

Supporting countries in documenting policy processes will ease learning across their tries for progressing towards Universal Health Coverage, as more than one try will be necessary.

How are global health policies transferred to sub-Saharan Africa countries? A systematic critical review of literature

Background

Most sub-Saharan Africa countries adopt global health policies. However, mechanisms with which policy transfers occur have largely been studied amongst developed countries and much less in low- and middle- income countries. The current review sought to contribute to literature in this area by exploring how health policy agendas have been transferred from global to national level in sub-Saharan Africa. This is particularly important in the Sustainable Development Goals (SDGs) era as there are many policy prepositions by global actors to be transferred to national level for example the World Health Organization (WHO) policy principles of health financing reforms that advance Universal Health Coverage (UHC).

Methods

We conducted a critical review of literature following Arksey and O’Malley framework for conducting reviews. We searched EBSCOhost, ProQuest, PubMed, Scopus, Web of Science and Google scholar for articles. We combined the concepts and synonyms of “policy transfer” with those of “sub-Saharan Africa” using Boolean operators in searching databases. Data were analyzed thematically, and results presented narratively.

Results

Nine articles satisfied our eligibility criteria. The predominant policy transfer mechanism in the health sector in sub-Saharan Africa is voluntarism. There are cases of coercion, however, even in the face of coercion, there is usually some level of negotiation. Agency, context and nature of the issue are key influencers in policy transfers. The transfer is likely to be smooth if it is mainly technical and changes are within the confines of a given disease programmatic area. Policies with potential implications on bureaucratic and political status quo are more challenging to transfer.

Conclusion

Policy transfer, irrespective of the mechanism, requires local alignment and appreciation of context by the principal agents, availability of financial resources, a coordination platform and good working relations amongst stakeholders. Potential effects of the policy on the bureaucratic structure and political status are also important during the policy transfer process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00821-9.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats.

Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups.

Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats.

Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

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.

How has sustainable development goals declaration influenced health financing reforms for universal health coverage at the country level? A scoping review of literature

Background

Achieving universal health coverage (UHC) requires health financing reforms (HFR) in many of the countries. HFR are inherently political. The sustainable development goals (SDG) declaration provides a global political commitment context that can influence HFR for UHC at national level. However, how the declaration has influenced HFR discourse at the national level and how ministries of health and other stakeholders are using the declaration to influence reforms towards UHC have not been explored. This review was conducted to provide information and lessons on how SDG declaration can influence health financing reforms for UHC based on countries experiences.

Methods

We conducted a rapid review of literature and followed the preferred reporting items for systematic review and meta-analysis (PRISMA) guideline. We conducted a comprehensive electronic search on Ovid Medline, PubMed, EBSCO, Scopus, Web of Science. In searching the electronic databases, we combined various conceptual terms for “sustainable development goals” and “health financing” using Boolean operators. In addition, we conducted manual searched using google scholar.

Results

Twelve articles satisfied our eligibility criteria. The included articles were analyzed thematically, and the results presented narratively. The SDG declaration has provided an enabling environment for putting in place necessary legislations, reforming health financing organization, and revisions of national health polices to align to the country’s commitment on UHC. However, there is limited information on the process; how health ministries and other stakeholders have used SDG declaration to advocate, lobby, and engage various constituencies to support HFR for UHC.

Conclusion

The SDG declaration can be a catalyst for health financing reform, providing reference for necessary legislations and policies for financing UHC. However, to facilitate better cross-country learning on how SDG declaration catalyzes HFR for UHC there, is need to examine the processes of how stakeholders have used the declaration as window of opportunity to accelerate reforms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00703-6.

Strategies for financing social health insurance schemes for providing universal health care: a comparative analysis of five countries

Background: Universal Health Coverage has become a political priority for many African countries yet there are clear challenges in achieving this goal. Though social health insurance is considered a mechanism for providing financial protection, less well documented in the literature is evidence from countries in Africa who are at various stages of adopting this financing strategy as a way to improve health insurance coverage for their populations. Objectives: The study investigates whether social health insurance schemes are effectively and efficiently covering all groups. The objective is to provide evidence of how these schemes have been implemented and whether the fundamental goals are met. The selected countries are Ghana, Rwanda, Tanzania, Kenya and Ethiopia. The study draws lessons from the literature about how policy tools can be used to reduce financial barriers whilst ensuring a broad geographic coverage in Africa. Methods: The study relies primarily on a review of literature, both documented and grey matter, which include key documents such as government health policy documents, strategic plans, health financing policy documents, Universal Health Coverage policy documents, published literature, unpublished documents, media reports and National Health Accounts reports. Results: The results show that each of the selected countries relies on a plurality of health insurance schemes with each targeting different groups. Additionally, many of the Social Health Insurance programs start by covering the formal sector first, with the hope of covering other groups in the informal sector at a later stage. Health insurance coverage for poor groups is very low, with targeting mechanisms to cover the poor in the form of exemptions and waivers achieving no desirable results. Conclusions: The ability for Social Health Insurance programs to cover all groups has been limited in the selected countries. Hence, relying solely on social health insurance schemes to achieve Universal Health Coverage may not be plausible in Africa. Also, highly fragmented risk pools impede efforts to widen the insurance pools and promote cross-subsidies.

Seeking care in the context of social health insurance in Kenya and Ghana

BACKGROUND

Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.

METHODS

This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.

RESULTS

Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.

CONCLUSIONS

Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

Examining user fee reductions in public primary healthcare facilities in Kenya, 1997-2012: effects on the use and content of antenatal care

BACKGROUND

In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and $0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes.

METHODS

Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women's ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth.

RESULTS

The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC.

CONCLUSIONS

This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access.

Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study

OBJECTIVE

To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya.

DESIGN

The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018.

SETTING

The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya.

PARTICIPANTS

A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members.

PRIMARY OUTCOME MEASURE

The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover.

RESULTS

The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69).

CONCLUSIONS

Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.

Health care purchasing in Kenya: Experiences of health care providers with capitation and fee-for-service provider payment mechanisms

BACKGROUND

Provider payment mechanisms (PPMs) play a critical role in universal health coverage due to the incentives they create for health care providers to deliver needed services, quality, and efficiency. We set out to explore public, private, and faith-based providers' experiences with capitation and fee-for-service in Kenya and identified attributes of PPMs that providers considered important.

METHODS

We conducted a qualitative study in two counties in Kenya. Data were collected using semistructured interviews with 29 management team members in six health providers accredited by the National Hospital Insurance Fund (NHIF).

RESULTS

Capitation and fee-for-service payments from the NHIF and private insurers were reported as good revenue sources as they contributed to providers' overall income. The expected fee-for-service payment amounts from NHIF and private insurers were predictable while capitation funds from NHIF were not because providers did not have information on the number of enrolees in their capitation pool. Moreover, capitation payment rates were perceived as inadequate. Capitation and fee-for-service payments from NHIF and private insurers were disbursed late. Finally, public providers had lost their autonomy to access and utilise capitation and fee-for-service payments from the NHIF.

CONCLUSION

Through their experiences, health care providers revealed characteristics of PPMs that they considered important.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

BACKGROUND

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services?

METHODS

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

RESULTS

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

CONCLUSIONS

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

Background

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services?

Methods

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

Conclusions

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

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

This article identifies and describes the reforms undertaken by the National Hospital Insurance Fund (NHIF) and examines their implications for Kenya’s quest to achieve universal health coverage (UHC). We undertook a review of published and grey literature to identify key reforms that had been implemented by the NHIF since 2010. We examined the reforms undertaken by the NHIF using a health financing evaluation framework that considers the feasibility, equity, efficiency, and sustainability of health financing mechanisms. We found the following NHIF reforms: (1) the introduction of the Civil Servants Scheme (CSS), (2) the introduction of a stepwise quality improvement system, (3) the health insurance subsidy for the poor (HISP), (4) revision of monthly contribution rates and expansion of the benefit package, and (5) the upward revision of provider reimbursement rates. Though there are improvements in several areas, these reforms raise equity, efficiency, feasibility, and sustainability concerns. The article concludes that though NHIF reforms in Kenya are well intentioned and there has been improvement in several areas, design attributes could compromise the extent to which they achieve their intended goal of providing universal financing risk protection to the Kenyan population.

Public-private partnerships in practice: collaborating to improve health finance policy in Ghana and Kenya

Social health insurance (SHI), one mechanism for achieving universal health coverage, has become increasingly important in low- and middle-income countries (LMICs) as they work to achieve this goal. Although small private providers supply a significant proportion of healthcare in LMICs, integrating these providers into SHI systems is often challenging. Public-private partnerships in health are one way to address these challenges, but we know little about how these collaborations work, how effectively, and why. Drawing on semi-structured interviews conducted with National Health Insurance (NHI) officials in Kenya and Ghana, as well as with staff from several international NGOs (INGOs) representing social franchise networks that are partnering to increase private provider accreditation into the NHIs, this article examines one example of public-private collaboration in practice. We found that interviewees initially had incomplete knowledge about the potential for cross-sector synergy, but both sides were motivated to work together around shared goals and the potential for mutual benefit. The public-private relationship then evolved over time through regular face-to-face interactions, reciprocal feedback, and iterative workplan development. This process led to a collegial relationship that also has given small private providers more voice in the health system. In order to sustain this relationship, we recommend that both public and private sector representatives develop formalized protocols for working together, as well as less formal open channels for communication. Models for aggregating small private providers and delivering them to government programmes as a package have potential to facilitate public-private partnerships as well, but there is little evidence on how these models work in LMICs thus far.

Understanding variations in health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania: Evidence from demographic and health surveys

BACKGROUND

Realisation of universal health coverage is not possible without health financing systems that ensure financial risk protection. To ensure this, some African countries have instituted health insurance schemes as venues for ensuring universal access to health care for their populace. In this paper, we examined variations in health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania.

METHODS

We used data from demographic and health surveys of Ghana (2014), Kenya (2014), Nigeria (2013), and Tanzania (2015). Women aged 15-49 and men aged 15-59 years were included in the study. Our study population comprised 9,378 women and 4,371 men from Ghana, 14,656 women and 12,712 men from Kenya, 38,598 women and 17,185 men from Nigeria, and 10,123 women and 2,514 men from Tanzania. Bivariate and multivariate techniques were used to analyse the data.

RESULTS

Coverage was highest in Ghana (Females = 62.4%, Males = 49.1%) and lowest in Nigeria (Females = 1.1%, Males = 3.1%). Age, level of education, residence, wealth status, and occupation were the socio-economic factors influencing variations in health insurance coverage.

CONCLUSIONS

There are variations in health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania, with Ghana recording the highest coverage. Kenya, Tanzania, and Nigeria may not be able to achieve universal health coverage and meet the sustainable development goals on health by the year 2030 if the current fragmented public health insurance systems persist in those countries. Therefore, the various schemes of these countries should be harmonised to help maximise the size of their risk pools and increase the confidence of potential subscribers in the systems, which may encourage them to enrol.

Challenges toward achieving universal health coverage in Ghana, Kenya, Nigeria, and Tanzania

Although many sub-Saharan African countries have made efforts to provide universal health coverage (UHC) for their citizens, several of these initiatives have achieved little success. This study aims to review the challenges facing UHC in Ghana, Kenya, Nigeria, and Tanzania, and to suggest program or policy changes that might bolster UHC. Routine data reported by the World Bank and World Health Organization, as well as annual reports of the national health insurance schemes of Ghana, Kenya, Nigeria, and Tanzania, were analyzed. The data were supplemented by a review of published and gray literature on health insurance coverage in these four countries. The analysis showed that some of the challenges facing UHC in these countries include (1) large proportion of the population living in extreme poverty and unable to pay premiums, (2) large informal sector whose members are mostly uninsured, (3) high dropout rate from insurance schemes, (4) poorly funded primary health care system, and (5) segmented health insurance fund pool. In order to achieve UHC by 2030, it will be important for these countries to (1) raise sufficient revenue to finance their health systems, (2) improve the efficiency of revenue utilization, (3) identify and provide coverage for the very poor, (4) reduce the proportion of the population that is underinsured, and (5) improve access to quality health care in rural areas.

Measuring progress towards Sustainable Development Goal 3.8 on universal health coverage in Kenya

BACKGROUND

The inclusion of universal health coverage (UHC) as a health-related Sustainable Development Goal has cemented its position as a key global health priority. We aimed to develop a summary measure of UHC for Kenya and track the country's progress between 2003 and 2013.

METHODS

We developed a summary index for UHC by computing the geometrical mean of indicators for the two dimensions of UHC, service coverage (SC) and financial risk protection (FRP). The SC indicator was computed as the geometrical mean of preventive and treatment indicators, while the financial protection indicator was computed as a geometrical mean of an indicator for the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments. We analysed data from three waves of two nationally representative household surveys.

FINDINGS

The weighted summary indicator for SC increased from 27.65% (27.13%-28.14%) in 2003 to 41.73% (41.34%-42.12%) in 2013, while the summary indicator for FRP reduced from 69.82% (69.11%-70.51%) in 2003 to 63.78% (63.55%-63.82%) in 2013. Inequities were observed in both these indicators. The weighted summary measure of UHC increased from 43.94% (95% CI 43.48% to 44.38%) in 2003 to 51.55% (95% CI 51.29% to 51.82%) in 2013.

CONCLUSION

Significant gaps exist in Kenya's quest to achieve UHC. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both, rather than on only either, of the dimensions of UHC.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014

Background

The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys.

Methods

Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya.

Results

There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time.

Conclusion

The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0774-4) contains supplementary material, which is available to authorized users.

A Critical Analysis of Purchasing Arrangements in Kenya: The Case of the National Hospital Insurance Fund

Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study.

Methods: We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n=62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach.

Results: The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited.

Conclusion: Addressing the gaps in the NHIF’s purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya’s devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC).

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya

Background

Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers’ perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa—the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.

Methods

In-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers’ reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Most providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers’ participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.

Conclusions

In expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa

Abstract

Globally, models of extending universal health coverage through primary care are influenced by country-specific systems of health care and disease management. In 2015 a rapid assessment of the ward-based outreach component of primary care reengineering was commissioned to understand implementation and rollout challenges.

Aim

This article aims to describe middle- and lower-level managers’ understanding of ward-based outreach teams (WBOTs) and the problems of authority, jurisdiction and practical functioning that arise from the way the model is constructed and has been operationalised.

Setting

Data are drawn from a rapid assessment of National Health Insurance (NHI) pilot sites in seven provinces.

Methods

The study used a modified version of CASCADE. Peer-review teams of public health researchers and district/sub-district managers collected data in two sites per province between March and July 2015.

Results

Respondents unequivocally support the strategy to extend primary health care services to people in their homes and communities both because it is responsive to the family context of individual health and because it reaches marginal people. They, however, identify critical issues that arise from basing WBOTs in facilities, including unspecific team leadership, inadequate supervision, poorly constituted teams, limited community reach and serious infrastructural and material under-provision.

Conclusion

Many of the shortcomings of a facility-based extension model can be addressed by an independently resourced, geographic, community-based model of fully constituted teams that are clinically and organisationally supported in an integrated district health system. However, a community-oriented primary care approach will still have to grapple with overarching framework problems.

Manifestations and drivers of mistreatment of women during childbirth in Kenya: implications for measurement and developing interventions

Background

Disrespect and abuse or mistreatment of women by health care providers in maternity settings has been identified as a key deterrent to women seeking delivery care. Mistreatment includes physical and verbal abuse, stigma and discrimination, a poor relationship between women and providers and policy and health systems challenges. This paper uses qualitative data to describe mistreatment of women in Kenya.

Methods

Data are drawn from implementation research conducted in 13 facilities and communities. Researchers conducted a range of in-depth interviews with women (n-50) who had given birth in a facility policy makers health managers and providers (n-63); and focus group discussions (19) with women and men living around study facilities. Data were captured on paper and audio tapes, transcribed and translated and exported into Nvivo for analysis. Subsequently we applied a typology of mistreatment which includes first order descriptive themes, second and third-order analytical themes. Final analysis was organized around description of the nature, manifestations and experiences, and factors contributing to mistreatment.

Results

Women describe: their negative experiences of childbirth; frustration with lack of confidentiality and autonomy; abandonment by the providers, and dirty maternity units. Providers admit to challenges but describe reasons for apparent abuse (slapped on thighs to encourage women to focus on birthing process) and ‘detention’ is because relatives have abandoned them. Men try to overcome challenges by paying providers to ensure they look after their wives. Drivers of mistreatment are perpetuated by social and gender norms at family and community levels. At facility level, poor managerial oversight, provider demotivation, and lack of equipment and supplies, contribute to a poor experience of care. Weak or non-existent legal redress perpetuate the problem.

Conclusion

This paper builds on the expanding literature on mistreatment during labour and childbirth –outlining drivers from an individual, family, community, facility and policy level. New frameworks to group the manifestations into themes or components makes it increasingly more focused on specific interventions to promote respectful maternity care. The Kenya findings resonate with budding literature – demonstrating that this is indeed a global issue that needs a global solution.