This document discusses universal healthcare and moving towards universal coverage in Kenya. It provides an overview of universal healthcare, describing it as a system that provides a basic package of benefits to all members of a society. The document then discusses healthcare financing models, including tax-based systems, social health insurance, and private insurance. It provides an analysis of healthcare financing in Kenya currently and proposals to expand coverage through the National Hospital Insurance Fund to work towards universal coverage. The document concludes by outlining next steps needed to achieve universal healthcare in Kenya, including bridging equity gaps, ensuring a strong public health system, and improving efficiency.

1. East Africa Healthcare Federation
Conference 2012
Towards Universal Healthcare
Dr. Peter Kamunyo,
Divisional Director – Healthcare, Aon
Kenya

2. Contents
• Overview & Setting the context
– The case for Universal Health care
– Universal Health Care in Africa
• Healthcare Financing in Kenya
• The Role of NHIF towards
Universal Healthcare

3. Universal Health Care
• AKA universal health coverage, universal coverage, universal
care or social health protection
• Describes health care systems organized around providing a
specified package of benefits to ALL members of a society.
• Aim
– providing financial risk protection,
– improved access to health services, and
– improved health outcomes.
• The ultimate objective of any healthcare financing system-
“effective access to affordable healthcare services of adequate
quality and financial protection in case of sickness”
(International Labor organization)
• Universal health care is not a one-size-fits-all concept; nor does
it imply coverage for all people for everything.
• Determined by three critical dimensions:
– who is covered,
– what services are covered, and
– how much of the cost is covered

4. Universal coverage
Total health expenditure Total health expenditure
Height: what
proportion of
Height:
the costs are
what
covered?
proportion
Include of the costs
Reduce cost other
sharing are covered?
services
Extend to
non-
Depth: covered
which Coverage
benefits are mechanism
Breadth: who is covered? covered? Depth:
which
Breadth: who is benefits are
covered? covered?

5. Funding models
• Universal health care in most countries has been achieved by a mixed
model of funding.
• General taxation revenue is the primary source of funding
• European systems - financed through a mix of public and private
contributions.
• The majority of universal health care systems are funded primarily by
tax revenue (e.g. Portugal, Spain, Denmark and Sweden).
• Some nations, such as Germany, France and Japan employ a multi-
payer system in which health care is funded by private and public
contributions.
• These contributions are compulsory and defined according to law.
• Universal health care systems are modestly redistributive.
• Progressivity of health care financing has limited implications for
overall income inequality.

6. Forms of healthcare financing
1. Compulsory insurance: This is usually enforced via legislation requiring
residents to purchase insurance, though sometimes, in effect, the
government provides the insurance.
2. Tax-based financing: In tax-based financing, individuals contribute to the
provision of health services through various taxes.
3. Social Health Insurance: In social health insurance, contributions from
workers, the self-employed, enterprises and government are pooled into a
single or multiple funds on a compulsory basis.
4. Private insurance: In private health insurance, premiums are paid directly
from employers, associations, individuals and families to insurance
companies, which pool risks across their membership base.
5. Single payer: used to describe a funding mechanism meeting the costs of
medical care from a single fund.
6. Community-based Health Insurance: A particular form of private health
insurance that has often emerged in environments where financial risk
protection mechanisms only have a limited impact is community-based
health insurance. Contributions are not risk-related, and there is generally a
high level of community involvement in the running of such schemes.

7. Healthcare Financing in Sub Saharan Africa
Private Public
User charges / out- Social Health
of-pocket costs Insurance (SHI)
Community Based Taxation (direct,
Health Insurance indirect, general,
(CBHI) Public Private earmarked)
Partnerships
Private Health
Insurance (PHI)
Medical Savings
Accounts (MSAs)
Informal payments

8. Healthcare Financing Triangle
Synergy between the
stakeholders End user
Patient
Payer Provider
Insurance companies
NGO funding Medical Service Providers
Public health schemes Doctors etc.
Government

9. Other considerations
• Extent of government involvement in providing
care and/or health insurance varies
• The common denominator for all such programs
is some form of government action aimed at
extending access to health care as widely as
possible and setting minimum standards.
• Most implement universal health care through
legislation, regulation and taxation.
• Legislation and regulation direct what care must
be provided, to whom, and on what basis.
• Usually some costs are borne by the patient at
the time of consumption but the bulk of costs
come from a combination of compulsory
insurance and tax revenues.
• Some programs are paid for entirely out of tax
revenues.

10. Universal Health Care Globally
GERMANY
• Germany has the world's oldest universal health care system, with
origins dating back to Otto von Bismarck's social legislation, which
included the Health Insurance Bill of 1883, Accident Insurance Bill of
1884, and Old Age and Disability Insurance Bill of 1889.
BRITAIN
• In Britain, the National Insurance Act 1911 marked the first steps
there towards universal health care, covering most employed persons
and their financial dependents and all persons who had been
continuous contributors to the scheme for at least five years whether
they were working or not.
• This system of health insurance continued in force until the creation
of the National Health Service in 1948 which extended health care
security to all legal residents.
UNITED STATES OF AMERICA
• Most current universal health care systems were implemented in the
period following the Second World War as a process of deliberate
health care reform, intended to make health care available to all, in
the spirit of Article 25 of the Universal Declaration of Human Rights of
1948, signed by every country doing so. The US did not ratify the
social and economic rights sections, including Article 25's right to
health.

11. Universal Health Care in Africa
• At least 50 percent of Sub-Saharan Africa’s total health
expenditure is financed by out-of-pocket payments from
its largely impoverished population.
• In 2001, the heads of state of the African Union countries
met in Abuja, Nigeria, and pledged to allocate at least 15
percent of their national budgets to the health sector in
the Abuja Declaration.
• A decade later, only two African countries, South Africa
and Rwanda, have managed to reach this goal, according
to the World Health Organization, WHO.
• Twenty-seven African countries have increased their
expenditure on health care, but 12 countries – including
Kenya – have kept theirs the same and seven African
countries have reduced theirs.

12. Sustainable Universal Healthcare Financing
• Healthcare financing options that have the capacity to endure
over long periods of time
Medicines &
Treat
Services
Education &
Teach
Outreach
Build Infrastructure
Serve Social
Advocacy
The sustainability of Africa's healthcare sector will depend on the
availability of robust and diverse insurance options for patients.

13. Sustainable Healthcare Financing
• Sustainable healthcare (Sustainable health
financing, universal coverage and social
health insurance) is a joint effort between
public and private stakeholders
Private Community
Social Health Health Based health
Insurance Insurance insurance

14. Healthcare Challenges in Kenya
• High burden of disease, including HIV/AIDS , Malaria, TB
• Healthcare infrastructure is insufficient and in some cases
old and dilapidated
• Acute shortage of health human resources
• Insufficient funding and inefficient use of resources is one
of the major underlying factor of the challenges
• Only about 40% of Kenyans live within 4 kms of a
functioning facility, mostly in rural areas; 70% access in
urban areas
• Public health facilities are overcrowded, while there is still
some underutilized capacity in private and Faith Based
facilities (exact figures not known) – issue of cost of care
and quality
• Whereas the policy and the plans emphasize preventive,
demand for curative services continue to increase

15. Healthcare Challenges in Kenya
• Households bear the highest cost of care – direct costs,
taxes and premiums
• About 40% of sick Kenyans do not seek care when sick due
to cost
• Removal of user fees in primary health facilities led to
shortages in health commodities due to lack of
compensation for loss of revenue
• About 1 million Kenyans drop below poverty line yearly as
a result of a sickness in the family
• Evidence from other countries show loss of productivity as
a result of illness, especially malaria and HIV/AIDS
• To achieve Vision 2030, we have to break the vicious cycle
of Disease – Poverty – Disease.
• 23% of Kenyans derives their earnings and support from
Formal sector of whom over 94% are insured.
• Approx. 80% of Kenyans are uninsured.
• 45% of Kenyans live below 1$ a day 17% of Kenyans are
living in abject poverty

16. The Funding of Healthcare Delivery in Kenya
Households, Donors, 29.4%
36.7%
Local
Foundations,
0.1%
Private
Companies,
3.4% Not specified,
Public, 30.0%
0.4%

17. Current Coverage Landscape
Kenya current coverage
landscape
Kenya current coverage: Height:
NHIF what
proportion
of the costs
are
covered?
User fees for
outpatient
services
+ residual fees for
inpatient services
Outpatient
services not NHIF
NHIF covered
Poor and most of informal Tax-funded services
sector not covered Depth: which
benefits are
covered?
Breadth: who is
covered?

18. Vision 2030
• Kenya will restructure the health delivery system and also shift the
emphasis to “promotive” care in order to lower the nations’ disease
burden.
• Provision of affordable and quality health care services is enshrined
in the bill of rights chapter of the new constitution.
• According the National Health Sector Strategic Plan (2005-10); the
Health Ministries Strategic Plans (2008-12) and Vision 2030, the key
objectives can be summarized as follows:
– Increase equitable access to health services
– Improve quality and responsiveness of services
– Improve efficiency and effectiveness of service delivery
– Enhance the regulatory capacity
– Foster partnerships in the delivery of services
– Improve the financing of the sector

19. What we need to ask?
1. How can poor people access health
services?
2. Which services are essential?
3. How much would this services cost?
4. How should contributions for the
financing of the sector be collected?
5. How are Providers paid for services?
6. Inclusion of all service providers into the
national planning and financing process

20. Universal Health Coverage in Kenya
• Since independence, universal coverage in health
has been a major objective. However the it has
eluded the policy makers and implementers alike.
• The delivery system has been dogged by several
weaknesses and threats that include the following :
-
– The perceived failure of the system to cater for the
indigents.
– Inequitable distribution of health resources leading to the
collapse of the referral system
– High cost of medication due to low coverage of medical
insurance
• A number of interventions have been tried
and some have achieved high success rate.

21. A step towards Universal Healthcare in
Kenya
• National Hospital Insurance Fund (NHIF) in
Kenya has recently taken on the challenge
of providing medical cover at low cost for a
large population of government workers.
• Part of their solution is to use capitation
schemes to deliver primary care.
• Currently, about 2 million of Kenya’s 40
million residents have public health
insurance under the National Hospital
Insurance Fund, which relies on
contributions from high-earning Kenyans to
cover hospital benefits for members and
their dependents

22. Snapshot of the National Hospital Insurance Fund
(NHIF)
• National Hospital Insurance Fund is a State Parastatal that was
established in 1966 as a department under the Ministry of Health.
• The original Act of Parliament that set up this Fund in 1966 has over
the years been reviewed to accommodate the changing healthcare
needs of the Kenyan population, employment and restructuring in
the health sector.
• Currently an NHIF Act No 9 of 1998 governs the Fund.
• The transformation of NHIF from a department of the Ministry of
Health to a state of corporation was aimed at improving
effectiveness and efficiency.
• The Fund's core mandate is to provide medical insurance cover to all
its members and their declared dependants (spouse and children).
• The NHIF membership is open to all Kenyans who have attained the
age of 18 years and years and have a monthly income of more than
Ksh 1,000.

23. Proposed NHIF Scheme
Total health expenditure
Pay higher
reimbursement and in
return lower residual Height: what
user fees proportion
of the costs
Include are covered?
outpatient
services
Increase
NHIF NHIF
coverage Tax-funded Depth:
which benefits
are covered?
Breadth: who is covered?

24. Way Forward
• Universal health care is the only way
to guarantee Kenyans medical care.
• Universal Health care has worked for
many other countries and we need
to borrow from their successes and
learn from their failures.

25. What we need to do
– Bridge equity gaps in access to quality health care and
nutrition services: Including developing health infrastructure
in favour of deprived communities;
– Ensuring that public health system remains backbone of
health system care: Including accelerating the
implementation of the National Health
insurance, Strengthening the exemption policy to enhance
access of poor and vulnerable groups to healthcare;
– Strengthening Efficiency in Service Delivery: Including
providing incentive schemes to support the retention and
redistribution of trained health personnel;
– Develop low-cost market – address high private hospital
costs

26. Thank You
Thank you…

27. Q&A