The road to health financing reform in Kenya i Atia Hossain

Transcription

1 The road to health financing reform in Kenya i Atia Hossain Kenya s health sector reflects the challenges of a developing nation: the vicious cycle of poverty, sub-optimal quality and standard of health care, lack or unplanned use of limited resources, emergence of life style diseases, wide income variance between rich and poorer section of population are only to name few. However, the Kenyan leaders and policy makers began health sector reforms soon after its emergence as an independent nation in It started with the formulation of Kenyan values, organizing the health service delivery structures, prioritizing investments based on disease pattern, understanding the role of non-state actors, and now more recently emphasizing devolution as an appropriate modality to ensure health services to all Kenyans. This paper attempts to compile the various reforms in health financing strategies the country has adopted. The changes (or are these the paradigm shifts?) in Kenya s health financing strategy dates back to 1965, as follows: Establishment of NHIF District focus for rural development Health SWAp and Joint Programme of Work and Funding Health care financing through general taxation Health Financing Technical Working Group reconstituted Parliament passed the National Social Heath Insurance Bill but not assented / Sessional paper # 10 African Socialism and its Application in Planning National guidelines for the implementation of primary health care in Kenya Introduction of voluntary membership Introduction of user fees Decentralisation identified as key management strategy Approved Kenya Health Policy Framework Multi-stakeholder Task Force established to develop healthcare financing strategy Sessional paper # 7 Achieving Universal Health Coverage Health Financing Strategy drafted The road to health financing reform in Kenya Page 1

2 A brief analysis of the changes in the healthcare financing strategies as depicted above is as follows: In 1965: Parliament of Kenya passed the Sessional Paper no. 10 on AFRICAN SOCIALISM AND ITS APPLICATION IN PLANNING. Eradicate and control of diseases Provision of equal access to health for all Kenyans Provide social welfare services on a large scale 1 st Development Plan prepared Creation of a National Provident Fund and National Health Insurance Abolition of user fees (Ksh 5/-) for every visit to hospitals Centralized provision of service delivery National Provident Fund and National Health Insurance were among other mechanisms to provide social welfare services NPF, NHI: created Equal access on a large scale. Not reached Access was meant User fee: abolished to increase Service delivery through abolition Service provision: Harmonized of user fees, and Decentralized (pre-1963) Regional disparity efficiency gain Centralized (1965) Remained through central control of service provision. However, Mwabu (1995) concluded that although the health service delivery was harmonized, but it did not eliminate regional disparities nor reached everyone. The road to health financing reform in Kenya Page 2

3 Between : National Hospital Insurance Fund (NHIF) is established. Introduce socialism in provision of and access to health care Contributory hospital based cover Voluntary membership introduced In line with Sessional Paper no. 10 of 1965 the NHIF was created. The operation of NHIF started with a contributory hospital based cover for workers earning over Ksh per month (in 1965); voluntary NHIF: created Cost share membership of Introduced those earning below 1000ksh and self-employed (in 1972). In other words, those who afford to pay were Government responsibility on less able to pay Introduced contributing so that the full (cost) burden of service delivery does not fall on the government which can on the other hand concentrate on providing services to those who are less able to contribute. The road to health financing reform in Kenya Page 3

4 Between : Announcement of District Focus for Rural Development (DFRD). Publication of National Guidelines for the Implementation of Primary Health Care in Kenya. Improvement of government performance Provision of primary health care for all Focus on decentralization, community participation and inter-sectoral collaboration DFRD was a sweeping cross-governmental/ sector decentralization programme (in 1983) of which health was part. Following 1978 WHO framework for Primary Health Care for all by year 2000, in 1986 the Government DFRD: announced Sector decentralization: Re-introduced published the National guidelines for the Access to health care: national implementation of PHC: Re-emphasized guidelines for published implementation of PHC. It was yet again focused on decentralization as compared to 1965 when the focus was shifted from decentralized system (pre-independence period) to centralized provision. The road to health financing reform in Kenya Page 4

5 Between : Introduction of (a) general taxation to finance health services; and (b) user fees in public health facilities. Free medical care Revenue collection to relieve budget burden Tax introduced to finance health services User fees re-established With introduction of general taxation to finance health services in order to provide for free medical care between 1965 and 1989 increased the budget burden for the government. In the face of Tax to finance health care: Budgetary burden: budgetary introduced Shared (through tax, user constraints, and fees) declining donor User fee: re-introduced support, the Access to health services: government then Compromised re-introduced of user fees in public health facilities, which was abolished in The fees were meant to supplement the budget in the running and maintenance of the health facilities. as Mwabu (1995) and Collins (1996) observes that the introduction of user charges in 1992 in as effort to inject money into the crumbling health facilities was a major set back in access to services. The road to health financing reform in Kenya Page 5

6 Between : Approval of Kenya Health Policy Framework. Development of National Health Sector Strategic Plan. Recommendation to establish National Social Health Insurance Scheme. Provision of quality health care that is acceptable, affordable and accessible to all Decentralization as the key management strategy Restructuring of NHIF Overhaul of NHIF management to covert NHIF from a hospital to a health insurance fund Set up of task force to explore other financing mechanisms The ongoing reform agenda was detailed in 1994 in the comprehensive Kenya Health Policy Framework Paper ( ) which was approved by the Cabinet. The policy outlined the Government Decentralisation: reemphasized goals: re-focused Achievement of health health policies and priorities in Increase funding to the next century, Health Policy Framework: health sector: and explicitly approved Recommendation to stated the establish NSHIS underlying vision for health developments and reforms as to provide quality health care that is acceptable, affordable and accessible to all (ROK, 1999). The financial reforms in particular included restructuring of NHIF to extend and diversify the range of benefits. The overhaul of the NHIF management was recommended with a view to converting NHIF from a hospital to a health insurance fund. Declining government share (<USD4 per capita) to health sector and high out-of-pocket (OOP) expenditures led to formation of Task Force to explore other financing mechanisms to increase funding to the health sector and reduce OOP spending. The Task Force recommended the establishment of a National Social Health Insurance Scheme. To instrumentalise the health policy, the National Health Sector Strategic Plan (NHSSP) was developed, later improved (for ). In order to achieve the health goals, the government identified decentralization as the key management strategy in the reform of the health sector. The Ministry of Health (2000: 12) articulated decentralization as the delegation of power and transfer of responsibility for planning, management, resource allocation and decision making from central level to periphery level. The road to health financing reform in Kenya Page 6

7 Between : National Social Health Insurance Bill passed by Parliament but not assented to. Healthcare financing strategy drafted. Develop long term, fiscally sustainable, equitable and efficient financing healthcare strategy Multi-stakeholder Task Force established Studies conducted to make informed decisions Health Financing Technical Working Group reconstituted One of the main reasons for the NSHI Bill (2004) not being assented to was due to lack of multi-stakeholder involvement, and thereby leading to non-ownership by the non-state actors who were increasingly NSHI Bill: Stakeholder consultation: becoming visible Passed by not assented to Missing & therefore noownership by the year Task Force was developed to Access to health services: provide for a Compromised platform of stakeholder dialogue based on informed decision making (e.g. through NHA, PETS, etc.). Policy makers were exposed to other country experiences. The draft strategy that was an outcome of such consultations still remains to be discussed and agreed upon. The road to health financing reform in Kenya Page 7

8 In 2012: Sessional Paper no. 7 on Achieving Universal Health Coverage was passed by Parliament but not assented to. Propose mechanisms to attain UHC Sessional paper developed without multi-stakeholder involvement Steps proposed to reform NHIF The same mistake was repeated in the preparation and approval process of sessional paper no 7, as it was done for NSHI Bill. That is, the stakeholders were not consulted. This resulted in the same situation Sessional paper 7: Stakeholder consultation: that the sessional Passed by Parliament but not missing & therefore noownership paper was not assented to assented to. Private sectors were also of the opinion that this paper was prepared just before election of 2013 in order to quickly transform NHIF from hospital insurance provider to health insurance provider. The road to health financing reform in Kenya Page 8

9 In 2013: Presidential mandate on healthcare: towards a healthier Kenya announced. Aims (among other goals): Achieve free primary healthcare for all Kenyans Reform of NHIF Within 100 days of power (i.e. from July 1), health care services to be offered for free Abolition of user fees and decentralization of planning, management, resource allocation and decision making to be reinstated. The challenges in the health service provision remains. The income inequality, high OOP exists. It is therefore to see the result of the good intentions of making healthcare more accessible and affordable to all Kenyans. Election 2013: President elected Decentralization: reemphasized?? The road to health financing reform in Kenya Page 9

10 Paradigm shifts: It is interesting to note how the two common elements have played central role in aiding the Government in opting for or paradigm shifts in the health financing strategies. The two common elements are decentralization or power and user fees. However, the Kenyan values and the broad (WHO) framework under which the services are to be provided remained same. Principles Kenyan values WHO Framework Socialism Health for All Start-end/ common elements Power User fees Decentralization Centralization Abolish Introduce Start Pre End 1965 Reinstate 1986, The blue arrows basically shows the pattern of changes: from decentralization (pre 1963) to decision to centralization (1965), and then reintroducing decentralization as a modality of service provision and administration and financial control. Equal rights or more socialistic view was reflected by abolition the fee structures during 1965, which was then cancelled in 1992, but then again became high in the current government manifesto (2013). When comparing the power play with introduction or abolition of user fees, some form of pattern comes out however, not distinctly. For example, from 1965 and until 1986, the country followed a centrally controlled system, that had no user fees. In 1986, decentralized management was introduced. Although it s not clear from various secondary literature reviews that how long the decentralized system continued, however, there were still no user fees. It may mean that decentralization of 1986 was more of administrative, and not necessarily on financial. Socialistic view was still kept under the national government docket. Socialistic view may have been compromised in 1992 by introducing user fees. It is unclear however, on the type of control mechanism (i.e. centralized vs. decentralized) that the government had during this time period. What is very interesting and yet to see the outcome is the combination of decentralized system with the instruction of abolition of user fees in Obviously, this is due to the government order and priority. However, how the counties would respond over the years awaits to be seen. The road to health financing reform in Kenya Page 10

11 Is there a conclusion? Every paper has a conclusion. However, the road to health financing reform is never an ending game: it evolves, matures, and transforms it is meant to be dynamic. In that sense, Kenya may or may not have enjoyed a smooth ride while trying to ensure access to health services to its population. The country may have to wait many more years, however, the journey shows the effort that the governments have taken, and the complexities of the system amidst which the country is and has been trying to come to a feasible solution on how to finance the health care so that all its citizens are protected from (some or all, predictable or unknown) health related hazards. i This paper is prepared based on various literature review and online sources. The author would like to acknowledge especially Mr. Elkana Ong uti, Chief Economist and Head of Planning Division, State Department of Health, Government of Kenya and Mr. Chacha Marwa, Manager, Strategic and Business Development, National Hospital Insurance Fund for using their presentations to help structure for this paper. The views and analysis presented in this paper is of the Author s own, and not of GIZ. The road to health financing reform in Kenya Page 11