The whole idea behind medical
insurance is one of pooling resources into a common fund to protect against a future
unexpected health emergency. This is truly noble and engrained in our cultures.
A culture of helping someone in need and taking that responsibility as a
community. But shockingly the uptake of medical insurance covers in Kenya is
less than 2%, but if you were to include NHIF as a form of medical cover then
8% coverage. Most of the members of insurance schemes are employees in a fund
mostly solely contributed by the employers. This has its origins in post-World
war II America where the labour laws necessitated a cap on salaries but the
benefits due to employees were not capped. This made it easy for big corporates
to lure the workers through a good medical or dental plan. The same replicated
itself all over the world and now the nascent Kenyan economy has to contend
with a burden of medical care as a cost of production.
The insurance providers in the country are reeling from huge losses in their healthcare portfolios that it’s a miracle that we still have a medical insurance industry in this country. The mood in the industry is one of doom and gloom only covered up with a surplus in other portfolios they may hold. The factors responsible for all these chaos are many but the major ones are:
A medical insurance system based on a fee for service is the prevalent form. This is a demand driven system with the health service providers and payers and users of the medical schemes holding the ace. They dictate how much the cost of service will be though some legal and at times abhorrent behaviors. Many providers have not put in place mechanisms to contain the runaway medical bills because it is not in their interest to do so. As long as the gravy train continuous they are ok with it. This results in increased claim payments with no commensurate increase in premium values due to the muscle of the employers when negotiating a cover and undercutting and competition among the insurance players. The users for whom the insurance is procured are a lot that does not seem to understand the basics of how modern health insurance works and end up adopting a kamikaze approach. It is not a secret that as the financial year closes most employees make a queue to the nearest facilities to make use of the cover they never utilized because they were healthy throughout the year. The pathetic excuse given in most instances is that, “I am covered for Shs 1,000,000 and I have not been admitted even once, so I should make use of it because it will expire in 15days.” This said by someone who paid a premium of Shs 30,000 at most. This is truly baffling as this mentality is what may eventually kill the medical insurance industry in Kenya. I guess majority of policy holders do not realize they are slaying the goose that lays the golden egg until itself to late and the goose is already cooked and on the table. A last supper.
Of greater concern though should be the increase in non-communicable lifestyle diseases mostly in urban areas and especially among the insured portion of the population. This is because the principle of insurance works best when there is a large proportion of the population that is healthy and a small portion that is ill. So when the equation is tilted and the insured are the ill ones coupled with skyrocketing costs of medical care, the recipe is disaster.
I do not have foolproof answers to the challenges but I can only hope that attempts are made to reform the system as the current fee for service system is untenable. There is a need to study the Kenyan health seeking behavior and devise a system that takes this into consideration. One of the most successful systems that could use is one of capitation where the health service provider is entrusted with a fixed amount per scheme per period. This would enable cost containment and a level of sanity among providers. But without checks and measures the quality of care provided would be jeopardized. That is why a value-based system as espoused by the management guru Michael Porter is the only solution. Through such a system cost, quality and outcomes of healthcare are entwined and can be measured .There would be standardization of care and non-conformity to set guidelines would be tracked, documented and corrected. All these are not just verbose narrations but the truth that can set us free and get the industry from life-support. It’s been proven elsewhere.
In lays terms if one leads healthy lifestyle they would be given rebates on their next premiums and better weight management and healthy lifestyle like use of gyms and good control of blood sugars and blood pressure would be the targets to achieve rather than asking “how much is left in my cover?” and therefore attainment of health goals .All these can only be achieved if there is better coordination and cooperation among the industry players whereby the database of members would although controversial be shared to prevent future non-disclosures of chronic conditions. There will also be need of standardization of care at all providers and incorporation of other useful features of a working health system.
The status quo can however be maintained if we seek to kill a useful feature of our health system and to cause a regression in attainment of international standards of life indicators. This is not so bad if we seek to promote the coffin industry and by extension the printing industry, for the obituaries will be many.
