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On
various occasions I have elaborated my ideas on different aspects of healthcare
systems and service delivery. I hold my own beliefs as relates Universal Health
Coverage that could be divergent with some of my friends and colleagues but we
all agree the status quo in healthcare is not sustainable and should be reformed.
Today, I seek to jot a few eye openers to elicit conversation and critical
thinking on key reforms in payment and pooling of resources and whether it
could be the way to go in health service delivery reforms.
Pooling
of resources
The
whole idea behind medical insurance is one of pooling resources into a common
fund to protect against a future unexpected health emergency. Scholars agree
that the bigger the pooled health fund, the better the coverage against unexpected
catastrophic health expenditure. This is truly noble and engrained in our
cultures. We all engage in it in an informal way through constant medical appeals
to which we contribute. This could be considered our “premium”, so that if we
ever fell into same situation we would be assisted in the same way. But
shockingly the concept of pooled resources in a formal way in Kenya is very
low. Medical insurance uptake in Kenya is less than 2%, and if you were to include
NHIF as a form of health insurance then 8% coverage. Most of the members of
insurance schemes are employees in a fund mostly 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 and it is an important consideration for many while
selecting a job.
The
extensive use of Out-Of-Pocket (OOP) payments for health services is a recipe
for financial ruin for many families. Annually many are forced to sell off
their prized possessions including land and driven to bankruptcy due to
unexpected high cost of health care in an emergency. So either through my idea
of government Universal health coverage scheme or pooled resources in the form
of social health insurances or private health insurances, individuals need to
cushion themselves against the potential catastrophic expenditure and
bankruptcy.
While
still waiting for the concept of universal health coverage to be accepted as a
mass movement and implemented through improvement of service in public
healthcare facilities, I urge you to take up at least an NHIF cover and if you
can afford an individual health insurance cover that too.(Don’t Thank me for
that).
Review of our healthcare payment system
Further
to the above, as healthcare management professions need to call for a review of
the payment methods in our health facilities as it contributes to the high cost
of care.
Fee-for-Service payment method
The
prevalent payment system for health services in Kenya is a fee for service
system. This is a demand driven system with the health service providers and
users of the medical schemes holding the ace. The providers dictate how much
the cost of service will be through costing for overheads and their mark-up. Through
this system, providers do not have an incentive to control cost of care because
it is not in their interest to do so. As long as the gravy train continuous
they are ok with it. These results in increased claim payments or in case of
OOP expenditure, high medical bills. The users for whom the insurance is
procured do 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 is called moral hazard in health
economics. I guess majority of policy holders do not realize they are slaying
their goose that lays the golden egg until itself to late and the goose is
already cooked and on the table. A last supper!
Capitation
system
One
of system that could be used 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.
Bundled
payment
Another
payment for services system could be the bundled care approach for services. In
this system costs of care for a hospitalization episode is batched and one does
not need to run like a headless chicken all over the hospital to enquire on the
actual cost of hospitalization during discharge. For example if you were to
have an emergency appendectomy, you would be able to know the expected number
of days of stay in hospital and the cost of treatment on admission. Once the
cost of care to the patient is known, hospitals of similar size could be made
to standardize their costs or risk getting only partial remittance from
insurance companies. This openness in billing system would force providers to
look at improving efficiencies of their system to reduce their expenses and
thus further reducing the cost of healthcare.
This
system is only partially in use in Kenyan hospitals with packages for maternity
and other surgical cases. But it can be expanded with stakeholders involvement
in order to tame the runaway cost of healthcare.
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.
All
these can only be achieved if there is better coordination and cooperation
among the industry players .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.
