Market Assessment of Private Prepaid Schemes in Kenya

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1 Market Assessment of Private Prepaid Schemes in Kenya

2 Market Assessment of Private Prepaid Schemes in Kenya October 2011

3 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes Disclaimer This report has been prepared principally from information supplied by and obtained from discussions with the National Hospital Insurance Fund ( NHIF ) and various private insurance and health stakeholders pursuant to the scope of the work contained in the terms of reference. Our services do not constitute an audit conducted in accordance with generally accepted auditing standards, or an examination of internal controls, or other attestation or review services, in accordance with standards established by ICPA (K). Neither Deloitte nor this report nor any other communication on this report, expresses an opinion or any other form of assurance. We accept no liability to any party in connection with this report. This document has been prepared exclusively for the International Finance Corporation ( IFC ) of the World Bank Group, under a joint Cooperation agreement with the Ministry of Medical Services ( MOMS ) and the National Hospital Insurance Fund ( NHIF ), Kenya. It should not be used, reproduced or circulated for any purpose in whole or in part, electronic or otherwise, without prior explicit written consent from Deloitte and the Project Steering Committee comprising IFC, NHIF and MOMS. 2

4 MARKET ASSESSMENT of private ACKNOWLEDGEMENT prepaid services 1 Acknowledgement This Assignment: A Strategic Review of NHIF and Market Assessment of Private Prepaid Health Schemes was carried out by Deloitte Consulting limited under the auspices of MOMS, NHIF and IFC. Deloitte Consulting Limited acknowledges the leadership and guidance provided by the Project Steering Committee comprising MOMS, NHIF and IFC. Deloitte wishes to express our appreciation to the many stakeholders, public and private who provided indepth information for the assignment. In particular: NHIF management and staff, NHIF Board, MOMS and MOPHS, Donor Partners and the World Bank Group, AKI, KMA, COTU, FKE, KEPSA, KHF and many other stakeholders including the private health insurance industry who were contacted during the assignment. We wish to express our appreciation again to the International Finance Corporation and the National Hospital Insurance Fund for providing the funding for this assignment. In turn, the Health in Africa Initiative ( HIA ) of the World Bank Group wishes to acknowledge the direct funding support from the the Bill and Belinda Gates Foundation and the Netherlands IFC Partnership Program (NIPP) on this report preparation. The findings and conclusions contained within are however, those of the authors and do not necessarily reflect positions or policies of Gates Foundation, NIPP or IFC. HIA also gives thanks to our many colleagues in the World Bank who provided advice and insights on the assignment. Finally, Deloitte wishes to acknowledge the participation of several associates both in Kenya and abroad for their immense contribution to the assignment. 3

5 4 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes

6 MARKET ASSESSMENT of private prepaid services PREFACE 1 Preface The development of a broad strategy on the sustainable financing of healthcare in Kenya has been a concern of all Kenyans. This is because many Kenyans have directly had to pay for health services whenever they need them, and sometimes at levels that can impoverish the family unit. Payment of out of pocket expenditures for health services has become a major barrier to access currently estimated at about 40 percent of total health expenditure. Efforts by the government and development partners to progressively increase funding to the health sector has not led to drastic improvement of health outcomes because of the way the funds are channeled. The first major attempt to develop a comprehensive and sustainable financing framework was started in 2004 through the efforts of the Ministry of Health and other stakeholders. These efforts saw the development of the National Social Health Insurance Fund Bill, whose objective was to pool resources for a universal access to healthcare to the population. However, though passed by Parliament, it did not translate into law due to issues of sustainability and vested interests by some of the stakeholders. Since 2006/07, there were concerted efforts by the government and stakeholders to ensure that the process moves forward. As a result, there were various studies that were undertaken to provide evidence for the overall strategy that would provide for affordable, accessible and quality healthcare services in the country. These studies were complemented by visits to other countries to get lessons on some of the best practices. The launch of the Kenya Vision 2030 also provided more impetus for the fast conclusion of these processes. The subsequent consultations that followed in developing the strategy underscored the need for the National Hospital Insurance Fund (the Fund) to play a major role in the pooling of resources for social health insurance for the population. The complementary role of the private sector was also recognized. However, in order to position the Fund for the enhanced role, it became necessary to carry out a strategic review of the Fund and a market assessment of the prepaid schemes in order to come up with recommendations that would be used in expanding social health insurance and private health insurance in Kenya so as to cushion Kenyans from catastrophic expenditures. It is due to the foregoing that my Ministry partnered with the International Finance Corporation (IFC) of the World Bank and the Fund to carry out a strategic review of the Fund and a market assessment of the private health insurance providers. The focus of the review of the Fund focused on the adequacy of the Fund and its operational systems, including identification of gaps that could be addressed to meet the larger expectations of the people. The market assessment of prepaid schemes focused on reviewing of all previous work commissioned by the Government of Kenya, donor groups or others as well as relevant data that could allow for recommendations that could be implemented to strengthen the role of the private health insurance players. The results from the two surveys have been well received by stakeholders in the sector and other supportive sectors. The recommendations from these studies will facilitate the firming up of the recommendations proposed in the broad draft strategy on healthcare financing. In particular, the recommendations will greatly assist in implementing policies and strategies that will help the government and the country as a whole meet the requirements of the Constitution, which makes access to quality healthcare on of the fundamental rights 5

7 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes in Bill of Rights. It is also my hope that the information and recommendations from these studies will not only help address the broad needs of the reform agenda in the sector, but also assist in strengthenng the role of the private health insurance providers. I wish to thank the International Finance Corporation for supporting this exercise and the consultants, Deloitte East Africa Limited for the good work and the stakeholders for the fruitful contributions during this exercise, and in other areas of partnerships. Finally, I would like to congratulate the Board and Management of the Fund for taking the bold step in opening up to public scrutiny. 6

8 MARKET ASSESSMENT of private TABLE prepaid OF CONTENTS services 1 Table of Contents Disclaimer 2 Acknowledgement 3 Preface 5 List of Tables 9 List of Figures 10 Abbreviations Executive Summary Background and Context Objectives and Methodology of the market assessment of prepaid health schemes Findings of the Market Assessment of Prepaid Health Schemes Recommendations Conclusion Introduction and Background Background and Context Healthcare Financing Status and Challenges in Kenya Summary of Kenya s Healthcare Financing System Scope of Work and Methodology Scope of Work Definition of Key Terms Assessment Design Limitations of Assessment Methodology Findings of the assessment Overview of Prepaid Schemes in Kenya Scope of Prepaid Health Schemes in Kenya Consumer Perception Of Prepaid Health Schemes Constraints for Strategic Growth and Effective Reach of Private Prepaid Schemes Recommendations Strengthening the Policy, Legal and Regulatory Framework Extending Health Insurance Coverage in Kenya Facilitating Strategic Growth and Reach of Private Prepaid Health Schemes Future Role of Private Prepaid Health Schemes in Contributing to the Achievement of National Healthcare Financing Goals Conclusions Recognition of the Mixed Model of Healthcare Financing in Kenya Leveraging the Competitive Advantages of Prepaid Health Schemes Role of Socio-economic Development 93 7

9 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes 6.4 Priorities for Change Appendices 95 Appendix 1: List of References 97 Appendix 2: Scope of Work 98 Appendix 3: Definition of Key Terms 102 Glossary of Terms* 102 Appendix 4: Key Documents Reviewed 106 Appendix 5: Stakeholders Interviewed 107 Other Interviews& Group Discussions 108 Appendix 6: Stakeholder Interview Guide 109 Appendix 7: Key Interviewees Survey Monkey 112 List of Some of the Key Stakeholders Sent the Online Survey Link 112 Appendix 8: List of Attendees 1 st Stakeholder Briefing Workshop 116 Appendix 9: List of Attendees, Deep Dive Workshop 118 Deep Dive Attendees 118 Appendix 10: Draft Healthcare Financing Policy Implementation Framework 120 Draft Healthcare Financing Strategy Implementation Matrix 120 Appendix 11: Data Sheet for Prepaid Health Schemes 122 Appendix 12: Summary of Recommendations 125 8

10 MARKET ASSESSMENT of private prepaid LIST OF services TABLES 1 List of Tables Table 1: Health worker to population ratios 32 Table 2: Global health financing data summaries for various regions (A. Preker et al 2010) 36 Table 3: Analysis of healthcare expenditure in sub-saharan African countries 2007 (Abt Associates HS 20/20) 37 Table 4: Private Health Insurance in Sub-Sahara African Countries (WHO Estimates 2005) 38 Table 5: General NHA summary statistics for 2001/2 and 2005/6 41 Table 6: Financing sources as a percentage of total health expenditure 42 Table 7: Household (HH) spending on Health 42 Table 8: Function distribution as a percentage of total health expenditure 43 Table 9: Various prepaid schemes in Kenya 57 Table 10: Gross premiums written in 2009 by risk pool vehicle. 60 Table 11: Community based health financing organisations data (KCBHFA report 2008) 63 Table 12: Contributions and claims summary Jamii Bora (Abt Associates, Catalogue of CBHF, 2006) 63 Table 13: Selected employer scheme data 65 Table 14: Estimates of 2010 population coverage of health insurance in Kenya 69 Table15: Level of population insurance coverage and GDP in selected Sub Sahara African countries from 2006 NHA s 70 Table 16: Level of population insurance coverage and GDP in selected countries 2008/09 estimates 70 Table 17: Possibilities of overlapping membership between NHIF and other prepaid schemes 71 Table 18: Health Insurance Range of products from various prepaid schemes in Kenya 72 Table 19: Comparison of premium rates for a family of four (M+3) in-patient cover of KSh. 500,000 per family per annum 74 Table 20: Benefit range of various prepaid schemes mapped against commonest causes of morbidity 74 Table 21: Benefit range of various prepaid schemes mapped against commonest emerging chronic diseases 75 Table 22: Summary of self reported hospital financing sources 80 9

11 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes List of Figures Figure 1: Kenya population (Kenya 2009 population and housing census report KNBS) 29 Figure 2: Trends in Infant mortality rates (KHDS 2008/09) 30 Figure 3: Leading causes of out-patient morbidity (MOH HMIS data) 30 Figure 4: WHO building blocks of health system 31 Figure 5: Healthcare financing system mechanisms (adopted from Skehri and Savedoff 2005) 35 Figure 6: Healthcare spending per country sorted out by GDP 37 Figure 7: Comparison of sources of total health expenditure OECD and selected African Countries 39 Figure 8: Government spending on health as a percentage of total government expenditure (MOMS data) 41 Figure 9: Private insurer s gross written premium written (source AKI Annual Reports ) 59 Figure 10: Gross premium MIP Figure 11: NHIF Member contributions (NHIF Accounts) 60 Figure 12: Payout ratios for private insurance (AKI Reports) 60 Figure 13: Acquisition, administration and payout ratios for NHIF: (NHIF Accounts) 61 Figure 14: Payout ratios for NHIF (NHIF Accounts) 61 Figure 15: Total administration expenses % for NHIF (NHIF Accounts) 61 Figure 16: Private health insurance gross underwriting profit/loss (AKI Reports) 62 Figure 17: Population pyramid with possible risk pooling financing of health to ensure universal coverage in Kenya 66 Figure 18: Insurance products current users would buy 68 Figure 19: Perceived barriers to accessing private prepaid schemes 78 10

12 MARKET ASSESSMENT of private prepaid ABBREVIATIONS services 1 Abbreviations Acronym AIDS AKI ANC AOP6 ARVs CBHF DANIDA DPHK FBO FONASA GDP GNI GOK HDI HH HIV HMIS HMO HSSF ICT IMF IPHI IRA ISAPRE s KCBHFA KDHS KFW KHHEUS KIHBS KPHSA KIPPRA KPLC KNBS MDG MIP NCAPD MOF MOH Details Acquired Immunodeficiency Syndrome Association Of Kenya Insurers Antenatal Clinic Annual Operating Plan six Antiretroviral Community based healthcare financing Danish International Development Agency Development Partners in Health Kenya Faith Based Organisations National Health Fund (Chile) Gross Domestic Product Gross National Income Government Of Kenya Human Development Index Household Human Immunodeficiency Virus Health Management Information System Health Maintenance Organisation Health Sector Services Fund Information communication technology International Monetary Fund International Private Health Insurance Insurance Regulatory Authority Instituciones de saludprevisional Kenya Community Based Health Financing Association Kenya Demographic and Health Survey Kreditanstalt fur wiederaufbau Kenya household health expenditure and utilisation survey Kenya Integrated Household Budget Survey Kenya Private Health Sector Assessment Kenya Institute for Public Policy Research and Analysis Kenya Power and Lighting Company Ltd Kenya National Bureau of Statistics Millennium Development Goals Medical Insurance Providers National Coordinating Agency for Population and Development Ministry of Finance Ministry of Health 11

13 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes MOM MOPHS NCAPD NESC NGO NHA NHSSPII NHIF OBA OECD OOP PEPFAR PETS PHI SHI RSBY SOW SS TB THE TPA TOR UNDP WB WHO Ministry of Medical Services Ministry of Public Health & Sanitation National Coordinating Agency for Population & Development National economic and Social Council Non-Governmental Organisation National Health Account National Health Sector Strategic Plan II National Health Insurance Fund Output-Based Aid/Approaches Organisation of Economic Cooperation and Development Out of pocket expenses President s Emergency Plan For AIDS Relief Public Expenditure Tracking Surveys Private Health Insurance Social Health Insurance RashtryaSwasthyaBimaYojna Scope of Work Sub-Sahara Tuberculosis Total Health Expenditure Third Party Administrator Terms of Reference United Nation Development Programme The World Bank World Health Organisation 12

14 MARKET ASSESSMENT of private prepaid services 1 1 Executive Summary 13

15 14 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes

16 MARKET ASSESSMENT of private prepaid services Executive Summary 1.1 Background and Context Socio-economic and health indicators in Kenya Kenya as a developing country in Sub-Sahara Africa is faced with major challenges in its endeavour to foster socio-economic development with the limited available resources. The Kenyan economy is still largely dependent on agriculture, with a GDP of US$ 763/capita in 2009 and a life expectance at birth of 55.6 years. The UNDP 2010 global human development index for Kenya was The structure of Kenya s economy is characterised by a relatively small and stagnant formal sector with about 1.9 million employees and large and growing informal sector with over 8.3 million employees (Economic Survey, 2010). Since independence, Kenya s total population continues to grow and is now estimated at 38.6 million (2009 Population and household census KNBS) with 68 % living in rural areas and the remaining 32% in urban areas. The population growth rate has been relatively high for the last 4 decades and this has major implications for sustainable socioeconomic development. The population is also urbanising and aging with the related impacts on socio-economic development. The Kenya Demographic and Health Survey (KDHS) shows a mixed picture with child mortality decreasing to 52/1000 live birth and under-five mortality to 74/1000 live birth from 77/1000 and 115/1000 live births respectively in KDHS in The number of fully vaccinated children was 77% (an improvement from 2003 when it was 57%) which is slightly below the WHO bench mark of 80%. However, the maternal mortality rate remained unacceptably high at 484/100,000 in While 92% of pregnant mother attend ANC care, only 43% delivered in a health facility. Wide regional variations exist in these important health indicators within the country. Preventable diseases which are easy and cheaper to prevent or treat continue to be the greatest contributor to morbidity. This is in the context of an emerging problem of non-communicable diseases which require greater resources to prevent and manage. At independence, one of the government s major commitments to its people was to fight diseases and provide free health for all. Today, the government remains committed to this goal as summarised by the current policy blue print for social and economic development to a middle income country status by 2030 (Vision 2030). The health vision as articulated in this document is to provide equitable and affordable healthcare at the highest achievable standard. While major strides have been made in achieving the set goals, achieving this commitment has been a major challenge and the attainment of acceptable standards of health in the general population in Kenya is yet to be fully realised Overall health system challenges Kenya has a mixed health system with the public sector as the main player. There is, however, a significant private and NGO sector (mainly faith based organisations). Kenya s health system is weak and still evolving like in most sub-saharan countries. In addition to being highly under-resourced in terms of financial and human resources, the system faces challenges such as erratic availability of health commodities, e.g. drugs and technologies and poor infrastructure. There are significant gaps in the efficient allocation and use of 15

17 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes resources with a skew towards curative care in urban based hospitals. The available resources also suffer high inefficiencies due to perennial leakages. One of the persisting critical challenges is shortage and mal-distribution of human resources especially in rural and remote areas. Upgrading and expansion of infrastructure for healthcare delivery has not been commensurate with increasing demand from a rising population, emerging and re-emerging diseases as well as changes and advancements in medical technologies and consumer choices and demands. The weak primary healthcare system contributes to a weak and failing referral system, thus the inability to ensure that healthcare needs are met at the most appropriate level for efficiency, effectiveness and equity. The health sector management capacity is also highly constrained, leading to sub-optimal deployment and utilisation of available resources. Despite recent advancements in the use of information communication technology to improve efficiency and productivity in other sectors, the health sector in Kenya has largely lagged behind in adopting the same. However, it is worth noting some successes especially in the adoption of medical technologies Healthcare financing status, structure and challenges in Kenya Mobilising adequate resources necessary for attaining and sustaining a globally acceptable standard of health in the population is a major challenge for all nations in the world and Kenya is not different. Recently the WHO reviewed the minimum per capita spending in health necessary to achieve the millennium development goals in health to $54 per capita. Other global targets include WHO s $41/capita in real dollar terms necessary for provision of the minimum package of health and $ 54 per capita to achieve the MDGs. Through the Abuja declaration of 2000, Sub-Sahara African countries committed to spending 15% of the annual government budget on health. The health expenditure estimates in the NHA 2005/6 indicate a per capita total health expenditure (THE) of $27. In 2010/11, the government total expenditure on health was 6.2% of the total government expenditure budget. Kenya s level of spending in health therefore falls well below the global and Sub-Saharan Africa benchmarks for achieving acceptable health standards in the country. The achievement of the set targets calls for a multipronged approach to mobilise necessary financial resources from the government, private sector, individuals and development partners to ensure universal coverage with an acceptable level of healthcare. Every year in Kenya, tens of thousands of households are pushed to extreme poverty due to catastrophic healthcare expenditure and needs to be addressed for equitable socio-economic development. A better understanding of the prepaid schemes in Kenya as they currently operate and the challenges and constraints to their growth and development is critical in understanding how they could play a more significant contribution to health financing and subsequent attainment of universal health coverage in Kenya Government healthcare financing policy initiatives and dialogue The overarching health policy in the health sector is the 1994 Kenya Health Policy Framework which is currently under review. Other key policies include the Vision 2030, National health sector strategic plans and ministries/ sector strategic plans 1. The key policy themes in healthcare financing in Kenya have been focussed on: Improvement of health sector financing through equitable allocation of resources for increased efficiency and effectiveness of resource allocation and use and shift from out of pocket expenses and user fees to Social Health Protection. Equitable access to quality care for all 1 A proposed Healthcare Financing Policy and Strategy for Affordable Healthcare has been developed through a consultative process but it is yet to be formally launched. A multi-sectoral technical working group on healthcare financing is also in operation under the healthcare financing Inter-agency Coordinating Committee (HCF ICC) and the Health Sector Coordinating Committee (HSCC). 16

18 MARKET ASSESSMENT of private EXECUTIVE prepaid SUMMARY services 1 Improved and efficient revenue collection and risk pooling mechanisms. Improved governance and transparency in the health financing system. More efficient and effective use of funds from development partners. Sustainability of the healthcare financing system. In order to realise the above goal, the general policy direction has been to develop a Social Health Protection Model which includes Tax financing (for the poor/indigent), Social Health Insurance (to be provided by one or more bodies depending on efficiency and effectiveness) and supplementary/complementary health insurance by private sector and communities. Healthcare financing structure The healthcare financing system in Kenya has developed over the years into a mixed healthcare financing system whose main components include: 1. General tax financing: This consists mainly of tax financed free healthcare services in public health facilities, later modified by introduction of user fees in National Hospital Insurance Fund (NHIF): This was established in 1966 to finance healthcare in both public and private facilities. The scheme is mandatory for formal sector workers. NHIF operates under the NHIF Act No. 9 of Private health Insurance: This has developed over the years becoming more visible in the early eighties with the introduction of HMOs and growth in health insurance portfolios of insurance companies. Insurance companies and MIPs are regulated by the Insurance Regulatory Authority (IRA) based on the Insurance Act Cap Employer Self-Funded Schemes: Employers provide health benefits as incentives to their workers and dependants through self-insured in-house medical schemes. The schemes are funded by the employer through annual budgets and are either managed in-house or through a third party administrator (TPA). A number of employers run their own healthcare facilities. There is no specific regulation as such for inhouse schemes. 5. Community based health financing (CBHF) schemes: community based financing schemes have emerged over time to meet the healthcare financing needs of low income earners who traditionally have been largely left out of private insurance and NHIF. There is no specific regulation for CBHF and most are registered by the Ministry of Gender and Youth Affairs. 6. Out of pocket (OOP) health spending: Like in most developing countries, OOP has been very high in Kenya although the trends show a reduction from 44.8% in 2002/2003 to 29.1% in 2005/2006 of the total healthcare expenditure (2005/06 NHA). OOP spending is a major barrier for accessing healthcare services and drives households into poverty through sale of assets and diversion of meagre income into healthcare services. However it also reflects a good opportunity to develop risk pooling mechanisms that provide better access to healthcare and reduce the vulnerability of households to uncertain financial shocks arising from healthcare expenditure. 7. Development partners & Non-governmental Organisations (NGOs): Various development partners and NGOs have traditionally contributed significantly to healthcare financing and provision. In the last decade, the proportion of healthcare expenditure contribution by development partners in healthcare financing has more than doubled (2005/6 NHA) raising concerns on the sustainability of the health system. 8. Other Mechanisms: Two other financing mechanisms in Kenya are worth mentioning namely: a) Health Sector Services Fund (HSSF) under MOPHS which was conceived some years ago but was launched It is a form of supply side financing to lower level health facilities (mainly health centres in the public sector but will also in future cover FBO/NGO providers). It is aimed at improving service availability and quality particularly for low income earners and the poor who are served by this level of 17

19 MARKET ASSESSMENT of private prepaid HEALTH SCHEMes facilities. HSSF is governed by gazette notice 401 of 2007 which was amended in HSSF is funded mainly by development partners and the government. b) Output Based Approach Reproductive Health Voucher (OBA) is a form of demand side financing that targets the poor. The poor buy the health vouchers at token prices and the voucher is redeemed within a specific service provider network for specified health services. The OBA program is managed by NCAPD under Ministry of Planning, administered by a private firm and funded largely by donors key among them KFW and to a small extent the government. National Health Accounts Summary According to the NHA of 2005/6, the public sector, private sector (including out of pocket expenses) and development partners contributed 29%, 39% and 31% respectively of the total health expenditure. The total public expenditure for health was low at 5.2% of total government expenditure for 2005/6 6.9% in 2009/10) compared to the 15% agreed on under the Abuja Declaration in WHO recommends a per capita spending on health of $ 41% in real dollar terms for the minimum essential health package but in Kenya the per capita spending stood at $ 27 in 2006 (NHA 2005/6). In low income countries, out of pocket spending tends to be the largest source of financing followed by government and then minimal private risk pooling (insurance). Generally, in middle income countries the proportion of OOP falls significantly while public pooling becomes the largest financing mechanism. Private risk pooling also grows but remains in third position. In high income countries, OOP becomes the least source of funds while public pooling remains the largest source of healthcare financing but with a larger contribution of private risk pooling. It is possible Kenya may witness a similar trend as the healthcare financing system evolves and develops. The funds mobilised for healthcare financing are managed through various financing agents. According to the 2005/6 NHA, the financing agents that managed the funds include: Public Sector % including 3.7% by NHIF. Private Sector % including 4.1% by employers and 5.4% by private insurers. Development partners: There was a dramatic increase in the proportion of funds managed by development partners rising from 7.4% in 2002 to 20.8% in There is an opportunity to channel some of these funds into a more sustainable and broad-based risk pooling mechanism. The distribution of insurance funds between NHIF and private insurance was 40.6% for NHIF and 59.4% for private insurance as per the 2005/6 NHA. Only about 9.1% of THE (Total Health Expenditure) was in any formal risk pool in 2005/ estimates of the distribution showed the following: NHIF 36%, Private insurers 42%, MIPs 14%, international insurance 7% and CBHF 1%. The population coverage of private insurance is small, at about 700,000 lives, compared to NHIF s 6.6 million lives by 2010 estimates. Challenges facing healthcare financing in Kenya Kenya s healthcare financing system, as in other developing countries, faces several major challenges including: High and ever escalating poverty levels. About 46% of Kenyans live on less than a dollar per day and nearly half of this group is considered absolutely poor/indigent (no observable income). High burden of disease from preventable infectious diseases and an emerging epidemic of noncommunicable diseases. Inadequate funding of the health system. MOH Annual Operation Plan 6 (AOP6) for 2010/11 has an estimated funding gap of KSh. 31 billion. Inefficient and ineffective allocation and use of scarce resources. Promotive and preventive health used only about 12% of the total health expenditure while administration took about 14.5% (NHA 2005/6). WHO estimates that about 20 to 40% of healthcare spending is wasted through inefficiency. High out of pocket expenditure (OOP) in the context of a weak risk pooling system. 18

20 MARKET ASSESSMENT of private EXECUTIVE prepaid SUMMARY services 1 Significant inequality in access to healthcare services largely due to financial barrier. Most of the healthcare funds are not in any risk pooling mechanism hence reducing effectiveness and efficiency. Weak health systems as above. High dependence on development partners. 1.2 Objectives and Methodology of the market assessment of prepaid health schemes Objectives The overall objective of the assessment was to assess Kenya s prepaid health schemes including private health insurance and health maintenance organisations (HMOs now referred to a MIPs) and determine their scope and probable role in the ongoing healthcare financing reforms. The assessment of private health insurance and MIPs is also aimed at providing a basis for the strategic growth of the sector and to determine the best way to structure the sector to support the broader financing of healthcare in Kenya Methodology A qualitative study design was used to carry out the assessment. The following methodology was used in data collection: Desk review of selected relevant secondary data. Self-administered survey questionnaire administered to a purposive sample of relevant stakeholders. Due to poor response rates particularly from private prepaid schemes, no quantitative conclusions were drawn from the survey. Key informant in-depth interviews with a purposive sample of relevant stakeholders. Broad-based stakeholder consultative processes to get buy-in and validate the information gathered in the whole assessment cycle. Three consultative processes were held Definition of key terms For the purpose of this assessment, a prepaid health scheme was broadly defined as: Any system or mechanism of financing healthcare services for members of a scheme or health plan as provided by insurance companies, MIPs, Employers, Micro-Insurance and the Community organisations. This broad definition was intended to capture most of the existing healthcare financing mechanisms. A true technical definition of prepaid schemes would be narrow and excludes employer schemes and CBHF. Where relevant, public health insurance (NHIF) was used for comparison. The full list of key terms is detailed in Appendix 2 of this report. 1.3 Findings of the Market Assessment of Prepaid Health Schemes The scope of existing prepaid health schemes Demand and supply analysis The potential market size for prepaid health schemes was estimated in terms of population and the Kenya shilling value. 19

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