Strategic Review of the National Hospital Insurance Fund - Kenya

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1 Strategic Review of the National Hospital Insurance Fund - Kenya

2 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA 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

3 EXECUTIVE ACKNOWLEDGEMENT SUMMARY 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

4 4 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA

5 EXECUTIVE SUMMARY 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

6 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA 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

7 EXECUTIVE TABLE OF CONTENTS SUMMARY 1 Table of Contents Disclaimer 2 Acknowledgement 3 Preface 5 List of Tables 9 List of Figures 11 Abbreviations 13 Preamble 14 Compliance to Terms of Reference Executive summary Healthcare financing in Kenya Objectives and deliverables of the Assignment Approach to achieving the Terms of Reference Summary of Findings and Recommendations Summary of Findings Summary of Recommendations Introduction Definition and Objective of the Strategic Review of NHIF Terms of Reference Objective of the TOR Scope of Work Deliverables Background The Kenyan Context Global Trends in Healthcare Financing Selection of Benchmarks Approach and Methodology Project Governance Conceptual Framework of Strategic Review Methodology Strategic Review Themes Introduction Definition Analysis and Findings Background of NHIF Overview of NHIF Review of NHIF s Strategy Governance Assessment Financial and Actuarial Assessment 83 7

8 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA 7.6 Actuarial Performance Performance of Core Functions Utilisation of Information Technology Human Resource Review Recommendations Improving NHIF as a Social Health Insurer Stewardship Role of Government Cost of Strategic and Organisational Reorientation and Change Conclusion 161 Selected Bibliography 162 Appendix 1: Terms of Reference 167 Appendix 2: Stakeholder Interactions 171 Focus group discussions & Interviews 171 NHIF Staff Interviewed 172 Site Visit Schedule 173 Deep Dive Agenda and Attendee List 174 Deep Dive Agenda 175 Deep Dive Attendees 176 Minutes of key stakeholder meetings 177 Notes from Meeting with Federation of Kenya Employers (FKE) 179 Notes from Meeting with Central Organisation of Trade Unions (COTU) 181 Notes from Meeting with Union of Kenya Civil Servants 183 Notes from Meeting with Kenya National Union of Teachers (KNUT) 184 Notes from Meeting with NGO Council 185 Notes from Meeting with Kenya Private Sector Association Kenya Health Federation 186 Final Stakeholder Workshop (October ) Report 188 Key Messages from NHIF Strategic Review and Market Assessment Final Stakeholder Workshop 189 Minutes from Final Stakeholder Workshop 190 Appendix 3: Proposed Amendments to NHIF Legal Mandate 200 Appendix 4: Risk Heat Map 202 Appendix 5: Risk Management Action Plan 207 Appendix 6: NHIF Network Architecture 208 Current NHIF Network 208 Proposed NHIF Network 209 Appendix 7: Server Data Sheet 210 Appendix 8: Summary of Recommendations & Indicative Costs 211 8

9 EXECUTIVE LIST OF SUMMARY TABLES 1 List of Tables Table 1: NHIF Fact Sheet - June Table 2: NHIF Key Trends to Table 3: Selected Economic Indicators - Kenya 45 Table 4: Labour Statistics Kenya Table 5: Kenya Health Expenditure 49 Table 6: Estimates of 2010 population coverage of health insurance in Kenya 53 Table 7: Summary of NHIF Contract Categories 74 Table 8: Analysis of NHIF Strategy ( ) 75 Table 9: List of NHIF Board Committees 77 Table 10: Analysis of Budget vs. Actual 83 Table 11: Financial performance 84 Table 12: Member contributions 85 Table 13: Contributions and members FY10 85 Table 14: Benefits analysis 86 Table 15: Rent and service charge comparisons 89 Table 16: Major expense categories 90 Table 17: Fixed costs 91 Table 18: Variable costs 92 Table 19: Personnel expenses 93 Table 20: Expenses benchmarking 94 Table 21: Expenses and pay-out ratio benchmarks 94 Table 22: Statement of financial position 95 Table 23: Surplus utilisation 96 Table 24: Accumulated fund analysis 96 Table 25: Return on property 98 Table 26: Office space utilization 98 Table 27: Networking capital 99 Table 28: Financial position benchmarks 100 Table 29: Historical cash flow statement 100 Table 30: Districts and branches visited and assessed 102 Table 31: Ratio of principal members to dependants 103 Table 32: Analysis of Rebates/Facilities 108 Table 33: Summary of NHIF rebates since Table 34: Current monthly contributions 112 Table 35: Inflation Rates 113 Table 36: Contributions - Inflation Adjusted 113 Table 37: Contribution Rates - comparison between current, inflation adjusted and proposed rates 114 Table 38: Estimated population coverage 117 Table 39: Contributions to NHIF FY06 to FY Table 40: Benefits payout ratio analysis 121 9

10 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA Table 41: Contribution and deduction rates 124 Table 42: Staff numbers per level 135 Table 43: Summary of staff distribution 136 Table 44: Personnel costs per level 138 Table 45: Employee turnover 139 Table 46: Observations on NHIF s organisational culture Table 47: Current NHIF contribution rates vs inflation 148 Talbe 48: Gross premiums at 2009 by risk pooling vehicle 151 Table 49: Current expense sensitivity assuming no growth in cont rates

11 EXECUTIVE SUMMARY 1 List of Figures Figure 1: Evolution of NHIF 19 Figure 2: NHIF Membership Trends FY 06 to FY Figure 3: Expenditure trends - FY 06 to FY Figure 4: NHIF Investments as at June Figure 5: Kenya s Economic Growth Rate 45 Figure 6: Kenya's Population Growth Figure 7: Leading Causes of In-patient Morbidity ( ) 48 Figure 8: Leading Causes of In-patient Morbidity Figure 9: Distribution of Health Facilities in Kenya Figure 10: Health Sector Reform - Key Elements 51 Figure 11: Healthcare Spending per Country Sorted out by GDP 54 Figure 12: Sources of Health Financing - Sub Saharan Africa 54 Figure 13: Conceptual Framework of Strategic Review of NHIF 62 Figure 14: Deloitte Risk Management Capability Framework 81 Figure 15: Investments as at 30 June Figure 16: Average Return on Investments in FY Figure 17 : Trends in Expenses 90 Figure 18 : Expenses per Category Fixed Costs 91 Figure 19 : Changes in Fixed Assets (FY 04-06) Cost Basis 97 Figure 20 : Net Fixed Asset Additions 97 Figure 21 : Fixed Asset Composition - June Figure 22 : Net Working capital trend: FY 06 to FY Figure 23 : Net Operating Surplus And Cash Conversion 101 Figure 24 : No. of Members 102 Figure 25 : Membership Growth 103 Figure 26 : NHIF Coverage of Kenya s Total Population ( ) 104 Figure 27 : NHIF Membership and Population 104 Figure 28 : Composition of NHIF s Assets 105 Figure 29 : Composition of NHIF s Assets as at 30th June Figure 30 : Annual Contribution Receipts for Benefits and Operational Expenses 106 Figure 31 : Cumulative Growth of Reserves from 2003 to Figure 32 : Average Annual Contribution per Member 107 Figure 33 : Total Return on Assets 107 Figure 34 : Average In-Patient Claims Frequency since Figure 35 : Average Daily Rebate Rate per Facility 110 Figure 36 : Average Claim by Facility ( ) 110 Figure 37 : Duration of hospitalisation by facility 111 Figure 38 : Active and Inactive Members 119 Figure 39 : Revenue Collection Process Flows 120 Figure 40 : Current NHIF Corporate Structure

12 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA LIST OF FIGURES Figure 41 : Staff Age Profile 135 Figure 42 : Distribution of Staff - HQ and Branches 136 Figure 43 : Suggested Branch Structure 137 Figure 44 : Gross Monthly Salary (September 2010)

13 EXECUTIVE SUMMARY 1 Abbreviations CBHF Community Based Health Financing COTU Central Organisation of Trade Unions FKE Federation of Kenya Employers FY Fiscal Year of Government of Kenya (July 1 to June 30) GoK Government of Kenya GRD Group Related Diagnostic ICT Information Communication and Technology IFC International Finance Corporation KDHS Kenya Demographic and Health Survey KEPSA Kenya Private Sector Alliance KHPF Kenya Health Policy Framework KNHA Kenya National Health Accounts KRA Kenya Revenue Authority KQM Kenya Quality Model KSh. Kenya Shillings MOF Ministry of Finance MOMS Ministry of Medical Services MOPHS Ministry of Public Health and Sanitation NHIF National Hospital Insurance Fund NSSF National Social Security Fund OOP Out of Pocket Expenditure PS Permanent Secretary SHI Social Health Insurance WB The World Bank WHO World Health Organisation 13

14 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA PREAMBLE Preamble The strategic review of the National Hospital Insurance Fund (NHIF) has been carried out by Deloitte Consulting Limited ( Deloitte ), covering the period from 2005 to The findings, conclusions and recommendations of this strategic review reflect the work undertaken by the consultants over the last 12 months from August This review was undertaken under the broader context of the terms of reference which seeks to determine how Kenya can improve health insurance coverage of its citizens. As part of this strategic review, an attempt has been made to engage stakeholders in health financing in Kenya in both the private and public sector. In addition, extensive consultation has taken place with both the Board of Directors as well as the management of NHIF. The views of the various stakeholders have been considered in developing the findings, recommendations and conclusions of this strategic review. Some of these views have differed from the recommendations and conclusions as presented in this report this report therefore includes the direct feedback received from key stakeholders as appendices and where there were differences of opinion, this has been noted in the various report sections. Engagement was with the sector stakeholders and not directly with members of the public; this was in congruent with the highly sensitive nature of the discussions and the need to safeguard the factual and independence attributes of the evaluation. The conclusions of this strategic review are paramount in determining the next steps in the on-going reforms in health financing in the Country. It is hoped that these findings and recommendations will form a factual basis on which strategies can be developed. Further, it is hoped that this will encourage public discussion on healthcare financing. Compliance to Terms of Reference In completing this assignment, the terms of reference (detailed in Appendix 1) comprised the main guideline. The table below summarises the deliverables of the strategic review of NHIF against the terms of reference. i ii Terms of Reference Based on applicable best practice models globally, as well as the proposed national health financing reforms in Kenya; review the adequacy of the mandate for the NHIF, and work with NHIF to develop a revised mandate for the institution. If applicable, recommend revised provisions of the NHIF Act to enable the NHIF pursue its revised mandate; Conduct a Gap Analysis of NHIF s capacity and potential with regard to: Its current mandate and capacities; and ii) the revised mandate as developed. This analysis should consider all aspects of the NHIF including but not limited to: roles and responsibilities of staff, appropriate skill matching, policies and procedures, governance, management, IT and MIS, as well as all financial considerations relating to receiving, disbursing, investing, risk management and controls; Report Reference Chapter 7: 7.1 Assessment of governance; Chapter 8: Appendix 6: NHIF Act amendments Chapter 7: analysis and findings Governance (7.4), Financial analysis (7.5), actuarial analysis (7.5), policies and procedures (7.6), MIS (7.7), HR (7.8) iii Benchmark NHIF s efficiencies against other similar organisations; Chapter 7 (7.4 to 7.8) iv Review the NHIF accreditation process and criteria for effectiveness and consistency with the national accreditation process for health entities in the country; Chapter 7, Section

15 EXECUTIVE SUMMARY 1 v vi vii viii ix x Terms of Reference Review the systems of cash collection and payments for benefits as well as current and previous applications of surplus and accumulated funds; Review and recommend sustainable investment procedures and guidelines for cash flow, investigate the structure of current revenue streams and explore other sustainable revenue streams that will enable the NHIF expand and sustain its reach; firstly to the formal and informal sectors; and secondly to indigents; Determine the role, if any, that the NHIF can play in serving the additional needs of indigents with its current income base and indicate any gaps; Assess the cost of strategic and organisational reorientation and change; Develop costs for capacity development, change management strategy and plan for NHIF (policy, organisation, staff) to be prepared for its future mandate and roles including a core strategy for internal and external change communication; Develop recommendations on: i) how to bridge the gaps identified in the Gap Analysis and to achieve the revised mandate; ii) improve operational efficiency; iii) improve the accreditation process; iv) improve cash and investment management; v) increase resources; vi) improve coverage; and vii) the costs of effecting recommended changes. Report Reference Chapter 7: Section 7.5 (surplus utilisation, accumulated funds), Section (registration), (collections), (payment of benefits) Chapter 7, section 7.5 & 7.6: finance and actuarial findings and analysis Chapter 8: (increasing contributions), (expanding coverage) Chapter 8: (no. 4) Chapter 8: Section 8.4 Chapter 8: Section 8.4 Chapter 8: to

16 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA 1 Executive Summary 16

17 EXECUTIVE SUMMARY Executive summary In August 2010, Deloitte Consulting Limited ( Deloitte ) was jointly commissioned by the Ministry of Medical Services (MOMS), the International Finance Corporation (IFC) and the National Hospital Insurance Fund (NHIF) to carry out a comprehensive strategic review of NHIF and a market assessment of the pre-paid health schemes/health Maintenance Organisations in Kenya. The outputs of this assignment are two reports as follows: 1. Strategic Review of NHIF and options for the revised future mandate of NHIF 2. Market assessment of pre-paid schemes This document presents the observations, findings, conclusions and recommendations from the Strategic Review of NHIF. 1.1 Healthcare financing in Kenya Healthcare financing refers to the pooling of funds from various sources such as government, households, businesses and donors to share financial risks across larger population groups, and using them to pay for services from public and private healthcare providers 1.The main players in Kenya s health financing sector are: the Government, which has a specific political and economic development agenda; the citizens of Kenya, of whom only 19% have attained health insurance coverage at present; private insurance providers who operate various health insurance schemes of varying sizes in a fairly competitive and unregulated environment; providers of health services including Government health facilities, faith-based mission facilities and private for profit providers; Kenya s development partners, many of whom have health as a major programme focus; and NHIF, the only government run health insurance scheme to which all people earning more than KSh. 1,000 per month have a statutory requirement to contribute funds. Kenya s health financing and broader health sector reforms are influenced by international resolutions and agreements that the Country is party to. In 2005, the World Health Assembly of member-states of the World Health Organisation (WHO) passed a resolution on universal health financing coverage. In addition, Kenya has committed to allocate 15% of its budget targets to health spending as stated in the Abuja declaration, as well as work towards achievement of the Millennium Development Goals(MDGs). Achieving universal health financing coverage is a challenge even to the most advanced economies. In the United States, the motivation behind the recent healthcare reforms is the desire to cover 32 million Americans that are without health insurance 2. It has been recognised that having a large proportion of the population without health insurance has a negative impact on overall health indicators. When people are unable to access healthcare due to the barrier of financing, then it is imperative for Governments to address this issue. 1 WHO, the World Health Report 2000: Health systems: improving performance, Geneva, World Health Organisation, Patient Protection and Affordable Care Act preamble, signed March

18 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA 1.2 Objectives and deliverables of the Assignment The overall objective of the assignment was to: 1. Conduct a Strategic Review of the operations of the NHIF with a view to improving the efficiency and reach of the NHIF; and 2. Assess Kenya s pre-paid health schemes including private health insurance/health Maintenance Organisations (HMOs) in Kenya and determine their scope and probable role in the on-going health financing reforms. It is expected that the assignment s deliverables will inform the current on-going efforts to develop a health financing policy framework for the country. According to the Terms of Reference, the deliverables from this assignment are: 1. NHIF Strategic Review Report, prepared for the NHIF internally and its funders. This report will include a mapping of how well the NHIF has been performing against its current mandate and provide recommendations for strengthening and moving towards universal health coverage. 2. An external version of the NHIF Strategic Review, prepared for stakeholder consumption. 3. A report on the market assessment of pre-paid health schemes in Kenya. 1.3 Approach to achieving the Terms of Reference In order to achieve the assignment objectives, a collaborative and inclusive approach was used. The major elements of Deloitte s approach were: Robust project governance: This project has been guided by a project Steering Committee (SC) formed at the commencement of the assignment. The SC comprises representatives from MOMS, NHIF, and IFC. The SC is responsible for providing leadership, guidance and advice to the Deloitte team, feedback and sign-off on deliverables and approving all stakeholder interactions. A systematic and phased methodology that encompasses the key thematic areas of the strategic review of NHIF, grouped in functional work stream areas that covered all aspects of NHIF s internal and external environments. Thorough and detailed review of documentation related to social health insurance, NHIF, Government health strategies and international trends in health financing. A selected bibliography is included in the appendices. Detailed fact finding site visits to NHIF branches and providers, meetings and discussions with NHIF CEO, Board, management and staff. The list of documents reviewed, sites visited and meetings held is included in the appendices to this report. Extensive consultations with the health financing sector stakeholders as well as NHIF s specific stakeholders aimed at gathering comprehensive views. The stakeholder interactions included an initial Stakeholder Breakfast held within a month of commencement of the assignment, a Deep Dive workshop, focus group discussions as well as one-on-one meetings. Deep Dive workshop was an innovative working session at which key sector stakeholders were brought together to brainstorm on ideas for the future of healthcare financing in Kenya with specific reference on the role of Government, private sector and NHIF. 1.4 Summary of Findings and Recommendations 18 NHIF was set up in 1966 under Cap 255 of the Laws of Kenya as a department under the Ministry of Health. Its establishment was based on the recommendation of Sessional Paper no. 10 of 1965: African Socialism and its Application to Planning in Kenya. The original act was revised and currently, the Fund derives its mandate from the NHIF Act no. 9 of 1998.

19 EXECUTIVE SUMMARY 1 Contribution rates increased with the introduction of a graduated scale in 1990 with NHIF contributions capped at salaries of KSh. 15,000 and monthly contributions ranging from KSh. 30 to KSh These are the current rates, as increased rates proposed in 2010 by the Fund are under suspension by court order. In 1998, the original Act was repealed and replaced with the NHIF Act of 1998, which established the Fund as an autonomous state corporation. The transformation of NHIF from a department of the Ministry of Health to a state corporation was aimed at improving effectiveness and efficiency. The unchanged rates since 1990 have impacted on the Fund s ability to expand the depth of cover to meet the growing population. Key highlights in the evolution of NHIF are illustrated in Figure 1. Pre-independence colonial Government health scheme Increase in contribution rates NSHIF Bill passed by Parliament but not signed by President Pre NHIF setup as Department in MOH Sessional Paper No 10 NHIF Act enacted NHIF becomes independent state corporation Outpatient benefit introduced and new rates gazetted Figure 1: Evolution of NHIF As at June 2010, NHIF has been able to reach 6.6 million beneficiaries, with 2.8 million principal members. This is by far the largest number of lives of any health insurer in the Country the private sectors health insurance covers 700,000 lives. The NHIF therefore covers approximately 18% of Kenyans. Countries with a long history of social health insurance such as Germany (127 years) took decades to achieve universal coverage. However countries such as Thailand and South Korea which started SHI more recently have taken a shorter time, 10 years and 35 years respectively. In Africa, countries with relatively impressive coverage rates include Ghana (56%) and Rwanda (70%); these have been achieved within a relatively short period of time. In all cases, strong government stewardship and contribution has been necessary to achieve high coverage. Some basic facts about NHIF are highlighted in the table below. Table 1: NHIF Fact Sheet - June 2010 NHIF Fact Sheet: 30 June 2010 Number of members Number of members + dependants Total contributions received (KSh.) in FY 2010 Total benefits paid out in FY 2010 No. of branches No. of window / satellite offices Total: 2.8 million Formal sector: 2.3 million Informal sector: 0.5 million 6.6 million No. of employees 1,629 No. of providers in NHIF network KSh. 5.7 billion KSh. 3.1 billion No. of claims in FY ,000 Amount of average claim (KSh.) 10, hospitals (98% of Kenya hospitals) 19

20 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA The main growth trends in the last 5 years are outlined below. Table 2: NHIF Key Trends to 2010 FY06 FY07 FY08 FY09 FY10 % annual Growth in number of members 11.6% 11.2% 12.3% 14.2% 13.9% Pay-out ratio 27.5% 33.7% 40.2% 49.3% 53.0% % Annual growth in contributions collected 11.0% 14.3% 14.9% 11.7% 13.0% % Growth in claims paid 32.7% 41.1% 37.8% 37.9% 22.0% % Growth in no of claims 20.3% 16.8% 26.4% 20.9% 24.8% Ratio of no. of claims/members 7.8% 8.2% 9.2% 9.7% 10.7% The figures presented in the two tables above (Table 1 and 2) are a direct reflection of the strategic plan that NHIF has been pursuing over the past 5 years. During this period a strategic focus has been placed on increasing revenues through aggressively increasing membership registration, aiming for higher levels of efficiency, improving the Funds effectiveness by expanding its benefit package and rebranding the Fund to improve on its perception in the public domain. The strategy has been reviewed in detail in Chapter 7 (section 7.3) of this report. Key highlights of the strategic successes of the Fund are outlined below: NHIF s membership has grown during the 5 year review period (from FY 2006 to FY 2010); NHIF has increased coverage of the informal sector from less than 200,000 in 2005 to 531,388 as at June The Fund s contribution rates have not changed since 1989, but increasing number of members have enabled a robust growth in contributions averaging between 11% and 14.9% per annum between FY 06 and FY10. The total contribution revenue has increased from KSh. 3.1 billion in FY 06 to KSh. 5.7 billion in FY 10. NHIF has also increased the level of pay-out of benefits to members and their beneficiaries. The pay-out ratio (i.e. the proportion of contributions received paid out for provision of benefits) has increased to 54% in FY10 from 32% in FY06. This growth in the pay-out ratio is driven by the rapid increase in the claims paid out, which have grown from KSh. 1.1 billion in FY 05 to KSh. 3.1 billion in FY 10. Over the past 5 years, the Fund has increasingly invested in information technology to reach members and support the delivery of its mandate. This includes the introduction of tools such as electronic funds transfer (e.g. M-Pesa), swipe cards, point of sales systems and other innovations that have increased the efficiency of the Fund. NHIF has improved its claims payment periods for undisputed claims comparing favourably with private insurers. On average, NHIF pays claims between 14 to 21 days compared to the best paying private insurers who pay at least within 30 days. Within the last 5 years from FY 06, NHIF has progressively been increasing the rebates on its in-patient package and increasing the number of hospitals in its network. The Fund has contracts with 645 hospitals, accounting for 44,299 beds in Kenya against a total of 49,000 beds. NHIF covers close to 100% of all hospitals in Kenya among the various categories from the public hospitals to faith-based and private hospitals. This is by far the largest coverage off all insurers in the Country. To add to the existing in-patient services, the imminent full scale implementation of out-patient services will be a major improvement on the level of service offered to members. 1.5 Summary of Findings Detailed findings and analysis are presented in Chapter 6 and 7 of this report. A synopsis of the findings along strategic thematic areas is presented below. 20

21 EXECUTIVE SUMMARY NHIF Structural/External environment It is important to recognise that NHIF s operations are not carried out in a vacuum. The Fund operates within a specific structural and external environment which has a direct impact on its daily operations as well as its longer term strategic aspirations. This structural and external environment was analysed as part of the strategic review. The main factors emerging from the external environment review included: Policy environment: the Government spearheads policy formulation through national strategies such as Vision 2030 on which the Ministry of Medical Services strategic plan and the National Health Sector Strategic Plans are based. The new Constitution also obligates the Government to undertake certain policies for health so as to ensure social security as well as the right to emergency healthcare. To integrate these aspects and provide practical guidelines to achieve the principles, a healthcare financing strategy that explicitly sets out the role of all sector players is required. This healthcare financing strategy does not exist. Legal and regulatory environment: Healthcare financing is currently influenced by two main legal and regulatory frameworks namely, the NHIF Act of 1998 from which NHIF s mandate and functions derive and the Insurance Regulatory Agency (IRA) Act (2006) which looks after the private sector in health insurance. Social protection structures: Social security has been defined as any programme of social protection established by legislation, or any other mandatory arrangement, that provides individuals with a degree of income security when faced with the contingencies of old age, survivorship, incapacity, disability, unemployment or rearing children. It may also offer access to curative or preventive medical care 3. Kenya s social security structures are very basic and do not offer the basic social protection required by the Country s citizens. The national provident Fund, National Social Security Fund (NSSF) and NHIF are currently seen as the Government s vehicles for providing social protection. NHIF s social protection mission is increasingly coming to the fore, as the Fund seeks ways of working as a social health insurer with broader social goals. The analysis contained in this report seeks to establish how well the NHIF s social mission is being achieved. Health insurance market structure: The health insurance market structure in Kenya comprises private healthcare insurance schemes as well as the NHIF. The private pre-paid schemes range from traditional indemnity insurers, community based health schemes, employer schemes and health maintenance organisations. As a result, the market has many fragmented risk pools and most financing is out of pocket. The market structure is also affected by supply side constraints which include poor regulation of providers and high provision costs Governance Governance in a Social Health Insurer (SHI) occupies a unique niche with characteristics of public and private entities. The public aspects come from the fact that NHIF is a public body formed by the Government to provide health financing, and the private aspects come from the fact that the Fund is based solely on contributor s funds, without any inputs from Government. In NHIF s case, the mandatory nature of the contributions adds an extra expectation on the Fund s governance by the contributors. The review therefore focused on the Fund s governance structures including the Board of Directors, the accountability of the Fund to contributors and risk management functions of the Fund as well as an understanding of the NHIF Act. The main instrument of governance at NHIF is the NHIF Act, 1998 which stipulates the mandate and functions of the Fund. The NHIF Act also defines the composition of NHIF s Board of Directors by designating specific officials from certain organisations broadly representing Government, employers, workers and other key stakeholders such as private insurers, and medical doctors. The entire governance structure of NHIF is predicated on NHIF being a state corporation, despite receiving funds from contributors only. This governance model is common among other SHI organisations (e.g. in Philippines and Thailand) and is based on the fact that the Fund is accountable to its contributors on whom mandatory contributions are levied. 3 International Social Security Association, based at International Labor Organisation, Geneva 21

22 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA The Act stipulates the membership of the Board from health insurance stakeholders representing employers, workers and the Government. This is in line with other SHI organisations and is based on social protection good practice as identified by the International Labour Organisation. The Board members are the means by which contributors are represented at the Fund. This diversity has helped ensure that specific skills, areas of experience and expertise are available to direct the Fund. However, the NHIF Act does not have specific skill requirements for Board members and these can therefore vary depending on the nominations to the Board by the representative organisations. As the Board becomes responsible for increasingly large sums of member funds, financial and investment management as well as legal knowledge become important to help the Board effectively execute its fiduciary responsibility. The membership of the Board needs to balance between the existence of essential skills, the need for effective representation and having manageable numbers on the Board. Skill enhancement would not necessarily entail an expansion of the Board of Directors. The NHIF s Board Charter is well defined and adhered to and the Board committees overseeing various areas (e.g. finance and audit) have been properly constituted with relevant terms of reference; however an independent Board evaluation is yet to be carried out. This would be an evaluation by an external party into the specific performance of the Board of Directors against its terms of reference. In common with other SHI organisations, NHIF s Board is intended as the link between the Fund and contributors. To that end, key contributor groups were identified in the NHIF Act and these bodies nominate members to the Board of Directors. This plays a key role in ensuring independence of the Board as in principle should minimise the political influence on the Fund and help safe guard the contributors Funds. In practice, it was noted that 5 of the 14 members of the Board are Government officials which increases the influence of the Government over the Fund. In addition, key contributor groups such as the Civil Servants and some informal sector groups are not represented on the Board. Through this representative mechanism there is no direct link between the members and the Fund. Public disclosure of operational and financial information is limited, with information being disseminated through Government channels e.g. parliament, but not directly to contributors. An independent mechanism for contributors to address any grievances has also not been set up and indeed is not envisaged in the NHIF Act. The Fund is also required to safeguard contributor s funds and ensure risk management procedures have been put in place. NHIF s Board must play a key role in risk management at the Fund and this role needs to be enhanced. In addition, with the increasing importance of information technologies, information systems risk security is a major area of risk for the Fund, as IT systems are used to collect revenues and pay out claims Financial sustainability Social health insurance functions on a pay-as-you-go premise and NHIF s financial sustainability is dependent on prudent matching of receipts (collections) to expenditures. Kenya is one of the few countries whose public health insurance scheme relies solely on funding from members contributions. Other schemes, such as in Germany, Chile, and Philippines have contributions from employers and Government. Others rely on some additional income from tax contributions including Ghana s National Health Insurance Scheme, Britain s National Health Service (NHS) and Sri Lanka s National Insurance Scheme. In the case of NHIF, longer term financial sustainability is a function of several factors including sufficient revenues, expenditures, assets and liability management. Review findings for each of these areas are briefly summarised below. Greater detail is available in the financial and actuarial analysis section in Chapter 7 of the report (Section 7.5). a) Sufficient revenues: This depends on the ability to optimise membership contributions as well as a sustainable contribution rate. 22

23 EXECUTIVE SUMMARY 1 i) Membership contributions: NHIF currently covers 2.8 million principal members for an estimated total of 6.6 million (including dependents); this accounts for 18% of Kenya s population. The membership has been growing at an average of 13.5% per annum for the last 5 years (from FY 06 to FY 10), with more rapid growth among the informal sector. Traditionally, NHIF has drawn its membership from the formal (employed) sector. Figure 2 illustrates membership trends over the past 5 years: 3,000,000 2,500,000 2,000,000 1,500,000 1,000, ,000 FY 06 FY 07 FY 08 FY 09 FY 10 Formal Sector Informal Sector Total Figure 2: NHIF Membership Trends FY 06 to FY 10 The membership has grown fastest in the informal sector though it still accounts for only 19% of the total membership of the Fund (i.e. as at FY 10, 523,000 informal sector members out of 2,800,000 total members). The year-on-year growth for informal sector members has averaged 38% in the last 5 years and 10% for formal sector members. It is expected that future growth will therefore largely come from the informal sector which has lower levels of coverage. Comparatively,according to the Economic Survey 2009, the number of new jobs created by the domestic economy declined from thousand in 2007 to thousand in Further, the informal sector which constituted 79.8% of total employment continued to form the bulk of total jobs created (433.5 thousand jobs). The formal sector s compliance rate is estimated by the Fund to be close to 100% and therefore any additional growth is likely to be from the informal sector. The formal sector in Kenya is stagnant and membership is saturated and growth will mainly come as the informal sector becomes formal. For the informal sector a growth pattern or trend cannot be extrapolated at present given its very nature as informal and its dynamic nature with the majority of workers being transitory, operating across the formal and informal economy. If, the recommendation that organisations that pool the informal sector such as SACCOs be collecting agencies on behalf of NHIF is implemented, then it would be possible to develop strategies to increase informal sector membership in a predictable manner. Despite the increasing number of members, NHIF faces variations in the level of activity among members with dropouts being experienced. Inactivity rates are higher among the informal sector members who make voluntary contributions. Inactivity occurs when contributions are paid inconsistently by members in a particular period. Overall, NHIF estimates 30% of all members are inactive with significantly higher levels of inactivity among the informal sector. The higher levels of inactivity are compounded by the fact that the informal sector members consume 33% of the benefits paid out and contribute a paltry 5% of contributions. 23

24 STRATEGIC REVIEW OF THE NATIONAL HOSPITAL INSURANCE FUND KENYA ii) Contribution rates: NHIF contribution rates are set on the basis of income for the formal sector members with a monetary cap, with informal sector rates being set at 50% of formal sector contributions. The contribution rates were last changed in 1990 and have been non-responsive to inflation fluctuations. b) Expenditure: From FY06 to FY 10, expenditure has increased with costs mainly consisting of: i) Benefits: Benefits paid have been increasing as the number of members grows. The benefit pay-out has grown by 29% over the past 5 years from 2006 from a pay-out rate of 26% to 55% from 2006 to 2010, whereas membership has grown by only 13.5% over the same period. Benefits paid are growing at a faster pace than membership and with a growing informal sector; this is particularly evident in the last 5 years. ii) Administrative/operating expenses: Administrative or operating expenses are the cost of running the Fund excluding the payment of benefits. Administrative expenses have been increasing from FY 06 to FY 10 at a rate of 16.3%. With the increase in contributions, the proportion of administrative and operating costs has fallen from 74% to 45% in % of operating / administrative expenses is accounted for by personnel expenses which have increased at the rate of 15.3% p.a. over the last 5 years. Figure 3 below summarises the trend in the administrative or operating expenses. 6,500 6,000 5,000 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, ,080 3,459 1,106 1,527 1, , ,903 1, ,546 2,054 2,186 1, ,813 2,375 1, ,110 2,729 1, FY06 FY07 FY08 FY09 FY10 Contributions Hospital & general claims Total operation expenditure Personnel expenses Other operation expenses Depreciation Figure 3: Expenditure trends - FY 06 to FY 10 From the above chart, the total operating expenditure has grown from KSh. 1.5 billion in FY 06 on contributions to KSh. 2.7 billion in FY 10, with personnel expenses accounting for 71% of these expenses. The expense rates have grown on average at 16% for the past 5 years, whereas contributions have grown at 13.5% with benefits growing at 29% in the past 5 years. These trends indicate that total expenses (benefits and administrative overheads) are growing at a faster pace than the growth in contribution revenues. Without an increase in contribution rates, increased membership, and/or a drastic reduction in administrative expenses, NHIF may face a challenge as it starts to utilise its reserves to meet recurrent expenditure. SHIs generally aim to maximise the benefit pay out and minimise the operating or running expenses so as to maximise the benefits to the beneficiaries. c) Assets: NHIF has both short term and long term (fixed) assets. The short term (current) assets include cash and bank balances, equity investments and income from Government bonds. As at FY 2010, the noncurrent assets comprise 20% of the total asset portfolio with fixed assets (property, plant and equipment) comprising the 80%. This is a legacy of the historical investments in property by the Fund before The fixed assets represent a significant proportion of the balance sheet and indeed the net current asset position was negative as at June For many SHIs, fixed assets are generally a much lower proportion 24

25 EXECUTIVE SUMMARY 1 of the organisation s assets (e.g. in the Philippines and Taiwan, fixed assets account for less than 10% of the asset portfolio). d) Reserves and investments: In a financial year a surplus or deficit may arise as a result of net dealings with members, that is, the difference between contribution revenues less benefits and administrative expenses. Before 2005, NHIF had been recording significant surpluses which had accumulated to significant reserves. In the 5 years from 2006, NHIF s reserves had started to decline. NHIF s investments are largely in fixed assets and the investment portfolio is structured as shown in Figure 4: Treasury bonds and bills, Kshs 398 m 4% Car loan and mortgage deposit Kshs 469m, 5% Call depostis Kshs 322m, 3% Treasury bonds and bills Car loan and mortgage deposit Call deposits Rental property Source: Management information Figure 4: NHIF Investments as at June 2010 The overall return on investment was just 3% as at FY 06. While typically in Kenya real estate can provide good returns on investment, NHIF generally has averaged a return of 2% for its real estate portfolio. Real estate forms a large proportion of NHIF s investment portfolio; this has had the effect of dragging down its overall return on investment. The Fund has in the past not made effective investment decisions, resulting in over-investment in property. The conclusion of this extensive financial and actuarial analysis is that the Fund faces a major challenge in ensuring financial sustainability. NHIF s financial position is currently characterised by rising pay-out caused by significant increase in informal sector membership, unchanging contribution levels and increasing expectations from members. Its current asset base consists largely of fixed assets which cannot be easily liquidated. The financial sustainability issue is also illustrated by the Fund s negative current assets position for the past 2 years as well as its declining cash flows Effectiveness and Efficiency NHIF seeks to provide effective financial protection from ill health to its members through an effective benefit package. The Fund has contracts with 645 hospitals in all parts of the Country for provision of in-patient services to members and their beneficiaries. Currently, NHIF has the most expansive network of hospitals of any health insurer in the country, covering all public hospitals, mission / faith-based hospitals and private hospitals, with a coverage of 98% of the hospital beds in the Country. NHIF provides services through contracts specifying the coverage rates or rebate rates depending on the contractual agreement with the providers. The best and most comprehensive coverage is achieved at public health hospitals and faith-based hospitals. These hospitals account for over 60% of facilities in the Country. Contractual terms are agreed with the various hospitals depending on the contract category. NHIF s rebates 25

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