National Hospital Insurance Funds Purchasing Mechanism and Access to Primary Care Health Services in Kenya

Abstract

Health care financing (HCF) is one of the six building blocks of a health system. Kenya envisions having Universal Health Coverage (UHC) by 2022. In order to achieve this Kenya has identified and settled on National Hospital Insurance Fund (NHIF) as a vehicle towards the realization of UHC. UHC is one of the country’s “Big-four” agendas. NHIF is Kenya’s sole social insurer which collects revenue, pools and purchases health services for its members. Purchasing can be passive or strategic, for health systems to be responsive and financially fair, strategic purchasing is the way to go. NHIF is currently undertaking strategic purchasing of primary care health services (PCHS) through capitation. Strategic purchasing should guarantee access to quality, equity and financial risk protection. Despite strategic purchasing, access to PCHS still remains a challenge, with patients still lacking drugs and paying for services. Strategic purchasing requires the purchaser to engage actively in three main relationships: with Government, with healthcare providers, and with the citizens. The aim of this study was to assess the effect of NHIF purchasing mechanisms on access to PCHS for its members. To meet this aim the study focused on determining how citizens’ engagement, providers’ responsibility and County government’s role affect access to NHIF s’ PCHS. This was a descriptive cross sectional study. Data was collected from Nakuru and Nyandarua counties, using semi structured questionnaires, from 395 patients, from 66 NHIF accredited health facilities, and from 115 county health management team members. Results obtained from logistics regression analysis of citizen engagement factors and access, indicate that NHIF communication to citizens (p <0.05, OR=2.4, 95% CI [1.4-4.0]), purchaser accountability (p<0.05, OR=2.07, 95% CI [1.02-4.23] and provider choice (p<0.05, OR=2.99, 95% CI [1.82-4.92) had a significant association with access. Under providers responsibility, monitoring provider performance (p<0.05, OR=31.25, 95% CI [1.58-620.05] had a significant association with access, while analysis of the County government’s role indicate that only the constant was significant while other variables such as communication by NHIF, guidelines for National scheme implementation, adequacy of capitation funds and county health facility infrastructure had no significant association with access to PCHS. In conclusion, citizen are partially engaged by NHIF as this study demonstrates that the citizens received communication from NHIF, and knew how to select a provider, however citizens ‘views and values were not accounted for in NHIF decision making. The providers were undertaking their responsibility as long as the monitoring mechanisms by the NHIF and the county government are in place, however monitoring of performance by NHIF was inadequate. The County health department role was not felt in NHIF purchasing of PCHS, thus this may hinder access of citizens to PCHS. The effectiveness of strategic purchasing of the NHIF National scheme should be based on the successful implementation and effective collaboration of all stakeholders. There is need to raise awareness of the strategic purchasing function in order to promote a shared understanding which will enrich knowledge of the roles and responsibilities of all the players including the County and National governments, NHIF, Citizens and providers, thus improving on access to health services.