How new Ruto health laws will change fees and referrals
Health Cabinet Secretary Susan Nakhumicha Wafula. She gazetted the Social Health Insurance Act on November 22, 2023.
The government has proposed tough new measures to address numerous corruption reports involving inflated hospital bills and fictitious statements as the national health insurer transitions to a proposed Social Health Authority.
In the published draft of Social Health Insurance (General) Regulations, 2023, to actualise the Social Health Insurance Fund (SHIF), which will replace the NHIF, the amount to be paid for health services in the country be it in private or public health facilities will be determined by the Social Health Authority.
The SHIF Act was suspended by the courts last week, after a petition challenged its constitutionality, especially on pegging provision of government services on whether or not one is a member of the proposed health authority.
The public has until December 12 to provide their input on the matter.
The SHIF will be funded by deducting 2.75 per cent of every employee’s earnings and this will also apply to those in the informal sector.
“The Authority shall pay healthcare providers and health facilities for the provision of services based on the tariffs prescribed and pay the claims lodged based on the tariffs prescribed in the Act,” says the regulations.
It states: “A contracted healthcare provider or health facility shall provide the healthcare services set out in the regulations, as applicable, within or outside Kenya while complying with directions issued by the Authority,” says the regulations.
Currently, hospitals charge according to the rates dictated by the Kenya Medical Practitioners and Dentists Council.
However, many Kenyans are still unable to afford treatment especially in private facilities.
Last year, the Health ministry called on private hospitals to reduce the charges on their services, this led to several hospitals threatening to stop serving patients with National Health Insurance cards since the government wanted to control what is reimbursed to hospitals after treatment.
“There are some things that will not happen and must change. We will not go back to hospitals charging high prices for services. There is a procedure being charged Sh6,000 in public hospitals with better equipment than private hospitals who charge Sh60,000 for the same procedure,” Mr Mutahi Kagwe, the then Health minister, said.
He said a procedure costing Sh60, 000 at Kenyatta National Hospital goes for Sh400, 000 in a private hospital, yet all the fees are paid by the NHIF.
“Is it just me who is not seeing the logic here? Something is not right and cannot continue... Kenyans must not cough more money from their pockets to pay for health when they are already paying monthly contributions to the NHIF.”
The regulations state that only medical insurance providers registered by the Insurance Regulatory Authority, have a valid licence and have at least two qualified and experienced medical doctors will be contracted by SHIF.
The insurance is to be registered with the Office of the Data Commissioner and comply with the provisions of the Data Protection Act, 2019 and the Digital Health Act, 2023.
This is part of the government's efforts to ensure that hospitals are interlinked and have one database for all Kenyans through the Digital Health Bill. This means that every hospital will have records of all Kenyans and every detail will be available for every doctor to access.
“Where a healthcare provider or health facility is contracted by the Act, the healthcare provider or health facility shall be onboarded into the Centralised Digital Platform maintained by the Authority,” says the regulations.
This will ensure that hospitals within Kenya and abroad do not send patients for tests that have already been done by other hospitals hence reducing expenses for the patients.
The Bill will also minimise double treatment that has always been recorded in many hospitals.
From the regulations, it will only be at the discretion of the Authority to refer a patient outside the country and only after due diligence has been followed.
One can only access treatment outside country where the treatment sought is not available in Kenya, and the treatment sought is being provided by a healthcare provider or health facility contracted by the Authority.
In 2017, KMPDC developed rules for referral of patients abroad, however, thousands of Kenyans are still travelling abroad for treatment with the most common referrals being those seeking oncology, heart disease and organ transplant services.
About 97 per cent of Kenyan patients who seek medical treatment abroad go to India. After India, the most popular destinations include South Africa, the US and the UK.
