Questions over Sh20bn NHIF payments delay as patients suffer

Health experts have fear that the country is staring at an imminent collapse of healthcare with the current state of low payouts of claims by the country`s national insurer.

Already, hospitals are turning away patients who rely on the National Hospital Insurance Fund (NHIF) cards to pay for service and instead compelling them to pay in cash.

According to a statement written by Dr Tim Theuri chief executive officer of the Kenya Healthcare Federation to the health Principal Secretary, the State Department of Medical Services, Mr Harry Kimtai, NHIF reimbursement rates have fallen below the actual cost of service delivery, posing an existential threat to the healthcare ecosystem.

The data from KHF indicates a payout rate of only 12.9 per cent of claims were approved last year with 58 per cent of health providers have not received capitation for managed schemes.

The industry is owed more than an estimated 20 billion.

“Many healthcare providers, particularly those outside major urban centres, rely heavily on NHIF reimbursements, the delay in reimbursement makes them vulnerable and inadequate. This has resulted in widespread defaults on supplier credit, payroll, rent, and other essential obligations, pushing many providers to the brink of insolvency,” says the statement.

Current reimbursement rates range between five to 13 per cent of monthly billing, undermines the quality of care as providers struggle to afford essential supplies and equipment.

This troubling trend, indicative of a healthcare system in disarray, leaves patients stranded at the intersection of illness and financial uncertainty, raising profound questions about access to essential medical services in an era driven by profit margins.

Read: e-Citizen - Double jeopardy for patients in public hospitals

Health Cabinet Secretary Susan Nakhumicha last week, while appearing before the National Assembly Health Committee, said the Ministry does not have enough cash to promptly settle all the NHIF claims.

She blamed the delayed payment of NHIF monies to late remittance of NHIF deductions to formal sector employers.

"Employers are remitting NHIF deductions late. There is no enough money to settle all the claims at once. We are in talks to see whether money can be released to hospitals,” said Ms Nakhumicha.

Even though the government claimed that the one-year transition from the NHIF to the Social Health Insurance Fund which started last year would have been smooth and patients would continue to get services, the reality is now hitting, many patients are forced to go without their normal clinics for lack of cash.

In 2021, doctors told Timothy Mwangi, a Nairobi-based graphic designer that both of his kidneys had failed. As he waits for a transplant, he has for the last two years, without fail, undergone dialysis twice a week.

While choosing a healthcare facility, a key priority was finding one that accepted NHIF, the now-defunct social health insurance program of the Social Health Authority (SHA).

Everything was going well, until last week.

“We received communication that in the coming weeks, we will have to pay for the dialysis services out of pocket and later claim from NHIF. The management explained to us that they are crippled because of the money owed to them by the then-state parastatal. For the last four months, the hospital has been going into its coffers to pay the staff and buy the much-needed equipment,” Mr Mwangi said.

Read: CS Nakhumicha - Rogue hospitals stole Sh171m from NHIF in one year

If Mwangi pays in cash, that will be Sh19,000 every week for the sessions and at least Sh2,500 for blood boosters, which were also being covered under NHIF.

“It is depressing. Before this, I was burdened with raising the necessary funds for the transplant which is about Sh3 million and transportation to the dialysis centre but I am now confronted by this. Tell me, how many people can afford to pay Sh19,000 every week?” he said.

At the start of every year since 2021, Mwangi has been remitting his annual contribution of Sh12,000 at a go. 

“It’s a requirement and with that, I was hoping that I would get treated without any challenge. So, when I was told to prepare to pay in cash, I wondered where to get the money? According to my doctor, I cannot afford to miss a session as that would be detrimental to my health. It feels like somebody is slowly killing us,” he offers.

Across the country, there is a growing reluctance among private medical facilities to provide dialysis treatment to previously NHIF-insured patients.

In one of the letters seen by Nation, CKS Dialysis Centre has communicated to its clients about significant service disruptions that will require them to cover dialysis costs out-of-pocket.

“Our umbrella organisation has issued this notice on our behalf since we have gotten less than 10 per cent of claims made to NHIF against services that we have provided you. We no longer have money to buy dialysis kits, pay salaries of staff, pay rent, water and electricity, and buy food.”

Read: NHIF boss admits staff colluded with hospitals to defraud the institution

“I have been attending dialysis sessions at a Nairobi-based kidney centre and we received communication last week that going forward, the facility will not accept NHIF payments and I am required to pay Sh12,000 per session. Further, I have to make prior appointments,” offers Patricia Njoki, a kidney disease patient.

Ms Njoki also said anaemic and will require blood boosters alongside the dialysis sessions.

“I paid for the first session on Tuesday and I am required to go for another one on Friday. Up to this point, I don’t know how I will be able to pay,” she says.

Margret Otieno, had to go back with her child home after a hospital in Kisumu refused to attend to them using the NHIF card.

“What scares me is I struggle a lot to get even the stipulated Sh500 to remit to NHIF every month and when I so need the service, I am unable to. I have paid till June,” she says.

She has resorted to buying drugs over the counter for flu and cough that has persisted for the last two weeks.

“I only had Sh500 with me, this would not have been enough for consultation and even the test which I am sure would have been suggested by the doctors. I don’t have the money,” she said.

The Kenya Demographic and Health Survey 2022 Report released by the KNBS earlier this year shows that an estimated 95 per cent of poor men and women in Kenya don’t have health insurance illustrating the magnitude of the financial pain whenever they fall ill.