In Kenya, where only 20 percent of the population has health insurance, an estimated 2.5 million people are impoverished every year as a result of paying directly for health services. Many more are discouraged from seeking needed care by the prospect of high out-of-pocket expenses. Low utilisation of basic health services intensifies people’s health risks and contributes to the continued marginalisation of disadvantaged population groups. The poor and workers in the informal sector are particularly vulnerable, as they are less likely to have health insurance than those who are formally employed.
In line with the Sustainable Development Goals and Kenya Vision 2030, the Government of Kenya is committed to the achievement of universal health coverage. It is supporting the gradual extension of coverage under the National Hospital Insurance Fund (NHIF), which is mandatory for Kenyans employed in the formal sector, to other segments of the population. In 2013 the NHIF introduced a sponsored program for vulnerable groups (i.e. orphans and vulnerable children, the elderly, persons with disabilities), followed in 2014 by the launch of the Health Insurancy Subsidy Programme (HISP) for the poor. To date, however, coverage among workers in the informal sector remains low.
On behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH has been advising the Government of Kenya since 2010 on the consolidation of a well-functioning, financially sustainable social health insurance system. Under the current Support to the Health Sector project (2017-2018), particular emphasis is being placed on the design and implementation of insurance products to expand coverage among workers in the informal sector and their families.
At the national level, the project has advised the NHIF on its Informal Sector Strategy (2016-2018) and on the design of group insurance contracts aimed at the members of collectives and other organised informal groups. Group insurance contracts can help to reduce the problem of adverse selection, because a pool of eligible beneficiaries who belong to the same group are likely to be diverse in terms of age and health status. In addition, grouping individuals together enhances accountability to pay for premiums, as payments are made collectively.
The project also works closely with NHIF Regional Branches and County Health Management Teams (CHMTs) in four counties – Kisumu, Kwale, Siaya and Vihiga – to encourage enrolment among informal workers and their families. Health Financing Technical Working Groups have been established, with project support, in Kisumu, Kwale and Vihiga counties. These groups, which bring together representatives of the county health department, county department of social services and the local NHIF branch, are developing county-specific health financing strategies to expand coverage among the population, particularly among the poor and informal sector workers.
In three counties, the project has supported qualitative research with representatives of informal groups to explore their understanding of health insurance and attitudes toward enrolment. On the basis of the research findings, it has advised CHMTs and NHIF branches on strategies for identifying, reaching out to and sensitising informal groups. It also supports registration and enrollment processes at county level.
Finally, the project also advises the NHIF at national level on how to improve the implementation of core insurance processes. Based on operational research into the implementation of HISP in Kisumu, Kwale and Vihiga counties, conducted by GIZ during the previous health sector support project (2014-2016), the project has worked with NHIF to identify weaknesses in areas such as claims processing, financial flows and recordkeeping, and has supported NHIF to address these through supplementary training for personnel at accredited hospitals in the four counties.
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