Dying to live: The search for universal healthcare

 

By TABITHA MWANGI

In Summary

• The situation room: In 2005, the 58th session of the World Health Assembly passed a resolution on universal health coverage for all. Key to this is that no-one gets to pay any money for any type of health care services at the point of need. The money must, however, come from somewhere, so governments in low and middle-income countries have to come up with creative ways to fund universal healthcare

On January 24 this year, the Industrial Court dismissed an application filed by the Kenya Union of Domestic Hotels, Educational Institutions, Hospitals and Allied Workers against the National Health Insurance Fund over the proposed increment of contributor rates.

One day later, the Central Organisation of Trade Unions (Cotu) urged employers to ignore the ruling, saying it “stands with manly firmness” that the new NHIF rates shall not be implemented without prior consultations among the social partners, namely, the Federation of Kenya Employers and itself.

These two events raised little dust in the country. Coming at a time of increased political temperature, they received minimal coverage in the mainstream media and absolutely no mentions on the campaign trail.

The fact that they were relegated to the back burner paints a grim picture of how health care matters are treated in a country where, every year, about 1.5 million people are pushed below the national poverty line due to health payments.

“Health charges trap those who are poor in their status and push even more people into poverty,” says Dr Jane Mumbi Chuma, a health economist and senior research scientist at Kenya Medical Research Institute in Kilifi.

For the 20 million or so Kenyans (half of the national population) who live below the poverty line — which is officially set at the rather low figure of Sh1,257 per person per month — nothing could be more important to them than the promise of reliable and effective health care.

And there is a good reason for this: Like everyone else, when a person living on Sh1,257 per month visits a health facility, they have to pay registration and consultation fees, diagnostic tests, drugs, surgery and daily bed charges if admitted. These ‘Out of Pocket’ (OOP) payments soar above their annual income, pushing a good portion of those 20 million Kenyans into extreme poverty.

Payments at health facilities discourage the poor from seeking health care as it results in substantial sacrifice. They may be forced to sell their few assets, which include livestock or farm produce, to meet the costs. But very few have any assets to sell, so they resort to borrowing from friends and relatives.

They are left highly indebted and with strained relationships as a result of the family illness. In lieu of this, poor families seek alternative modes of treatment first, and only visit a formal health facility when absolutely necessary.

When there is a sickness in the home, a poor family will hope for a spontaneous recovery. If this appears not to be forthcoming, they will buy painkillers and other, often unhelpful, drugs at a local shop. They may also use drugs that had been left over from a previously ill family member or try mitishamba (herbs). It is only when all these efforts fail that they will seek medical attention in a formal setting.

At the end of the day, the poor family has incurred extra costs and has a more critically ill patient who may require in-patient care. A caregiver has to spend time with the patient in hospital and therefore will not earn any money during that duration. Researchers have shown that loss in income from taking care of a sick patient may result in larger monetary losses for the family than the actual cost of treatments. In the end, the poor end up paying over five times more in health services than the well-off.

It is not only money that is lost. The outcomes for the child whose treatment was delayed are worse than that of a more well-off family that did not hesitate to take the child to hospital.

According to a 2009 review by Rob Yates in the Lancet journal, more than three million child deaths could have been averted in 20 African countries over the past 20 years had fees not been charged at health facilities.

Unfortunately, health systems in Africa rely heavily on these OOP payments to manage their health systems. In fact, in Kenya, 37 per cent of the total health care expenditure in 2009 was derived from these payments.

In 2005, the 58th session of the World Health Assembly passed a resolution on universal health coverage for all. Universal health care refers to free provision of health care services at the point of delivery. Key to this is that no-one gets to pay any money for any type of health care services at the point of need. The money must, however, come from somewhere, so governments in low- and middle-income countries have to come up with creative ways to fund universal health care.

In Kenya, the NHIF collects compulsory payments from all workers in the formal sector. However, it only covers the workers and their dependants. The rich rely on private health insurance and the poor are left to fend for themselves. There is, therefore, a need to have a health care insurance scheme that covers all Kenyans, what is often referred to as a National Social Health Insurance Fund.

In 2011, the Minister for Health suggested raising the air fare tax by Sh100 to raise money for ARV drugs.

The airline industry claimed not to have been consulted and, in the end, the idea was shot down. According to the 2010 Public Expenditure Review, over 75 per cent of the HIV/Aids budget is externally funded, and the monies earned from the Sh100 tax on air travel would have helped a great deal to plug the gap. Better negotiations with the industry may have yielded favourable results compared to a top-bottom approach and that idea may need to be revisited.

But there are some more innovative ways of raising money for health care.

“According to the Central Bank of Kenya, money remitted by the diaspora is growing monthly,” says Dr Chuma. “Last year, over Sh85 billion, higher than the revenue earned from coffee or tourism, was remitted to the country. Putting a little levy on foreign transactions for health tax would raise money for health. In 2009, Gabon raised $30 million (Sh2.6 billion) from diaspora remittance tax, which they put into health care.”

Another option is to pool all the resources that are currently available into one pot and stop the duplication of effort. “Tax funds allocated to health, NHIF contributions, community health insurance schemes and donor money, if pooled together, can create a large enough single pool. This will ensure that both the rich and the poor are covered while reducing administration costs. As there will only be one organisation buying services, it will have bargaining power.”

Whatever the means of raising money, people need to feel that the money will not be misused. The history of NHIF is plagued with corruption and there is little trust in the public that they will deliver should they take on the role of National Social Health Insurance Fund.

“A new institution would need to be in place to swallow NHIF. It would require re-branding, with a new board, new staff. It should be independent from the Ministry of Health, just like NHIF. However, it shall require a lot of work to build trust in the public health care system where beneficiaries will be expected to seek services,” says Dr Chuma.

Removing charges from health facilities will however not be enough to keep patients coming. The public health facilities have to be well equipped. It is not enough, for example, to say that giving birth at a maternity ward is free and then expecting mothers to buy gloves, cotton wool and drugs because there are none available at the facility.

To reduce costs of payments for treatments, the government will need to invest heavily on preventative measures to reduce the heavy burden of infectious diseases. According to the expenditure report, more money is going to curative rather than preventative health care.

To date, the greatest weapon against infectious communicable disease is good hygiene. This will require the government to provide safe water and improve waste disposal. The second greatest weapon is provision of essential vaccines followed by use of insecticide-treated bed nets. To reduce costs on the National Social Health Insurance Fund, the government will need to invest in these simple tools or face an unnecessary dent on the health fund.

Public health facilities need to be closer to the people, well equipped and charge no fees. Most important though is that the public needs to have confidence in the services provided. In this way, each citizen in the country will be able to walk into any health facility, get whatever treatment is required and walk out without paying a shilling.

There has been discussion in the past to start a National Social Health Insurance Fund in Kenya during the NARC government when Charity Ngilu was the Minister for Health. This was passed by Parliament but the president did not sign it. ‘The big boys’ as Hon Raila Odinga said in the presidential debate of February 11, ‘shot it down’. These ‘big boys’ included private health insurance schemes and private hospitals.

“What Kenya needs are leaders who are willing to put the private sector to task. That they either be part of these reforms or lose altogether by not working together with the public system under universal health care.

There are many innovative ways of using private doctors to provide health care in public facilities. What we lack is political will and leadership,” says Dr Chuma.

Another fear of a ‘walk in, walk out’ health facility is being overwhelmed by people who may not need the service but take advantage of its availability. This is an unnecessary fear because there are other costs related to seeking care like costs of transport or the cost of losing a day’s work to go to a health facility. Few therefore, will come to the facility when they really do not need services.

A National Social Health Insurance Fund will need to engage better with the public to gain popular support and ensure coverage for all.