Why the new medical insurance scheme is a game-changer for the success of UHC

President William Ruto signed the Social Health Insurance Bill into law on October 19, signalling the replacement of the National Health Insurance Fund with the Social Health Authority (SHA).

This is the agency that will, once it is put in place, manage the new Social Health Insurance (SHI) scheme. The SHA will oversee three critical funds: Social Health Insurance Fund (SHIF), Primary Healthcare Fund and Emergency, Chronic and Critical Illnesses Fund.

While SHIF will be funded by expanding the pool of premium contributions from the formal and informal sector, the Primary Healthcare Fund and Emergency, Chronic and Critical Illnesses Fund will be financed by the government through taxes, donations and gifts.

The new scheme will not only expand insurance coverage but also fix the challenges that NHIF has experienced, including undertaking functions that resulted in conflict of interest. Such functions include the accreditation and empanelment of health facilities, claims management, dispute resolution and quality assurance of hospitals.

As all Kenyans become members and contributors to the SHIF, the premium contributions will likely change from the previous Sh150 to Sh1700 range to a fixed rate to be ascertained once regulations are concluded, based on a household’s income. The government will continue providing health insurance subsidies to orphans, vulnerable and people with severe disability based on data provided by the State Department for Social Protection and to people experiencing extreme poverty.

The implication for the poor is that those currently enjoying the benefits from the government subsidy programme will continue doing so until their premiums are due. The informal sector contributions will be annual and premium financing modalities for those unable to pay due to the inconsistency of their income flows.

The aim is to get 85 per cent of the population under the insurance scheme, meaning that other parallel schemes such as Linda Mama and Edu Afya, which are individual-based and not household-based, will have no place since the SHIF will have catered for the entire household.

The formation of SHA will ensure an expanded benefit package to all Kenyans from what was previously covered under NHIF. For example, the government will allocate resources for emergency, chronic and critical illnesses to improve access to intensive care and high-dependency units, particularly for Kenyans who cannot pay and would otherwise be turned away from hospitals.

The Primary Healthcare Fund will also meet nearly 90 per cent of the population’s health needs at the primary level, focusing on people experiencing poverty, with a return on investment of up to $16 for every dollar spent.

Article first published on https://www.standardmedia.co.ke/opinion/article/2001484205/why-new-medical-insurance-scheme-is-a-game-changer-for-success-of-uhc