OBWOGO: This Is What the Govt Must Do To Provide Universal Health Care (Part 32: Think-Like-A-Virus)

The quest for universal health care is certainly not unique to Kenya and there are many ways of attaining the goal. In fact, every industrialised country in the world except the US has universal health coverage. But what worries me is that what the Government of Kenya is proposing to achieve the goal isn’t anything but a fairy tale hearkening back to the frog that meets a prince, falls in love, gets married and lives happily thereafter. But first-things-first.

Four in every five lack health insurance

You see, only about 20 percent of Kenyans have any form of health insurance coverage, of whom 85 percent and 15 percent respectively are under public and private insurance plans. In addition, about 83% of Kenya’s workforce is in informal sector, and only 15% are insured. Most important, out of a total of 25.36 million Kenyans above 18 years, only 8.898 million are members of the National Hospital Insurance Fund.

Therefore, in order to expand coverage to achieve UHC, the 2021 NHIF Amendment Bill proposes to use subsidies and mandates to enroll more than 16 million adult Kenyans who are not covered by the fund. I’ve summarised the numbers in the figure below (see Fig. UHC 1).

 Now, joining NHIF will be mandatory for everyone and employers will be required to match their employees’ NHIF contributions, among other measures. But the majority of Kenyans are either unemployed or subsist in the informal sector making it difficult to recruit, retain and collect regular contributions. Requiring proof of NHIF membership to obtain an ID card, to enroll your child in school, or get other government services such as licences is cruel, counterproductive and may infringe an individual’s basic rights. So what should the government do instead?

Subsidies, mandates and Regulation

Universal health care is a system that delivers quality healthcare to everyone regardless of their ability to pay. To expand coverage to the poor, the government plans to extend subsidies to cover all five million poor households, starting with  one million poor households in the first year. The rest of the informal sector households are expected to contribute Ksh 6000 ($60) per year. But wait a minute! Roughly 18 million Kenyans live below the poverty line and most informal sector households are either unemployed, underemployed, live from hand-to-mouth or depend on employed relatives. In fact, many patients who use public health services cannot afford sh100 for the health card, let alone buy drugs such as anti-malarials, antibiotics or painkillers. Okay, let’s get this straight.

First, there is only one way to make health insurance accessible and affordable to everyone, regardless of income or health status, which is by pooling a) health risks of individuals and b) contributions of individuals, households, businesses and governments.

Pooling risks and contributions

Second, this money is then invested in two ways: a) through a government sponsored health insurance plan, also known as national health insurance, or single payer, or; b) through private sector insurance plans with mandates, subsidies and regulation. Here you regulate insurers so they can’t decline or charge higher premiums to people with preexisting conditions; impose some penalty on people who don’t buy insurance, to induce healthy people to sign up and provide a workable risk pool; and you then subsidise premiums so that lower-income households can afford insurance.

Third, the policy rationale for setting up a national health insurance plan to reach UHC is so that taxes, rather than payroll deductions or disposable income, pay the bills. The idea is to replace premiums with taxes in order to eliminate insurance through jobs, payroll deductions or using disposable income to buy premiums. That way, you a) achieve automatic eligibility and; b) eliminate a two-tier system pitting rich vs poor, or employed vs unemployed, or private vs public. A tax-financed national health insurance scheme could include a portion of sin-tax, sales tax, income tax, fuel tax, budget, grants and loans, which is then ring-fenced to pay for health care services.

Disposable income to pay premiums

Think about it this way: the 5 million poor households set to receive insurance premium subsidies from the government and the informal sector households also pay sales tax (VAT), sin-tax and fuel tax and asking the latter to pay $60 annual premiums is double taxation. If you ask me, a ring-fenced health insurance tax base would collect far more in premiums than mandating annual payments from disposable incomes of informal sector households.

Fourth, government-run insurance plan is not the same as government-provided medical care. For example, Canada, Taiwan and Australia have national health insurance/ single payer systems where everyone gets insurance from the government but doctors and hospitals remain private. Under single payer systems, individuals are free to supplement their public coverage with private insurance for services not covered under single-payer systems.

Last, affordable health insurance whether public or private doesn’t translate into affordable health care without collective bargaining on cost of prescription drugs, tests and hospitals charges. Affordable healthcare also doesn't translate into quality of health services meaning that you need additional policy initiatives besides improving access and affordability to achieve UHC.

The bottomline is that you can choose to make every problem to look like a nail and deploy a hammer, but you can't solve problems by using the same kind of thinking you used when you created them.   

Dr Obwogo is a medical doctor, specialist in public health medicine, and consultant in health policy and systems strengthening.

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