What you need to know:
- Currently, NHIF enrolment is mandatory among workers in the formal sector
- The informal sector employs over 80 per cent of Kenyans
On July 15, the 2021 International Health Economics Association (iHEA) Congress came to a close. After four busy days of health economists and health system leaders exchanging bold ideas, five ThinkWell attendees shared their main take-aways from the conference.
With vaccination on top of everyone’s mind more than ever these days, the Immunization Economics Special Interest Group, of which ThinkWell is an active member, has been in the spotlight this year. The Group’s session at iHEA confirmed the value of vaccination and the high return on investment of immunization, while demonstrating that much remains to be done to ensure these benefits are equitably distributed. Researchers also added to the tremendous body of research on the cost and cost-effectiveness of delivering immunization services. We presented novel findings on the cost of integrated immunization campaigns during an engaging session that also discussed the important role of labor in delivering immunization, an analysis of the impact of campaign-like routine delivery of vaccines on other essential health services, and an efficiency assessment of reduced scope costing studies. Looking beyond this year’s iHEA congress, we are excited to continue and keep on filling remaining critical evidence gaps, particularly on what it costs to deliver interventions to hard-to-reach populations, and further explore efficiency and equity tradeoffs.
In the session “Digital Technologies for Health Financing: What Are the Benefits and Risks,” the presenters shared how few experiences with digital technologies for health financing have been evaluated in the peer-reviewed and grey literatures. There is a sense among practitioners and experts that digital technologies have the potential to revolutionize the use of data in health systems.
In the Philippines, PhilHealth has introduced a fraud detection process using machine learning and artificial intelligence that helps to flag suspicious claims for further scrutiny prior to payment. The savings are substantial relative to the upfront and recurrent costs of the system, although the upfront investment was large and required considerable advocacy to secure support from senior decision-makers. Ongoing challenges include information security and privacy; and the possibility that providers, faced with higher legal costs to contest fraud findings, could pass costs on to patients (i.e., increased out-of-pocket costs).
Indonesia’s single-payer national health insurance scheme (Jaminan Kesehatan Nasional), has explored digital technologies, including an online ticketing system for complaints and a mobile app to help members access information, communicate with providers, and more. There’s been modest uptake, and disparities in access to technology, connectivity, comfort, etc. with technology have hindered utility, especially for the poor, whose needs require other (typically non-digital) solutions.
In the session “Are public facilities set up to respond to strategic purchasing signals: insights from East Africa,” panelists shared how health facilities’ level of financial autonomy in Kenya, Tanzania, and Uganda affects how the facilities respond to purchasing signals sent from the central and district level.
Tanzanian panelists described how recent reforms that allow for direct financing to health facilities has improved the predictability of funds, reduced stock-outs, and enhanced accountability at health facilities. Kenyan panelists discussed how health facilities with less autonomy had more frequent stockouts and delays in decision-making. Ugandan panelists shared how health facility autonomy is operationalized across districts and discussed authority issues across central and district purchasing.
The panelists described three common challenges across the countries. First, local governments are often conflated with health providers; these are two distinct groups who have different responsibilities. Second, in Kenya, Uganda, and Tanzania, health authority has been decentralized to the districts, but recent health reforms have recentralized much of how health services are purchased and where decisions are ultimately made. Third, a misalignment of rules and regulations for public financial management often does not adequately recognize the planning and budgeting functions for health facilities. Clear communication and alignment of signals to health providers is critical to improve service delivery.
The session “Health Financing in Devolved Contexts and Its Implications for Progress Towards Universal Health Coverage,” which Nirmala Ravishankar from ThinkWell chaired, explored the linkages between devolution and health financing. Dr. Inke Mathauer opened the session by sharing insights from a study implemented by ThinkWell and the World Health Organization that explored how devolved government structures shape the design and execution of health financing functions. She noted how local governments are responsible for a large share of health spending but depend on transfers from central governments to finance their budgets. She hypothesized that earmarked health grants could reconcile decentralized decision making to enhance resource allocation to health. She also explored how devolution can result in fragmented pooling and purchasing arrangements. Dr. Marife Yap discussed the Philippines’s experience, focusing on how the country’s UHC law is (re)defining the roles of local governments, provincial governments, and national health agencies. Reflecting on Kenya’s experience with devolution, Boniface Mbuthia emphasized the importance of aligning public financial management rules and processes so local governments can become strategic purchasers of health services while granting financial autonomy to public health providers. Finally, we heard from Dr. Mulwa and Dr. Castroverde, who work at the sub-national level in Kenya and the Philippines. They reflected on the politics of health financing reforms in devolved government systems. The session underscored the need for more disaggregated data on health budget allocations and spending at the subnational level, as well as the importance of more learning on the topic.
First, it’s easy to get sucked into the weeds of implementing programs—program implementers constantly think about contextual and political challenges. IHEA reminded program implementers to take a step back and reflect on health economics concepts and principles from a high-level. It’s important to always have an ear to the ground when you’re implementing health systems programs, but it’s also important to keep the main goals and big picture concepts in mind.
Second, ThinkWell’s Health Financing Activity is currently working on a health facility readiness assessment for HIV to understand whether health facilities in Indonesia have the needed supplies and resources to treat HIV. At iHEA, a session shared how if you have a robust health facility readiness assessment framework, you can apply that same framework to different regions or to different health areas, like maternal and child health.
Finally, in the field of health economics, it’s nice to have a community with which you can exchange knowledge and ask questions. IHEA provides that chance to connect with health economists from around the world.
The Kenyan government has identified universal health coverage (UHC) as part of its Big Four development agenda, with the National Hospital Insurance Fund (NHIF) at the center of this plan.
Countries face significant challenges as they develop and implement UHC strategies. Many low- and middle-income countries, including Kenya, are opting to introduce or expand national health insurance as a way to progress towards UHC.
Providing health insurance coverage for people outside the formal employment sector poses a key hurdle for this approach. It is administratively difficult to collect premiums from the informal sector as it is not organized, and many rely on low and irregular sources of income.
The informal sector employs over 80 percent of Kenyans in jobs that often expose them to hazards and illness, thereby increasing their need for healthcare.
Currently, NHIF enrolment is mandatory among workers in the formal sector, but voluntary for the informal sector.
The question, therefore is, how will the government extend coverage to the informal sector? Two main options have been discussed to date: Collect contributions to NHIF from the informal sector enrollees, which could either be voluntary or mandatory, or use general government taxes to provide full or partial subsidies to informal sector households.
What happens if we go with the first method?
World over, voluntary contributions lead to low coverage. Many are more likely to pay for NHIF when they are sick leading to adverse selection. Mobilizing resources from the informal sector through mandatory NHIF enrolment would increase coverage and revenues.
Other concerns regard equity in contributions: Is it fair to charge the same flat rate to all informal sector households? Kenya can learn from countries such as Rwanda, where Ubudehe, a socio-economic stratification system is used. The wealthier pay higher health insurance premiums compared to the poor.
The other option to expand informal sector NHIF coverage is using government revenues to subsidize NHIF enrolment. Countries that have financed informal-sector health coverage from general revenues have high coverage rates.
A tax financing approach requires significant resources and commitment.
One of the other ways of increasing fiscal space to finance UHC would be introduction of special “sin” taxes to earmark funds for UHC.
The ideal scenario would involve government using tax revenues to subsidize enrolment for the informal sector. However, due to the current fiscal landscape, the government should consider a phased approach and a mix of financing approaches.
Having a single flat premium for the contributing informal sector will still not be equitable, but if all the poor are covered, this is a way to strike a compromise in the short term.