In an effort to broaden treatment options while keeping costs under control, the National Health Insurance Fund (NHIF) will allow members to directly access consultant doctors and private pharmacies.
NHIF CEO Peter Kamunyo stated that the board is currently finalizing the roll-out of the model, which will provide members with more options for accessing healthcare and reduce amounts spent on claim payment.
Currently, NHIF only pays for services provided by accredited hospitals, excluding consultants working in private clinics and pharmacies.
This has forced its members to pay for medicines and consult with doctors outside of qualified hospitals.
“Right now, we can only reimburse hospitals and that has been a problem. Why don’t we have consultants who charge less, we can negotiate with them because the Act was that we could only reimburse hospitals,” Dr Kamunyo said on Monday.
“Now we will be more creative in cost containment, adding quality and value to our members. The [NHIF] team is working very hard to ensure we get there because this is one of the big-ticket items [needed] to achieve quality and cost containment.”
The shift is based on changes to the NHIF (Amendment) Act, 2022, which now allow the State insurer to directly contract individual healthcare professionals to provide consultancy, preventive care, and other services.
The previous law limited the NHIF to public, private, and faith-based hospitals for inpatient and outpatient services.
The NHIF will now negotiate payment rates with private clinics and pharmacies as it races to adopt the business model used by insurance companies.
The fund did not specify how its members will be able to use the planned service.
As of December of last year, Kenya had 13,376 registered doctors and 4,285 registered pharmacists, according to official data.
The NHIF is banking on its large membership of 13.8 million people to negotiate fees that are lower than market rates.
In the fiscal year ended June 2021, the State-backed insurer spent Sh54 billion on claims, accounting for 91 percent of the Sh62 billion in premiums collected.
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