This study set to explore communities’ understanding of health insurance, their perceptions of a future NHIS in Kenya and preferred design features. This section discusses the main findings and their implications on the efforts to transform the Kenyan health system financing towards universal health coverage.
Membership of health insurance schemes in the communities under study was quite high. More than half of the households had at least one member in health insurance scheme, while 41% of all individuals had insurance cover. These figures are significantly higher than national health insurance coverage levels, which are estimated as 10% of the population. High insurance coverage in the study area can be attributed to the fact that the study was conducted in a rural area with a long history of CBHI schemes, and which records the highest level of CBHI membership in Kenya. Consequently these results should be interpreted with caution since the study community had engaged with health insurance scheme for a long time and were more likely to be members of health insurance schemes compared to the rest of the Kenyan population.
The findings have demonstrated that there was some level of understanding of health insurance due to experiences working with CBHIs, but key concepts and how health insurance functions were not well understood. The majority of participants were aware that health insurance addresses the financial difficulties related to seeking health care, but it was not always clear why health insurance schemes operated differently from merry-go-rounds (rotating savings group). For example, there was very limited understanding of risk - pooling and cross-subsidization. The community hardly understood why contributions could not be refunded by the end of the financial year or forwarded to the next year’s contributions if they or their dependants had not fallen ill. Failure to do this was viewed by many as a loss, more so because these contributions did not attract any interests. Income cross-subsidisation was relatively well understood, with the majority of the population expressing their willingness and importance of the well off in society to subsidise contributions by the poorest groups. This could be associated with the fact that solidarity was common in the community, with people often coming together to help relatives and neighbours in cases of large hospital bills or in the event of death. However, there were concerns that even where the rich subsidised the poor, they were more likely to benefit from health services than the poor. The fact that health insurance is not well understood is not new. A recent study in South Africa reported similar findings, where only 53% of respondents understood the concept of risk - pooling, compared to 62% who were in favour of a system where the rich subsidised health care contributions for the poor . An important factor that is likely to influence future implementation of a NHIS in Kenya is the communities’ acceptance of change. People are likely to accept something if they understood key concepts and how they work. As the country continues to find solutions to the ailing health system and the appropriate design of a NHIS, it is important that the community, who are the major beneficiaries of change, are sensitised and engaged to promote awareness, understanding of key concepts and their application. The presence of CBHIs in the study setting played a big role in people’s understanding of health insurance. Considering that CBHIs are not widespread in Kenya and only cover 1.2% of the population, it is important that efforts to engage the public go hand in hand with the design of health financing policies to ensure that the same are acceptable to the population, come implementation.
According to the community, membership of health insurance schemes was for the rich, the old and the sickly. None of the CBHIs operating in the study setting had mechanisms to waive premiums for the poor or destitute in society. This means that CBHIs discriminate against the poor, have significant implications for risk- pooling and sustainability of insurance schemes. A recent review of the literature identifies similar weaknesses associated with CBHIs in low income countries [21, 22]. Nonetheless, CBHIs continue to be regarded as important avenues for UHC in many African settings. In Kenya, for example, the draft national health financing strategy emphasises the need to promote CBHIs in Kenya as part of financing mechanism for UHC . In the financing strategy, membership of health insurance schemes will be compulsory for all Kenyans. CBHIs are being considered as the financing mechanisms for the informal sector workers, while formal sector workers will have their own pool under the National Health Insurance Scheme. Should this approach be adopted, the government must be willing to subsidise and support CBHIs to ensure that they are well designed, attract large numbers to allow for risk-pooling and subsidise membership for the poor. Most important is to allow for risk equalisation among pools to help address problems of bankruptcy for CBHIs that attract high risk individuals.
It was very clear that there is wide dissatisfaction with the current public health system. Concerns were expressed about quality of care, particularly related to availability of drugs, patient- provider interactions, long waiting times and discrimination against CBHIs members. However, it was not clear the extent to which these negative opinions were based on recent personal experiences or historical issues in the public health system. These concerns, it was reported, would have to be addressed for people to gain confidence in the public health system and in so doing contribute towards a NHIS. Similar findings were reported in Ghana, where the insured population reported waiting longer at health facilities than the non-insured and being discriminated by providers, receiving low quality drugs or being asked to buy them at private pharmacies, thereby incurring additional costs, and being subjected to verbal abuse [24, 25]. Negative perceptions impact on trust in the public health system and hinder progress towards universal health coverage. In Ghana, dropouts of the national health insurance scheme gave poor experiences with the public health system as a major factor that contributed to their decisions of not renewing their membership . It is important that the concerns raised regarding poor quality of care in Kenya, particularly in the public sector are addressed before implementation of the NHIS. CBHIs working in these areas should also note the concerns related to discrimination and work closely with health workers to ensure that their members are not discriminated. Experiences reported elsewhere suggest that discrimination could be due to many factors including cumbersome claiming process on the side of health facility, often leading to long gaps between providing services and payment; long administrative procedures, meaning that scheme members take longer to be attended to as their names have to be searched in databases that are often not in a user friendly manner .
Regarding benefits package, it was clear that people preferred a comprehensive package that included both inpatient and outpatient services, although inpatient services were perceived to be more deserving compared to outpatient care. Despite the negative perceptions of quality of care in the public health system and the belief that private facilities offered better services, when it came to collecting revenue for a NHIS, the community clearly favoured a system where the government collected the revenue and purchased services on behalf of the population. Only a minority preferred a private institution to take up this role, even when the government took some control of such an organisation. This shows that people still trust the government to look after their interests compared to private institutions. These findings have important implications for the design of a NHIS in Kenya. The government should take advantage of this trust and improve the care in the public health system before embarking on the implementation of NHIS. Improving the public health system will be of major contribution towards acceptability of financing mechanisms (health insurance and tax funding) for universal health coverage. Nonetheless, additional wok is needed to inform the design of UHC reforms in Kenya, including assessing the range of service entitlements that would be accessible and affordable to all Kenyans and which are implemented in a sustainable way.
Affordability of premiums, timing of contributions and the extent to which the needs of the poorest population would be met under a contributory scheme were major issues of concerns for a NHIS design. Nonetheless, there was a general agreement that premiums should not be set too low, to an extent that they undermine provision of quality services. Access to cash in many rural areas and in the informal sector is seasonal and making sure that timing for making contributions correspond with peak seasons when people have access to most of their annual income could improve on affordability and sustainability of premiums. Affordability of health insurance premiums was central in Ghana, where community members reported that the premiums were too high and unaffordable to many . Although the Kenyan policy discussions are more geared towards a contributory national health insurance scheme, participants expressed their preference for a tax - funded scheme, since all Kenyans pay taxes either directly or indirectly. A tax - funded health system was regarded as more inclusive compared to a NHIS, which was perceived to target the rich more than the poor. The design of health systems reforms in Kenya should also consider the possibility of achieving UHC through a predominantly tax - funded system.
This study was conducted in two settings with a strong presence of CBHIs. The community was therefore more exposed to health insurance concepts and to the NHIF compared to other settings in Kenya. It is possible that this exposure contributed significantly to their perceptions on health insurance and that these are likely to be different in other settings. However, the study still reported very limited understanding of health insurance, implying that much more education and sensitisation regarding health insurance is needed in settings without CBHIs. Thus the findings presented in this paper have important policy implications regardless of this limitation.