JUNE 2015 01F SmartLessOns WORLDBANKGROUP ABOUT THE AUTHORS The Path to Universal Health Coverage in is an Operations Officer and leads Health in Africa's Kenya program. Njeri is also responsible for managing Health K n a e o iinn h oeo h in Africa's day-to-day demand-side fi- nancing and policy activities in Kenya Kenya: Repositioning the Role of the under the AHME project. National Hospital Insurance Fund is a ha The National Hospital Insurance Fund's (NHIF) mandate by the Ministry of in gexpert providing technical assistance to t Health (M4H) of Kenya to implement Universal Health Coverage (UH tional Hospital Insurance Fund on a range of health financing reforms. * generated controversy among stakeholders. Prior allegations of corruption and financial sustainability of the initiative were key concerns. is a Lead Health Specialist and Program- Leader since September 2014, respon-- sible for facilitating coordination be- tweenThe World Bank Group (WBG), through a collaboration between the Health and Global Practices for Health, Educa- tion, in Africa initiative programme and the Kenya Health Sector Project, worked Environment, including the cross-cut- ting themes of gender and donor coor-- clinaion.with the NHIF on a reform agenda and advised on a strategic review of the organization. The WBG had an extensive dialogue with the NHIF and is a Senior Economist working in the WB India health program. Prior MOH which led to the approval of an independent strategic review that he was a Policy Officer with the Health- inConcluded that, although there had been reputational challenges in the Kenya, Nigeria, and Tanzania between past, NHIF has the capacity to deliver universal health coverage in Kenya. i a L H - BACKGROUND based and microfinance insurance t h isThrfhe World Bank Group,tr age of the population, while private, in reforming and repositioning the mcoiac n omnt-ae nionAfric hitaienrace nd t health insurance provides 2% cover- The goal of Universal Health Cover- age. The NHIF is a state corporation age is to provide everyone with af- established in 1966, mandated to fordable access to health services. provide accessible, affordable, sus- Recently, Kenya has undertaken a tamable, and quality social health number of health system and financ- insurance to the Kenyan popula- ing reforms to increase coverage tion. As the largest national insurer, for quality health services, improve the NHIF is best positioned to deliver availability of essential medicines, UHC in Kenya. However, due to a and reduce out-of-pocket payments.2 number of corruption allegations, Health insurance in Kenya is offered mismanagement, poor capacity, in- by the NHIF and private insurance efficiency, and weak governance and companies, as well as community accountability mechanisms; stake- holders doubted the NHIF's capacity 1 Definition of Universal Health Coverage, World Health to deliver UHC in Kenya. Organization http://www.who.int/universan health- coverage/en/ 2 See past SmartLesson to read more on health reforms The WBG began to change the per- in Kenyai http://smartlessons.ifc.org/smartessons/lesson. html?id= 551 ception of Uvs NHIFH Coverag there SMARTLESSONS -JUNE 2015 I mitment to implement the recom- P 1.4 mended reforms. N After the rigorous strategic review by the WBG, the Kenyan MOH made a major decision to implement its UHC initiatives through the NHIF. The Kenyan Cabinet approved a policy paper on UHC on October 11, 2012 that made a stronger case for NHIF. The country's commitment to achieve UHC and recommendations from the strategic review were at- tached to the paper, reflecting the government's commitment to pro- ceed with the reform. The Kenyan 0 a government also appointed a task force to manage specific recom- were reservations about the NHIF, it is clear that mendations and implement the re- it remains a major organization, with the poten- forms agenda with the objective of "transform- tial and capacity to realize UHC in Kenya. The ing NHIF into an efficient and effective purchaser first private health sector assessment in Kenya of quality health care services that are afford- contributed to changes in the perceptions about able and accessible to the different constituents NHIF. The assessment revealed that the organiza- of Kenya's population." The draft Health Bill is tion was a major player in providing insurance under review by the Kenyan Parliament, which coverage. The private health sector players rec- specifically recognizes the role of the NHIF as the ognized that a strengthened NHIF with improved key health insurer in Kenya. coverage would widen the market for potential The WBG has played a key role in supporting the paying clients. payin clints.NHIF to implement a number of key reforms. For The WBG took the initiative by collaborating example, the NHIF partnered with the WBG and with the NHIF on a reform agenda. The WBG rec- the Rockefeller Foundation to develop a Health ommended a strategic review to identify NHIF's Insurance Subsidy Programmeforthe poor(HISP) strengths, weaknesses, opportunities, and areas which aims to provide comprehensive coverage of reform. The WBG's commitment to extensive to the 9 million people living in extreme poverty dialogue with the NHIF and MOH led to the ap- in Kenya by 2020. The World Bank has provided proval of an independent strategic review of the US$20 million funding for the initial phase of the NHIF as well as an agreement to cost shared ex- program, which includes a US$6 million grant penses from the review conducted by Deloitte from the health results innovation trust fund Consulting and allow full access to its records supported by the UK Department for Interna- and data. The latter was viewed as a major mile- tional Development and the Norwegian Govern- stone, due to the NHIF's secretive nature on mat- ment. The WBG is providing technical support ters relating to its financial records. for the design and implementation of the pro- gram. Also, through the Africa Health Markets The review confirmed NHIF's challenges, but also for Equity (AHME) consortium, funded by the revealed the organization's ability to success- Bill and Melinda Gates Foundation and the UK fully deliver UHC. Despite the heated reactions Department for International Development, the that the strategic review generated, the findings WBG is supporting the NHIF to increase insur- were adopted and approved by the MOH and ance coverage among the informal sector and the NHIF board of directors, who made a com- increase the number of low-cost private facilities 2 SMARTLESSONS - JUNE 2015 contracted as service providers. The WBG is col- without the evidence provided by the strategic laborating with the NHIF in its implementation review and inclusive policy dialogue. of a certification system for increased quality as- surance and improvement. The NHIF is contribut- Lesson 2: Don't focus on discovering problems, ing 40% of the costs of this quality improvement but find solutions; it's critical to use local project. The WBG together with the World Bank institutions for country-driven solutions. and other development partners are supporting Local institutions in countries play important the MOH to develop a health financing strategy roles in driving sustainable solutions by develop- and roadmap for UHC in Kenya. ment partners. Although the NHIF was initially These reform efforts, coupled with the catalytic decried as a vehicle for social health insurance, effect of the WBG's work. have resulted in a pro- the strategic review and assessment of private gressive shift in perceptions about NHIF, espe- prepaid schemes in Kenya, both supported by cially among key stakeholders, who are increas- the WBG, highlighted the criticality of the NHIF ingly recognizing the crucial role that the NHIF in achieving UHC. The NHIF is a home-grown could play in Kenya's efforts to achieve UHC. For solution for achieving social health insurance example, the ongoing support from the World in Kenya, and to date it remains the single larg- Bank Group is being complemented by the Ger- est health insurer, providing coverage to more man Development Corporation (GIZ) through 20 than 90% of the insured population, with over million Euro financing provided through KfW 40 years of experience in providing health insur- Development Bank. The Japanese government, ance. Rather than discard such an institution, through the Japan International Cooperation a more effective approach would be to reform Agency (JICA), has also committed to supporting and strengthen it. The success of policy and in- the NHIF. stitutional reform lies not in abandoning local institutions but in strengthening them. It is insuff icient to simply identify problems; find- Sing solutions is necessary. As outlined earlier, the tWBG did not stop with the NHIF strategic review. One of the key lessons learned was the critical It has actively worked with the NHIF to support importance of evidence-based problem solving its reforms. This support helped build NHIF's in- related to reform policies and public stitutional capacity to support and deliver re- institutions. Stakeholder apathy to- ward the NHIF was a key challenge;y however, the initiative by the WBG to undertake a comprehensive stra- tegic review of NHIF involving MOHo i and other key stakeholders resulted in a breakthrough. The findings of the strategic review of the NHIF provided concrete evidence on the status of the NHIF and provided the basis for developing a roadmap for its reform. This evidence providedteo a convincing case on the need for all players in the sector to focus on supporting the NHIF to reform and build its capacity to deliver on its mandate. The success of this pro- cess would not have been possible SMARTLESSONSLJUNE 2015 forms while keeping the broader re- Finally, as shown by the NHIF, the form agenda alive. availability of financial and opera- tional data to public scrutiny en- Lesson 3: Appropriate policy and hances trust in parastatal organi- regulatory frameworks lead to zations. The reform initiative also successful reforms. helped the NHIF to be proactive and develop a communication strategy A supporting policy and regulatory to more effectively engage with Ke- framework remains essential for im- nyan citizens and inform them about plementation of reforms. The WBG its products and services. Reforms has supported the MOH in the devel- without such transparency and en- opment of a comprehensive health gagement will not be effective. bill which is currently being debated by the Kenyan parliament and await- ing enactment. The importance of The NHIF remains one of the most UHC and the critical role of the NHIF important institutions for realizing is clearly articulated in this draft law. UHC in Kenya. Despite the challeng- Furthermore, the WBG is working es faced by the organization, there to support the MOH in the develop- is a growing recognition that the or- ment of a health financing strategy ganization is on the path to reform. and UHC roadmap that clarifies the By choosing to proactively engage NHIF's prominent role. These legal with the NHIF, the WBG has made and oliy frmewrks re mporantsignificant contributions to reorient- and policy frameworks are importantinstkhdeprctosabu for guiding the planned institutional t kFhis eaemen abeen reforms at the NHIF.deliberative, inclusive, action orient- Lesson 4: UHC is an important enabler efm a moeefficient and trans- of private sector growth. parent NHIF can help to realize the The Kenyan experience has empha- pein ofhd Ba Groupxs sized the key role that UHC plays in promoting private health sector engagement with the NHIF offers growth. Private sector players recog- withrexitingspubicoinstiutionsrt nize that increased insurance cover- reform and strengthen their capac- age among the population expands ity to more effectively deliver their their market. Being the largest health mandate. insurance provider in Kenya, there is now a general acceptance that the NHIF is the best placed to drive the UHC agenda. Strengthening the NHIF has been identified as an important priority by private sector providers with the recognition that a reformed NHIF is an important enabler for pri- Finally, asy shownnbybthetNHIF, the vate sector development in Kenya.oper tionalrmaio dataine to pulihsrtiysn Lesson 5: The need for transparencya and citizens' engagement in success- itsora prdut andrservices.iReforms ful reform. 4 SMARTLESSONS - JUNE 2015