Inside ambitious plans by State to reform healthcare

President William Ruto’s government has proposed changes to various health laws that will enable hospitals to deal with chronic illnesses as well as ensure accountability in terms of claims lodged by patients.

The changes will also seek to ringfence money generated in health facilities, ensure a predictable, regular and steady source of funding for health facility operations in the counties in order to guarantee that funds are utilised for the improvement of patient care at individual health facilities, preventing them from being absorbed into county coffers.

“The principal object of the bill is to provide for public health facility improvement financing and management and administration of the improvement financing and for connected purposes,” reads the Facilities improvement-Financing Bill, 2023.

The said proposals are contained in the Social Health Insurance Bill, 2023 and the Facilities Improvement Financing Bill, 2023.

Endorsed by Cabinet

The two bills are among four others including the Primary Health Care Bill, 2023, and The Digital Health Bill, 2023 that were last week endorsed by the Cabinet at Kakamega State Lodge.

The said draft Bills are expected to be forwarded to Parliament for consideration once it resumes sittings later this month.
With regards to the Social Health Insurance Bill, which seeks to replace the National Health Insurance Fund (NHIF) Board with the Social Health Authority, the government is proposing to establish within the authority a Claims Management Office which shall review and process the claims.

According to the Bill, the authority will only make payments to a contracted healthcare provider or healthcare facility upon submission of a claim by the Claims Management Office. Reads the Bill: “The Cabinet Secretary shall make regulations for the better carrying out of the provisions of this section.”

The Claims Office, says the Bill will be responsible for reviewing, processing and validating medical claims from healthcare providers and healthcare facilities, appraising medical claims based on the benefit package, issuing pre-authorisations for access to healthcare services based on the benefit package as well as developing an e-claims management system.

Quality assurance

It will also be mandated to undertake quality assurance surveillance in respect of claims, establish systems and controls for detecting and identifying fraud appropriate to the fund’s exposure and vulnerability, sensitize claimants on the consequences of submitting false and fraudulent claims, collect and analyze data for purposes of claim management, prepare quarterly reports on claims for submission to the to the board and the Cabinet Secretary as well as perform any other functions as may be necessary.

Reads the Bill: “The Claims Management Office shall delegate the performance of its functions to a suitable entity. The entity referred to shall be a medical insurance provider or a broker licensed by the Insurance Regulatory Authority under the Insurance Act: Provided that not more than five entities shall be contracted to manage the claims from the zones identified in the manner prescribed in the Regulations.”

And to further ensure that transparency and accountability when dealing with patients and hospitals, the Bill is proposing the digitization of all the processes and services using appropriate, reliable, secure, inter-operable, verifiable and responsive technology through an information system developed.

The processes and services to be digitized include registration of members, member identification, contributions to the Fund, empanelment of facilities, execution of contracts, notification and preauthorisation, claims management; and settlement of claims.

Reads the Bill: “Every Kenyan shall be uniquely identified for purposes of provision of health services. The digitization of processes and services under this Act shall conform to the provisions of the Data Protection Act, 2019 and all other relevant laws.”

Fraudulent claims

The move comes at a time when NHIF acting CEO Samson Kuhora is on the spot over fraudulent claims and payments made to various hospitals. Kuhora, is currently facing the National Assembly Committee on Health for a 90-day inquiry into allegations of fraudulent claims and payment to the said hospitals.

The investigations started after Health Cabinet Secretary Susan Nakhumicha suspended eight rogue health facilities.

With regards to Chronic and Critical Illness and Emergency, the Bill recommends the formation of a Fund to defray the costs of management of chronic illnesses after depletion of the social health insurance cover as well as cover the costs of emergency treatment.

According to the Bill, the sources of funds for the Chronic and Critical Illness and Emergency Fund will comprise of monies appropriated by the National Assembly, gifts, grants, donations or endowments; and such monies from any other lawful sources. “Implementation of Chronic and Critical Illness and Emergency Fund.

The Cabinet Secretary may make regulations for the implementation of the Chronic and Critical Illness and Emergency Fund,” reads the Bill.

With regards to benefits, tariffs and empanelment, the bill proposes that every beneficiary be entitled to an essential healthcare benefits package prescribed by the Cabinet Secretary in consultation with the Board. The benefits will be payable based on a tariff that will be developed by the CS in consultation with the Board,

“The authority shall make payments out of the funds to health care providers or health care facilities that are empaneled and contracted in accordance with the provisions of this Act,” reads the bill.

With regards to a health care provider or healthcare facility seeking to be empaneled, the Bill states that they will be required to make an application to the body responsible for accreditation for quality of care in the manner prescribed by the Cabinet Secretary.

Once approved, every contracted health care provider and healthcare facility will be issued with such identification as may be prescribed by the Authority and such identification shall be displayed in a conspicuous position.

The Primary Health Care Bill, 2023 on the other hand roots for provision of primary health care at the community level – with the help of community health workers and the lowest facility.

In the Bill, the government seeks to hire 100,000 community health promoters whose roles shall include health education and promotion, disease prevention and control and family health services.