Utilization of the National Hospital Insurance Fund Among Community Members in Embu County, Kenya

Abstract

Health insurance schemes have been recognized as among the major tools to finance Universal Health Coverage (UHC). The Kenyan government has identified the National Hospital Insurance Fund (NHIF) as one of the vehicles towards achievement of UHC, with the goal to cover 100% of the population by 2022. Catastrophic health expenditure in Embu County stands at 9%, higher than the national average of 6.2%, yet NHIF coverage remains low. There is paucity of data on the extent of NHIF utilization and whether it meets the needs of the insured. Consequently, this study set out to determine the utilization of NHIF in Embu County, Kenya. The study employed a mixed-methods study design that incorporated both quantitative and qualitative methods. A community based cross-sectional survey was conducted on households identified through systematic sampling. Data was collected using a semi-structured pre-tested questionnaire, focus group discussions and key informant interviews. Quantitative data was analyzed using the Statistical Package for Social Sciences software version 23 while qualitative data was analyzed thematically. Less than half of the respondents (n=113; 40.8%) were enrolled with NHIF despite a vast majority (n=262; 94.6%) reporting to have ever heard of the fund. Among those enrolled with NHIF, only about a third (37.2%) were predominantly using the fund to meet their health service needs. Majority of the respondents (n=255; 92.1%) routinely paid for health services despite abolition of user fees in primary care facilities. Over half (54.9 %) of the respondents reported that they had ever failed to access a health service they needed because of cost in the preceding 12 months. Majority (n=147; 53.1%) reported paying out of pocket to access health services. Socio-demographic factors were shown to influence enrollment into NHIF. Employment status was significantly associated with NHIF enrollment, with enrolment being highest among those employed (69%) compared to the self-employed (37.3%) and the unemployed (24.2%) (p=0.007). Increase in wealth index was significantly associated increasing NHIF enrollment, with the proportion of those in lowest wealth quintile having NHIF being 16.1% compared with 67.6% among those in the highest wealth quintile (p=0.033). Of those who were not enrolled with NHIF, 53.7% reported the premiums were too high, 25% reported they didn’t know how to enroll or how the fund works, 17.6% reported they didn’t find NHIF useful and 3.7% were not interested. Availability of services and commodities, flow of capitation/reimbursement funds from NHIF through the county accounts to health facilities, requirement to co-pay in some facilities, distance to an accredited facility and limited knowledge on the scope of services covered influenced the extent to which those enrolled with NHIF actually utilized the fund to meet their health service needs. In conclusion, NHIF utilization in this community was low and was influenced by socio-demographic and health system determinants. The assessment recommended targeted enrollment in the informal sector, better means of creating awareness about NHIF services and packages, improved flow of capitation/reimbursement funds, increased number of accredited facilities and strengthened service delivery especially at lower level facilities to improve the effectiveness of the fund.