Will Corruption at the NHIF Derail UHC Gains?

The attainment of the Universal Health Coverage (UHC) as envisaged in President Uhuru Kenyatta's Big 4 Agenda might hit a snag, if medical fraud is not nipped in the bud at the National Health Insurance Fund (NHIF).

For years now, the organization has been riddled with corruption with most cases being impersonation and fake claims by both public and private facilities.

Looting at the health fund has been a disease that cuts across from the staff at NHIF, health service providers and patient who are members of the Fund.

The state insurer fund led by Chief Executive Officer (CEO) Dr Peter Kamunyo is seeing to use a full electronic system which has been completed in phases so as to contain fraud and avoid the risk of depleting the health fund due to corruption.

"One of the key areas to ensure we limit and increase accountability is digitization. With digital records you can view and go back in time. We have noted that this medical fraud occurs in many shapes and forms. That's why our digitization process and organizational transformation to ensure our team of case mangers pick out these cases," said Kamunyo.

In an exclusive interview with Capital FM, Kamunyo admitted that entrenched corruption in the fund especially by staff at NHIF and health care providers has prompted them to work with the Director of Criminal Investigations (DCI) and Director of Public Prosecutions (DPP) to ensure swift action is taken on graft cases.

"We have created a division on compliance and enforcement to ensure swift investigation of any graft cases. It's in collaboration with other graft agencies to ensure we are able to prosecute as soon as we can," he said.

NHIF is working towards integrating with the Huduma Namba as an enabler to a more robust digitized system to ensure a seamless digitized system.

Last year, the Fund flagged health facilities in Nyamira, Homa Bay and Migori counties for involvement in various forms of fraud.

The scam involves nine hospitals in the three counties where healthcare providers claimed to have performed various operations and procedures when, in fact, they did not.

"You would be surprised that they are institution that are currently in court that have rooms full of people just manufacturing claims. We are zero tolerant to fraud because defrauding the fund is equal to denying a Kenyan health care. We are actively going through these cases," Kamunyo said.

Health Cabinet Secretary Mutahi Kagwe has previously lamented over the rise of claims payment from hospitals that rose from Sh19.7 billion in financial year 2015/2016 to Sh54.6 billion in financial year 2020/2021.

While Kamunyo attributed the rise to increased membership over the three financial years, fraud cannot be entirely ruled out.

"Fraud plays a part in increasing cost not just in Kenya but globally. That's why we are using electronic claims for all hospitals doing business with NHIF," Kamunyo stated.

The NHIF CEO revealed that moving forward they will use prospective reimbursement (a method of reimbursement is made based on a predetermined, fixed amount) as compared to fee for service to pay claims to Public and Private hospitals contracted to give out health services to members of the fund.

"It's basically like packages so as institution if you have a certain diagnosis like pneumonia what you get reimbursed is the same amount or a fixed amount. This now calls the health providers to fix themselves within the same amount," he stated.

On the flip side, prospective reimbursement may be detrimental as some health providers might seek to employ cost-cutting measures to maximize profits while not necessarily keeping their patients' best interests in mind.

Because providers receive the same payment regardless of quality of care, some might be moved to offer less thorough and less personalized service.