Nungo Susan, Filippon Jonathan, Russo Giuliano
Wolfson Institute of Population Health, Queen Mary University of London, London, UK
Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
BMJ Open. 2024 Dec 11;14(12):e085903. doi: 10.1136/bmjopen-2024-085903.
To analyse the potential of the Social Health Insurance (SHI) model to support the achievement of Universal Health Coverage (UHC) in Low and Middle-Income Countries (LMICs) through a policy analysis case study of Kenya's National Health Insurance Fund (NHIF).
We used an adaptation of the policy triangle framework to perform a retrospective policy analysis of Kenya's NHIF, drawing from semistructured interviews and analysis of published documents and grey literature.
We focused on Kenya's NHIF as a case study.
We conducted 21 interviews with key stakeholders including policy experts, healthcare providers and formal and informal sector workers. We then triangulated the interview findings with document analysis.
Only 17% of Kenya's population are currently covered by the SHI as of 2023. Only 27% of the informal economy is covered by the NHIF, implying very low uptake and/or retention rates. We found little stakeholder engagement in the policy implementation process and minimum adoption of expert advice. Our analysis suggest that political affiliations and positions of power heavily influence health financing policies in Kenya. Purchasing and payment of healthcare was found to be riddled with inefficiencies, including slow bureaucratic reimbursement procedures, little expertise by rural hospital clerks, misappropriations and favouritism of specific private healthcare providers. We also found that group-based parallel schemes and penalty payments for defaulted premiums widened the existing inequity gap in healthcare access.
Although the SHI system is perceived to increase coverage and the quality of health services in Kenya, substantial structural and contextual challenges appear to deter its suitability to finance the attainment of Universal Health Coverage. From Kenya's experience, we identify little informal sector participation, inefficiencies in purchasing and payment of healthcare services, as well lack of political goodwill, as key bottlenecks for the implementation of SHI schemes in LMICs. LMICs adopting SHI need to also implement co-financing arrangements that do not impose on the population to co-finance, strategic purchasing systems, political goodwill and good governance for the SHI systems to be beneficial.
通过对肯尼亚国家健康保险基金（NHIF）的政策分析案例研究，分析社会健康保险（SHI）模式在低收入和中等收入国家（LMICs）支持实现全民健康覆盖（UHC）的潜力。
我们采用政策三角框架的改编版，通过半结构化访谈以及对已发表文件和灰色文献的分析，对肯尼亚的NHIF进行回顾性政策分析。
我们将肯尼亚的NHIF作为案例研究重点。
我们对包括政策专家、医疗服务提供者以及正规和非正规部门工人在内的关键利益相关者进行了21次访谈。然后，我们用文件分析对访谈结果进行了三角互证。
截至2023年，肯尼亚目前只有17%的人口参加了社会健康保险。非正规经济部门中只有27%被NHIF覆盖，这意味着参保率和/或续保率非常低。我们发现利益相关者在政策实施过程中的参与度很低，对专家建议的采纳也很少。我们的分析表明，政治派别和权力地位严重影响肯尼亚的卫生筹资政策。医疗保健的采购和支付存在诸多低效问题，包括官僚报销程序缓慢、农村医院办事员专业知识不足、挪用资金以及偏袒特定的私立医疗服务提供者。我们还发现，基于群体的并行计划以及对拖欠保费的罚款加剧了医疗服务获取方面现有的不平等差距。
尽管社会健康保险制度被认为可以提高肯尼亚的保险覆盖面和卫生服务质量，但重大的结构和背景挑战似乎阻碍了其为实现全民健康覆盖提供资金的适用性。从肯尼亚的经验来看，我们发现非正规部门参与度低、医疗服务采购和支付效率低下以及缺乏政治意愿是低收入和中等收入国家实施社会健康保险计划的关键瓶颈。采用社会健康保险的低收入和中等收入国家还需要实施不强制民众共同出资的共同筹资安排、战略采购系统、政治意愿和善治，以使社会健康保险制度发挥作用。
