The quest for universal health coverage (UHC) is a global commitment, underscored by the Sustainable Development Goals adopted in 2015. The objective of UHC is to ensure that all people have access to the health services they need without financial hardship.
This is a critical endeavour as healthcare costs continue to rise, putting immense financial pressure on individuals and governments alike. According to the World Health Organization, a significant portion of healthcare spending is inefficient, with 20 to 40 per cent of all health spending wasted through inefficiency.
To move towards UHC, it is essential to explore and implement effective healthcare financing models. These models play a pivotal role in collecting revenue, pooling financial resources, determining covered healthcare benefits, and purchasing services.
Social Health Insurance (Bismarck Model): This model involves the collection and pooling of funds through payroll taxes from both employers and employees, known as sickness funds. It covers health services for contributors and their dependents, with contributions based on income. Some governments also subsidise these contributions to extend coverage to the poor and unemployed.
Taxation-Based Financing (Beveridge Model): Here, public health services are funded through taxes collected from individuals on income, consumption, property and capital gains. This model is not dependent on formal sector employment and aims to provide quality healthcare regardless of an individual's financial means.
Kenya's Hybrid Model: Of the healthcare financing models Kenya appears to have adopted a hybrid of both the social health insurance model and a tax-based model with the chronic disease fund, emergency medicine fund and primary healthcare funds being tax-funded and the SHIF being contributor-based. As I have argued before, this puts an undue burden on the employed Kenyans who are a minority as those not in formal employment only contribute voluntarily.
The reliance on the formally employed population to contribute to the SHIF underscores a significant burden borne by a relatively small segment of the Kenyan workforce.
With a considerable portion of the population engaged in informal employment or subsistence activities (estimated at 83.6 per cent according to the Kenya National Bureau of Statistics 2020 Labor Force Report), the responsibility of financing healthcare disproportionately falls on the formal sector.
This disparity raises critical questions about equity and sustainability in the financing model, the money collected may not be enough to adequately cover the healthcare needs of all Kenyans.
Those not in formal employment are encouraged to contribute voluntarily to the SHIF, yet this voluntary contribution system risks leaving significant gaps in coverage, potentially sidelining those who are most in need of financial protection against healthcare costs.
Reimbursement methods are crucial for allocating resources effectively and ensuring the delivery of healthcare services.
Pay-for-Performance Systems: These systems reward healthcare providers for meeting specific performance targets and emphasise the quality rather than the quantity of care. An example is the Affordable Care Act in the US, where physicians are rewarded based on the quality of care measured by patient outcomes.
Diagnosis-Related Group (DRG) System: Developed in the US, the DRG system classifies hospital cases into groups to facilitate reimbursement. It encourages efficiency and cost-control by hospitals.
Integrated Healthcare Models: These models promote a coordinated approach to healthcare delivery, integrating various services to improve patient outcomes and make efficient use of resources.
The newly formed Social Health Authority is now engaged in formulating the new benefits packages. In this endeavour it has sought the input of various stakeholders, including professional associations that include the various surgical societies.
This brings me to my point of issue concerning these new packages and how they will affect the provision of surgical service which cannot be neglected if true UHC is to be achieved. According to a 2018 Lancet Commission report, and also as I had argued in my article last week, surgical care is essential for addressing a significant portion of the disease burden in Sub-Saharan Africa.
The financing and reimbursement models significantly influence the provision of surgical care, particularly in the context of UHC and surgical benefits packages. Efficient financing models ensure that funds are available for essential services, including surgery, without placing financial strain on individuals. Meanwhile, effective reimbursement methods encourage healthcare providers to offer high-quality surgical care efficiently.
To enhance surgical care under UHC, it is essential to:
Ensure that surgical benefits packages are included in healthcare financing models and that they adequately cover the costs related to various surgical procedures.
Implement reimbursement methods that incentivise quality and efficiency in surgical care.
Foster integrated care models that support the seamless delivery of surgical services across different levels of healthcare.
Healthcare financing models and provider reimbursement methods are foundational to achieving universal health coverage and ensuring the equitable provision of healthcare services, including surgical care.
By carefully selecting and implementing these models and methods, Kenya's UHC system can move towards a future where everyone has access to necessary health services without experiencing financial hardship.