Why NHIF has to rethink its operating model

The National Hospital Insurance Fund (NHIF) over the last couple of years have been on a reform agenda including change from hospital insurance to health insurance fund. As these reforms drive much debate in the industry among service providers, policy makers, patients are to an extent not getting involved much. The cost of this is that the ultimate reforms may not serve patients but rather provide an additional revenue stream to service providers while not serving the critical needs as should be the case. Another concern is that for those patients being involved, they are keen on specialized services in critical cases which is not the bulk of our healthcare needs. This in turn drives apathy from the general public with few members signing up to the fund. Anchored on these, I believe the NHIF needs to rethink it’s operating model factoring the following:

1. The fund is driven by membership contributions and therefore the higher the membership, the more the funds they are able to raise. And as insurances work on the principle of spreading the risk, more members signing up translates to a higher margin considering those who will fall sick drawing a substantial amount from the fund may not be substantial. This will help the fund to be sustainable and to meet the needs of more people. In order to do this, the fund needs to look at ways of driving membership which in my perspective should be driven by a focus on our healthcare seeking behaviors and patterns. If I am the kind of person who when unwell goes to the pharmacy, chances of taking a cover that doesn’t enlist pharmacies to offer healthcare services is dismal. This ultimately works against the fund and NHIF has to think through this.
2. According the epidemiological patterns in the country, different regions face a substantial burden of certain diseases compared to others and therefore in each location or through a harmonized service pool, the NHIF needs to ensure that all disease areas are covered. When the fund fails to cover for certain diseases, regions affected substantially by such conditions will have fewer people signing up and thus disparity in care especially when they are not able to afford the cost of care.
3. Through the national scheme, outpatient services are reimbursed at a standard capitation rate which only covers for consultation services in most of the healthcare facilities. In most cases, the co-payment is always substantial compared to the individual contributions that one would rather not consider having a cover in the long run. It is therefore imperative for the fund to reevaluate the services being covered through capitation covering for the diseases which may be managed through outpatient clinics and probably even cap the amount that can be used for outpatient services per year to ensure a member derives value out of the cover. Perceived value will help build on the membership even for those who may not use the services entirely throughout the year.
4. Healthcare services work within an ecosystem which includes healthcare professionals, health facilities, health products and technologies and policy instruments that put these different building blocks into a functioning framework. NHIF as a social insurance needs to have overarching interest in these other pillars and actively engage with stakeholders in driving development of the same to ensure ultimate service users get services conveniently, reliably and of the right quality.

Reflecting on a quote by Jeff Bezo, consumers will always want quality products, conveniently and at the lowest price point. If you can hack this, you are assured they’ll always be your clients to serve. NHIF is failing to view members of the public as conventional clients who need quality healthcare services conveniently and affordably. The role of NHIF is to guarantee them that by signing up they are bound to enjoy these benefits. There’s work to do on this and I hope the ongoing reforms will factor such key business principles.