Increasing health insurance coverage in Kisumu County, Kenya: a model for social health insurance
Kenya’s Kisumu County, also known locally as the Sunset County, is situated on the shores of Lake Victoria and is home to 1.15 million people, many of whom are involved in rice farming and fishing. The County intends to provide equitable and quality social health insurance for at least 70 per cent of residents in the next five years. In October 2020 and with technical support from PharmAccess Foundation, they launched the Kisumu Solidarity Health Cover programme “Marwa”, which has the goal of driving health insurance coverage in Kisumu and is linked to Kenya’s National Health Insurance Fund (the NHIF).
One of the objectives of the Kisumu County government is to finance the health system through insurance. Residents are encouraged to pay for insurance while those that cannot afford to pay the insurance premium are supported by the County government. As for the population of Kisumu, 10 per cent are estimated to be in the formal economy, 60 per cent in the informal economy, with the remaining 30 per cent classified as most vulnerable. To achieve the goal of 70% insurance coverage, there’s a need to pay attention to the informal economy.
Formal economy workers in Kisumu are typically automatically enrolled into the NHIF and they may also have complementary private health insurance. NHIF membership is compulsory for all residents of Kenya with deductions made directly by the employer for those working in the formal economy, however, most of the population works in the informal economy. Without any form of insurance, people end up paying out of pocket when they need healthcare, which can push them into debt and poverty. Informal economy workers need to self-enrol but many, for various reasons, do not enrol or default in their subsequent premium payments. It was recently announced that about 8.8 million or 43 percent of NHIF members default on monthly contributions, effectively condemning them to out-of-pocket medical expenses. Together with the ILO and PharmAccess Foundation, Kisumu County has started to design a strategy for onboarding new members from the non-poor informal economy into Marwa, which includes NHIF cover and has the possibility of broadening the NHIF benefits package with other Marwa specific benefits (such as a reduced hospital waiting period from the standard NHIF cover) and value-added services (for example, telemedicine). More on this project can be found here.
Initially, Marwa focused on the most vulnerable population. A survey in 2019, which used a socioeconomic index from the County and PharmAccess Foundation, helped identify just over 90,000 of the most vulnerable households. With the support of the John Martin Foundation, Kisumu County paid the NHIF insurance premium for 42,564 of these most vulnerable households (around 170,000 individuals). This gesture increased the number of households in Kisumu covered by NHIF by 117 percent, from 36,366 to 78,930 households. Marwa also serves as a platform for collective negotiation for Kisumu residents and for improving health systems, both core deliverables of Marwa. In the first phase (ending December 2022), Marwa set up a network of 49 public healthcare facilities and improved services and care quality by implementing “SafeCare Methodologies”. Marwa also set up a 24-hour call centre as a source of information, to ensure that complaints are easily resolved, and emergency cases promptly handled.
Kisumu’s Health Financing Bill, which was passed in 2020 and amended in 2022, legitimized the framework on which Marwa is established. It made sure that Marwa is legally embedded in the Bill and that its earmarked funding is kept separate from other public funding. Marwa also pays attention to data collection, analysis and interpretation in decision-making and policy formation. Data is collected through the M-TIBA platform (a digital health wallet and administration platform) and M-TIBA is also used for enrolment and administration of the scheme. This ensures that the beneficiary’s experience is digital, and that data can be captured at every point of interaction.
Given the capitation arrangements between public healthcare facilities and the NHIF, a secondary consequence of improving enrolment in Kisumu County is that it also increased the income received by participating facilities. This increased income has allowed for the purchase of additional healthcare commodities (such as drugs), which has enabled an improvement in the quality of care over this period.
Marwa will leverage Kisumu County’s governance and legal structure, the administration’s political will, the technical knowledge and experience of partners as well as (non-)financial resources of donors. However, the key to success is the distribution of Marwa: so succeeding in raising awareness, marketing, enrolment and premium collection, and creating behaviour change around voluntary enrolment. We hope to distribute Marwa through groups and make health insurance as accessible as “buying salt”. Technology will be extensively used in distribution, onboarding and administration. We have the benefit of the M-TIBA platform and learning from their vast experience in the inclusive insurance space servicing over 400,000 Kenyans. The collaboration with the ILO has just begun and we look forward to sharing our journey.
This blog was written by Akinyemi Alebiosu and reviewed by Lisa Morgan and Shana Fabienne Hoehler (ILO).
