What is the true cost of Healthcare? and what does it entail?
Amref Health Africa in partnership with Kenya Healthcare Federation (KHF) held a forum on cost of healthcare on 12th February 2019, at Sarova Pan-Afric Hotel. In order to unpack the areas where costs lie in healthcare, the following guiding questions were asked: What is the true cost of care? How can healthcare be made affordable to all? The forum was well attended by the private sector, civil society organizations, health regulatory bodies, insurance providers and representatives from the Ministry of Health. In his opening remarks, Dr. Amit N. Thakker, chairman, KHF, emphasized on the need for Universal Health Coverage (UHC) and its linkage to preventing catastrophic health expenses leading Kenyans into poverty. He encouraged frank and open dialogue on: commercialisation of medicine, remuneration of human resources for health, understanding public perceptions of cost in the private sector, specifically, the perception of providers (doctors and facilities), insurers and manufacturers and governance of practice.
Mr. Nathaniel Otoo, Executive Director, Strategic Purchasing Africa Resource Centre (SPARC) reiterated that achieving UHC calls for the right capacity and collaboration between public and private sector to fill in the gaps. He took the forum through the Ghana UHC journey focusing on financing strategies. Ghana moved from passive to strategic purchasing with monitoring of quality, performance, and pricing. The National Health Insurance Scheme in Ghana moved from a price taker to a price setter. Along their journey they noted that private sector is not always a marker of efficiency. Mr. Otoo offered to support KHF in its move to tackle the cost of healthcare through capacity building in strategic purchasing, and improving of efficiency and quality of services.
The panel discussions revolved around fraud, supply chain, human resources for health and lack of robust health information systems. As a summary of the meeting, the following priority focus areas were outlined: supply chain management – regulation, distribution, purchasing, prescription; local manufacturing of key products, methods to determine true cost of healthcare at provider, distributor, manufacturing and payer levels; operational efficiencies – equipment sharing, centralised ambulance services, utility costs, models of healthcare worker remuneration; enforcement of professional standards; governance including guidelines or protocols on management of costs; self regulation; patient behaviour change and right of choice; data generation, analysis, and governance; and finally healthcare financing including increasing the risk pool which calls innovative insurance models and social health insurance to capture a larger population, and incorporation of the prevention aspects of healthcare into our current insurance models
10TH Ministerial Stakeholder Forum
The 10th Ministerial Stakeholder Forum took place on 26th February 2019 at the PanAfric Hotel, Nairobi. The Cabinet Secretary Health Hon. Sicily Kariuki chaired the meeting with the Chairman of Kenya Healthcare Federation, Dr. Amit N. Thakker as the co-chair. The forum took place immediately after Hon. Sicily Kariuki inaugurated the NHIF Reforms Expert Panel. In her opening remarks, the Cabinet Secretary (CS) welcomed the attendees emphasizing that the government still holds the vision of a more efficient, socially accountable and a transparent NHIF. The CS said, “As you are all aware, to kick-start the Universal Health Coverage Program, the President launched the UHC Pilot Programs on 13th December, 2018. Further to the pilot program and as part of the UHC agenda, His Excellency Uhuru Kenyatta directed the strengthening and reform of the National Hospital Insurance Fund (NHIF) and the Kenya Medical Supplies Authority (KEMSA).”
The CS informed the attendees that through intensive stakeholder engagement and expert review, the independent panel of experts would be required to develop an action plan for the key objectives of the panel. The panel of experts will focus on legal and regulatory reforms towards transforming NHIF to be a strategic purchaser of health services in the context of UHC, organisational and business process re-engineering reforms aiming at repositioning NHIF as a national social health insurance provider and strengthening fiscal and social accountability and sustainability. The Ministry of Health (MOH) will continuously engage the media to keep stakeholders updated. During the forum, the CS reiterated that MOH would continue working together with the private sector especially in strategizing towards achieving the UHC. She challenged the private sector to ensure implementation of action points discussed while being sensitive to timelines.
Dr. Amit N. Thakker congratulated the CS for inaugurating the NHIF Reforms Expert Panel noting the steps the MOH is taking toward reforms under the leadership of the CS. The KHF Chairman said, “The steps you have taken shows the public that you are serious about reforms. The 90 days timeline [for recommendations from the NHIF Reforms Expert Panel] will give good time to NHIF to make progress towards taking it the next level. It’s also great to hear that the same reforms process will be done for KEMSA”. Dr. Thakker advised the CS that the private sector would continue working with the pilot counties on three key focus areas. The first is the supply chain of medicines and non-medical health commodities where private sector will collaborate in ensuring that the supplies are available, affordable and of good quality. The products will include both locally produced and imported products. Secondly, the private sector will support in healthcare financing by expanding private medical insurance coverage to the pilot counties to complement UHC thereby enabling provision of wider coverage and higher quality of care. Lastly, on the matter of strengthening local referral systems, he informed the ministry that the private sector could help build local clinical capacity in the county referral hospitals effectively reducing the cases referred to Kenyatta National Hospital, Moi and Teaching Referral Hospital and other national referral hospitals. The KHF Chairman, Dr. Thakker, and the entire KHF fraternity congratulates our KHF director, Ms. Joyce Wanderi on her appointment into the NHIF Reforms Expert Panel by the Cabinet Secretary Health Hon. Sicily Kariuki.
Role of Supply Chain towards achieving Universal Health Coverage
Kenya Healthcare Federation supply chain committee held the last committee meeting of the year at Kenya Private Sector Alliance (KEPSA) offices on 22nd November 2018 to confer about Public-Private Partnership (PPP) areas in Supply Chain, Innovations in Health Product Distribution/Supply Chain, Promoting Local Manufacturing and the Role of Supply Chain towards achieving Universal Health Coverage (UHC). Dr. Chris Masila of PractHealth chaired the meeting.
Innovation in healthcare is rapidly growing and can contribute positively to healthcare accessibility. However, Mr. Rolando Satzke CEO, COSMOS Limited, raises a major concern that the patient is not put at the center of the innovations and that the quality of medicine must be maintained to the point of delivery. Further, Dr. Christine Sadia, Chair Kenya Medical Women Association, questioned whether the instructions of the prescription would be clear to the patient at point of delivery.
Dr. Nyalita backed the ideas by adding that most of the innovators focus on the commercial side which raises the question on quality. On the matter Mr. Rolando Satzke concluded by saying “I strongly suggest that all innovations should be patient centrered ensuring that all patients should be able to access quality medication without financial strain.” Dr. Anastasia Nyalita updated the committee on price regulations where she informed them that the Pharmacy and Poisons Board(PPB) is working on the price regulation strategies that was mandated by the Ministry of Health(MoH) and the final report will be ready by the beginning the year 2019. It was good to note that Kenya Healthcare Federation is well represented in the technical working group that is working together with the Pharmacy and Poisons Board.
There was a unanimous agreement by the supply chain committee that it will contribute and support UHC. However, price controls gives less opportunity for profit makers to distribute and resell drugs at a margin to typically unreachable markets, eventually resulting in less impact on patients. This argument links to the importance of patient awareness of and understanding of factors affecting commodity prices. Its important to bring this issue up now when the UHC is being strategized. Countries like Japan Switzerland, Ethiopia and Lesotho are good examples of price regulation models.
The committee has also been discussing the parallel importation Act and Dr. Nyalita updated the committee that the Act by PPB has been finalized and was presented at the Ministerial Stakeholder Forum and will be gazzetted. The Act will look into regulations of parallel importation and Illicit Trade.
On national coding of drugs, Dr. Nyalita updated the attendees on the consensus that was reached where KHF was asked to prepare and present a proposal to the Ministry of Health on coding of pharmaceutical products. In the ninth Ministerial Stakeholder Forum, it was agreed that Kenya should select a global pharmaceutical coding system such as the Anatomical Therapeutic Chemical Classification System(ATC) codes as used by PPB to register medicines. Dr. Daniella Munene was requested to work closely with PPB on this in order to propose a workable coding system for medicines. During the Ministerial Stakeholder Forum, it was agreed that the private sector should share an updated paper on the role of the Private Sector in achieving Universal Health Coverage. The presentation should include bottlenecks that should be addressed to increase coverage and access to quality, affordable healthcare for all.
Ninth Ministerial Stakeholder Forum
The Ministry of Health (MOH) held the ninth ministerial stakeholders forum on 23rd October 2018 at the MOH, Afya Annex building. The meeting was chaired by Dr. Jackson Kioko, Director of Medical Services (DMS) and co-chaired by Dr. Amit Thakker, chairman, Kenya Healthcare Federation (KHF). This forum brought together different health stakeholders including Christian Health Associations of Kenya (CHAK), Nursing Council of Kenya, Kenya Medical Practitioners and Dentist Board (KMPDB) and Kenya Private Sector Alliance (KEPSA), to discuss emerging issues in the private health sector, the progress made since the eighth MSF, and the way forward.
In his opening remarks, Dr. Kioko thanked the private health sector team led by their chairman Dr. Thakker for their great efforts in advocacy and strengthening the partnership between the private sector and MOH. The DMS noted that MOH and the counties may not be able to provide 100% of the services therefore are very grateful for the contribution of the private sector. “Both public and private health sector should ensure that quality is at the core of delivering health services. We also need to train the health workers in having a good mind set, right attitude and good etiquette”, said Dr.Kioko. He further added that the human resource norms and standards need to be reviewed because they do not reflect the reality on the ground.
Dr. Thakker in his opening remarks thanked all the attendees for making the time to attend the forum and discuss Kenya’s health agenda. He emphasized that public – private dialogue is a two way engagement and PPP cannot be left to one party alone. Dr. Thakker assured indicated that KHF’s presentation on the role of the private sector will be shared with MOH ahead of Presidential Round Table (PRT). In the previous MSF, there were major issues that were discussed with much progress made including: Health Regulations – control of the cost of healthcare – it was agreed that implementation of the Health ACT 2017, including the Kenya health professional oversight authority will contribute towards control of healthcare costs; Regulation of doctor’s charges – it was suggested that a strong taskforce be formed to assess the doctors fees and procedures e.g. diagnostics, scans, medications, laboratory e.t.c. and give a report that will inform the regulation of the same.
It was agreed in the previous MSF meeting that KHF should be involved in the process of making Kenya quality model for health (KQMH) the minimum standards certifying tool in Kenya. Ms. Faith Muigai, regional director- Pharm Access foundation informed the attendees that AMREF has been an implementing partner and will share an official report soonest. Dr. Kioko reiterated that quality and standards is a vital area to focus on for UHC. “When it comes to matters of quality and standards, we are looking at collaborations”, said Dr. Kioko. Dr. Thakker suggested that the assessment starts with the areas providing low quality, then progress to areas providing high quality. KMPDB announced a joint inspection of health facilities, and requested KHF to send representatives to join the inspection team and give their input, to which KHF obliged.
Healthcare financing is very key in achieving UHC and the private sector is a major contributing partner. Dr.Kioko requested the private sector to present a well structured action plan on the role of the private sector. Dr.Thakker informed the DMS that the role of the private sector has not been clearly defined particularly in healthcare financing, because the role of NHIF vis-a-vis private health insurance is unclear. Dr.Thakker reported that KHF has visited seven counties to assess their healthcare financing needs and existing models. “The urgency of the counties is now. They have already modelled their own schemes and the big question is where does MOH see the role of the county schemes fitting. It is important that a risk pooling structure be clearly defined so that the private sector can engage”, added Dr. Thakker.
Dr. Kioko responded by saying that MOH is supporting the county financing schemes. “Although issues of sustainability and acceptability of the county medical schemes have been raised, we need to look at them positively and allow them to continue, as we look into how we can support them to be more cost effective” Dr. Kioko added. He further explained that the choice of pilot counties for UHC roll out was based on the need to cover the vulnerable first then the less vulnerable, and that the pilot will be a learning phase which will be monitored to determine which partners need to be brought on board.
Commenting on county managed schemes, Mr. Elkana Onguti of MOH however cautioned that too may pools end up in excessive administrative spend. Dr. Thakker then suggested to MOH to implement a regulatory authority that will regulate the schemes.
In matters of supply chain, KHF requested that regulations for appropriate control of parallel imports should be implemented. Dr. Siyoi, CEO, Pharmacy and Poisons Board (PPB) reported that regulations have indeed been drafted and are due to be gazetted in a few days. Ms. Faith Muigai, regional Director, Pharm Access Foundation emphasized that when looking at strengthening quality and standards, supply chain should also be strengthened. Mr. Onguti, reported that a legal framework has identified some gaps in supply chain though the discussions have not been finalized.
On price control of medicines, Dr. Siyoi reported that a task force has been formed that is looking at price reduction strategies, and he will give a report on this once the task force completes their report. The issue of coding of medicines was raised by Dr. Peter Kamunyo, CEO, Medsource Group. Dr.Kioko invited KHF to prepare and present a proposal to MOH on coding. Dr. Daniella Munene, CEO, Pharmaceutical Society of Kenya (PSK), suggested that Kenya should select the global language of ATC codes as used by PPB to register medicines. Dr. Munene will work closely with PPB on this, to propose a workable coding system for medicines.