Susan Nyambura Njuguna, June Wahito Wachira & Macharia Waruingi
Saturday, March 24, 2018

We summarize, in this document, take home messages from Kenya Medical Association (KMA) Nairobi Division Annual General Meeting. The meeting took place on 8th Floor, Jubilee Insurance Building, Kaunda Street, Nairobi, Saturday, March 24, 2018, 9.00 am – 3.00 pm. This document contains only a review of podium presentations pertinent to health financing. It does not contain discussions of official business of Nairobi Division of KMA, other than appointment of the Chairman of Ubrica, Macharia Waruingi, to the Governing Council of Nairobi Division of KMA. We developed this document as a memo of take home messages for Ubrica team. We focused on presentations about health financing, as the subject of central interest to Ubrica.

Message from the Regional CEO of Jubilee Insurance, Dr. Julius Kipng’etich, highlighted three critical elements to effective practice of medicine. He advised that doctors should:

• learn principles of business. Principles of business would help a doctor plan his/her time better. All doctors could greatly benefit from an MBA.
• embrace three important technologies namely biotechnology, information technology and blockchain technology. We live in a world of fast changing technologies. Doctors must learn and keep up with these technologies. Financial technology is an additional technology not mentioned. Indeed, in our view, financial innovation from works in financial engineering that creates financial technologies is requisite to innovations in the three stated technologies: biotechnology, information science and blockchain. Without financial innovation large scale innovation is not possible.
• be service oriented in their approach to work. The job of a doctor is a service. Doctor must learn the skill of customer service to remain competitive.

Dr. Roslyn Ngugi spoke about improving cardiovascular outcomes in people with diabetes. Diabetes increases incidence of cardiovascular illness. Indeed, diabetes accelerates incidence of burden of disease, disability and death due to cardiovascular disease. Optimal blood sugar control is important, but not enough to forestall incidence of cardiovascular diseases. Instead, doctors should use combination of approaches that include diet, physical activity, and statins, besides anti-glycemics. There was no mention about specific things to include in a good diet to eat, or what not to eat. It would be important to address the role of natural food supplements, nutricicals, such as wheatgrass, and the like in glycemic control. There remain many questions about appropriate approach to diabetes control under conditions of economic deprivation, and in absence of universal health coverage. Cert, low income populations in urban and rural areas may not have access to anti-diabetic treatment, and pricey statins.

Dr. James Soki explained that health insurance is a net loss business in Kenya. Every insurance company meets severe loss in health business. Furthermore, we have extremely low health insurance coverage in the Kenya. The government sponsored National Hospital Insurance Fund (NHIF) covers only about 16% (Dr. Suleh explained that recent reports indicate approximately 25%) of the Kenyan population. The fact of the matter is that health insurance coverage is extremely low. The prevailing talk in town about universal access leaves wide gaping holes on exactly how universal coverage could be achieved. Besides the extremely low coverage, health insurance is plagued with other woes such as moral hazard and adverse selection, borne of the third party structure of the health insurance business in Kenya.
Two fundamental questions arise from Dr. Soki’s presentation:
• How do we achieve universal coverage in the context of net loss in the health insurance business?
• How do we restructure the health risk pooling business to eliminate the third party structure, so that everyone is in a single party?

In the sections that follow, we address these two questions, and propose a continued monthly dialogue organized jointly by the KMA, Ubrica, and Jubilee. This would be a continuation of Ubrica Monthly Dialogue Series on What Next, Health in Kenya that has been taking place every third Saturday of the month, at Ubrica on Munderendu Road, Karen, Nairobi. So far Ubrica has sponsored two dialogue sessions. We have appended reports of those two sessions to this memo. We attempt to respond to the two questions arising.

1. How do we achieve universal coverage in the context of net loss of the health insurance business?
In the previous dialogues, we have confirmed that is impossible to improve health of a poor person. In order to improve health of a person we have to think about how to improve the health of his or her pocket first. With money in the pocket, a person is then able to purchase a basket of goods that will include good nutrition, shelter, health insurance and the like. This argument begs the question: How can we put money in pockets of people in Kenya?

To answer this question, we have to think about why millions of people in Kenya do not have money to buy health insurance. As it is, private health insurance covers only a paltry 3% of Kenyan adult population needing coverage. A whopping 97% is uncovered. To achieve universal coverage, we would have to cover the 97%. Bringing this number of people to coverage requires deep thinking about why they are not buying insurance in the first place. Insurance is not a top priority during budgeting of cash in families who are barely meeting their basic needs. Only after people have met their basic needs, do they allocate their excess disposable income to insurance products. If we were to increase insurance coverage, we have to help local people earn more money to have disposable income that they can use to buy health insurance. We know that people increase their income when they are able to sell what they produce.

We built Soko Janja to help people sell their products and services. Soko Janja is an online market place created specifically to create market for produce, products and services in Kenya. All sales on Soko Janja will be marked up to include a small fee that goes to a health fund. Results of our actuarial studies indicate that an average of 300,000 people per county contributing KES 300 per member per month will raise sufficient money to pay for the best quality of care in the country.

2. How do we restructure the health risk pooling business to eliminate the third party structure, so that everyone is in a single party?
We can avoid moral hazard and adverse selection inherent in third party insurance structure by having all actors in the same party. In this case, the health consumer, the provider and the payer are in the same party. We have formulated actors in Soko Janja to belong to the same party (Figure 1). As we encourage consumers of health fund to participate in investing in development, construction and operation of health facilities, we will also encourage providers to purchase produce and products from health consumers, and payers also to participate in promoting local produce, products and services.

Figure 1. Soko Janja Single Party Health Financing Structure

We propose to create a tri-partite strategic partnership among Ubrica, Jubilee and Kenya Medical Association. The purpose of the partnership will be to actuate occurrence of universal health access. In this relationship:
1. Ubrica will mobilize people in communities throughout Kenya to list their products on Soko Janja. The goal of Soko Janja is to enroll 14,000,000 families in Kenya on the e-commerce platform, where they can buy and sell produce, products and services. Enrolled individuals become members of Co-operative Society of Ubricans. Soko Janja will drop KES300 per member per month from the proceeds of a sale into a health fund. Soko Janja will also allow members to elect to buy health investment instruments created specifically for funding design, development and implementation of life-science and health services projects.
2. Jubilee will manage the health fund on behalf of consumers, and other funds created for funding design, development and implementation of life-science and health services projects.
3. Kenya Medical Association will organize medical professionals as health providers, who would receive support for design, development and implementation of health services projects.

Way Forward
We propose continuance of Ubrica’s year-long series of dialogue meetings to deliberate different futures of health in Kenya, and the strategic directions that could lead to those futures. This dialogue series is in response to the deplorable state of health in the country, and the role of the Kenyan medical professional to redress this state. The expected outcome of this dialogue series is discovery of theoretical model that would explain how we can achieve universal health in Kenya that is of greatest quality possible, and available to all Kenyans. Universal health access is a function of comprehensive health coverage to ensure realized access to good quality health services to all Kenyans.

This dialogue also seeks to discover operational structure of universal health, and the processes that would drive such a structure. Finally, the dialogue seeks to find the place of the medical professionals, and in particular physicians and surgeons of Kenya, in ensuring access to health services of good quality, affordable, and accessible to all Kenyans. The next dialogue session will take place Saturday, April 21, 2018. Traditionally the dialogue series has taken place on at Ubrica on Munderendu Road, Karen, Nairobi.


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