Eleven months into the SHIF Bill became the Social Health Insurance Act (SHA) on October 2023 the Kenya Medical Association board position in the Social Health Authority remains unfilled. I have a few assumptions as to why.
The Kenya Kwanza (KK) government is very allergic to contrary opinion. Beyond SHA we have witnessed clamping down of persons perceived to have a contrary opinion to the regime.
Specifically for SHA I’m not afraid to express contrary opinions when I think that policies are going in wrong. As President of KMA I actively participated when the KK government was crafting the SHA Act. My first fight was to object to the persistent effort to kick out KMA from SHA board.
Traditionally KMA has had to fight to represent the medical profession in NHIF. It was not always that way. It was when KMA was tired of politicians not prioritizing funds for health service delivery that in 1996 KMA petitioned for a change of the law to include KMA to represent the medical profession. After a long struggle and despite KMA being enacted into the National Health Insurance Fund Act, KMA was not invited to NHIF board meetings by the Ministry of Health. Because of this that the then chairman of KMA Prof Khama Rogo stormed an NHIF meeting and refused to leave despite being threatened by the Minister of Health. From that significant day KMA rightfully sat in the NHIF board and pushed for NHIF funds to be directed away from administrative expenditure to medical services. KMA input drastically improved NHIF’s mandate that progressively expanded from paying for bed fees only, to paying for medical services like dialysis, dental care, eye care and the latest being surgical packages that dramatically changed the lives of many Kenyans for better. KMA was a lone voice in resisting the proposal of giving the ‘tender’ of civil servants’ medical cover to private insurers in the early times of the last decade. KMA organized a meeting to discuss provider input into NHIF packages that had grossly been undervalued in 2017. The packages improved.
The Jubilee government commissioned a review of NHIF in 2019. KMA participated in the review and was represented by Dr Dorcas Supa. KMA was initially excluded from the NHIF review team until the KMA NEC objected to this by asking the review team: ‘How can you review a health financing body without representatives from health workers?’ The review team was led by an insurance professional.
During the tumultuous Jubilee tenure there were numerous efforts to kick out KMA from NHIF via changes in law. Changes in law seems to be the most favored technique of removing possible perceived dissenting voices. The Health Amendment Bill 2017/2018/2019/2020 were all efforts aimed at removing KMA from NHIF. We made a lot of noise. KMA survived. A cursory search of the hashtag #RejectHealthAmendmentAct is very revealing.
KK government kicked out KMA from Pharmacy and Poisons Board using a different law from the PPB Act to constitute the PPB board – the State Corporation Act.
There was an effort to dilute the quorum of doctors in the @Kenya Medical Practitioners and Dentists Board now Council (KMPDC) by changing the law via the Health Act 2017. Prior to this Act doctors used to elect five representatives to KMPDC. The Health Act 2017 effectively eliminated the voted representatives to KMPDC mainly because they were considered ‘noise makers’. This was best manifested in the Cuban Doctors saga.
With new thinking the Kenya Kwanza government muted a new way of attempting Universal Health Coverage they introduced the Social Health Insurance Bill. KMA participated actively during the feedback meetings. KMA’s assessment of the issue was to ensure that the health workforce who give the health service are represented in the Social Health Authority. KMA’s role is to ensure that service delivery payment is prioritized. Effective NHIF representation of providers and patients is so important to KMA has traditionally sent its President of the time to represent KMA in the NHIF board. The logic for this was simple. The KMA President was elected nationally and thus has the doctors’ mandate and thus accountable to the KMA AGM on matters that affected the medical profession in NHIF.
During the crafting of the SHA Act, after successfully managing to defend the position of KMA in the SHA board (with the help of a few of our friends) KMA rejected the proposal that the KMA representative should be restricted to a private doctor. KMAs argument was simple – The President of KMA is elected from across the country and could be a Public Servant or a private doctor. KMA input was rejected. The Act was passed with restrictions of the KMA nominee ‘not being a public servant’. I speculate that this aspect of the law was targeted to exclude specific individuals within the KMA leadership at the time. KMA through the KMA policy committee is drafting a memorandum to change the SHA Act to remove the limitations of the KMA nominee. As proof-of-concept KMA did send the names of two nominees who qualified as nominees as per the act for SHA board nomination. Eleven months into the SHIF Act KMA has not been party to the decisions of SHA.
During the discussions about the SHIF regulations KMA and many other professional associations and societies provided input via memoranda to the Social Health Authority. Many of the inputs were not taken into consideration. When I interviewed Dr Chitayi Mirabula, past Kenya Psychiatrists Association chairman in the #OneHealthLensPodcast he reported that the problem with SHIF is that none of the input they gave was adopted. He reported even giving his own views, SHA did not input it. He has reservations on SHA. Social Health Insurance as a concept is good but the way it is being implemented is not fully agreeable. Exclusion of health workforce is also unacceptable.
The feeling of non-inclusion runs beyond medical personnel. I asked a taxi driver if he had registered into SHA. He said that he was waiting for health workforce to say if it was good or bad. This shows that health workforce are influencers in guiding uptake.
A self-employed economists reported that she tried to register for SHA and the experience was not smooth. She has previously been using NHIF but reported that the information that popped up as she tried to register had her names wrong. She called SHA and was told that that is the way it is. She was furious at the wrong importation of her data and the poor customer relations of SHA. She also reported that she was unclear about the benefits that she would get from SHA and reported that before she attempted to register again her issues must be addressed.
Many of the ‘teething’ problems of SHIF uptake stem from exclusion of the voice of the health worker and of the profession. The voice of health workforce cannot be ignored. The Cabinet Secretary of Health has no option but to gazette the KMA nominee.
Surely the government must not be afraid of perceived contrary opinion. I came across a quote that speaks to this scenario ‘a true sign of intelligence is understanding that other people may have opinions that differ from yours, but you don’t have to attack or berate them over it.
Dr Simon Mucara Kigondu
President, Kenya Medical Association
