Implementing an Outpatient Service in A Social Health Insurance System in Kenya: A Capacity Building for Effective Health Fellows

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Implementing an Outpatient Service in A Social
Health Insurance System in Kenya A Capacity
Building for Effective Health Fellows Perspective

• Kenya Health Morans
• Hanoi, Vietnam
• 10 May, 2010

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PROJECT OPTIONS
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Option 1 Research question

• Can capitation assure quality of healthcare and
  reduce out of pocket expenditure for the poor and
  vulnerable in Kenya?

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Option 1 Justification

• Will offer new perspective to HF reforms.
  Previous reforms have focused on resource
  mobilization
• Addresses targeting shortcoming in NHIF
  outpatient pilot which does not cover poor and
  vulnerable
• Experiential approach advocated as a powerful way
  of testing PPMs
• Inform the design of the planed HFT pilot
• Develop field internship sites for CBEH
  programme
• Field internship sites will give CBEH Fellows the
  practical experience necessary to complement
  didactic training, while giving the health
  institutions new resources to improve management
  analysis.

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Project Goal

• To contribute to the improvement of the health
  status and quality of life of all Kenyans,
  especially the poor and vulnerable groups.

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Project Objectives

• Assure quality of outpatient services
• Reduce the OOP spending on OP services by
  Mathare residents

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Capitation Project Cost Estimate
These are order of magnitude estimates to be
fine tuned
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Assumptions

• Funding and Stakeholder Support
• Provider buy in.
• Provider Management and Clinical Capacity
• Availability of an Implementation Team

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Success Criteria

• Capitation project implemented
• Providers compliance with agreed treatment
  guidelines
• Increased client satisfaction with outpatient
  services
• A reduction in outpatient out of pocket spending

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Project implementation-Challenges

• Funding
• Buy-in from stakeholders
• Duplication of efforts- three pilots planned-
• Acceptance by the potential beneficiaries

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Option 2 Research question

• Can capitation assure quality of healthcare and
  reduce out of pocket expenditure for the poor and
  venerable Kenya?

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Option 2 Project Approach

• Same as for option 1, but piggy back on NHIFs
  pilot.
• NHIF will provide funds for members
• Fellows will seek support for funding of
  indigents

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Option 2 Pros

• Will have benefits of option 1, but to a limited
  extent

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Option 2 Cons

• Stakeholder buy-in ( NHIF and funder of
  indigents)
• Perceived conflict of interest with private
  sector Fellows
• Logistics of changing project design to
  accommodate poor and vulnerable population
• Fellows will have no control over time, scope and
  quality, key tenets of project management
• There may be no results to report at evaluation
  seminar in Hanoi, Vietnam

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Option 3 Research Question

• What are the critical factors for the successful
  implementation of capitation in out patient
  services for primary health care?

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Option 3 Project Approach

• Literature review of implementation of
  capitation in a number of countries, both
  developing and developed
• Identification and critical analysis of critical
  success factors
• Project documentation
• Development of implementation manual

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Option 3 Pros

• Well thought out actionable plans for successful
  introduction of outpatient services under a
  social health insurance system

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Option 3 Cons

• Lacks experiential approach of Options 1 and 2
• Limited documented experience of capitation in
  developing countries

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Implementing an Outpatient Service in A Social
Health Insurance System in Kenya A Capacity
Building for Effective Health Fellows Perspective
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Assumption

• This paper assumes that there are enough revenues
  to provide individuals with a basic package of
  essential out patient services and financial
  protection against catastrophic medical expenses
  caused by illness and injury in an equitable,
  efficient, and sustainable manner.

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Methodology

• Development of this paper was based information
  obtained from
• Literature review
• Formal and informal meetings with health systems
  and health financing experts.

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Benefit Package

• The benefit package important consideration in
  the uptake of health services under SHI
• Benefit package must be economically feasible,
  and socially acceptable
• Based on KEPH and WHO 2008 report
• Research on regional epidemiological profiles to
  inform definition of benefit packages.
• Carry out study to collect expectations of a
  minimum health benefit package
• Will evolve over time

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Cost Management

• Costs of benefit package will determine the
  financial sustainability and survival of
  outpatient coverage.
• Use GTZ costing tool to cost service, triangulate
  with capitation rate calculator
• Carry out market survey to determine OP service
  delivery costs
• Obtain win-win situation
• Control service delivery costs through use of
  clinical standards and treatment protocols
• Manage administrative costs outsourcing and
  process improvement
• Aim at not exceeding 10 of throughput

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Players in OP Service Delivery

• Palyers include
• Risk Pooling Agency
• Purchasing agencies
• Service Providers
• Beneficiaries
• Separation of functions NHIF to do risk pooling.
  Purchasing of OP services to be done by appointed
  service managers

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Capitation Service Manager

• Competitive selection process
• Competition to increase efficiency
• Selection should be based on
• Critical skills and competencies
• Financial and accounting experience and HR
  capacity
• Systems- ICT, membership/claims/accounts
  payable/customer service, audit, reporting
• Health Sector Experience
• Draw up contract. Adapt from existing private
  sector documents.

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Service Provider

• Selection criteria should be based on
• Location/Accessibility
• Physical capacity
• HR mix
• Range of outpatient curative and Preventative
  services offered
• Turnaround time(and customer service)
• Quality assurance (clinical and non-clinical)
• Integrity
• Clinical Risk management
• Cost management
• Medical infrastructure
• Accounting and Record Management systems
• Apply franchising principles to develop provider
  systems
• Contract to manage purchaser/provider
  relationship

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Member Recruitment

• Identification of poor- Tool adapted from
  OBA/UNICEF and GOK Poverty identification tool.
• Classify poor according to serverity government
  will first pay premiums for the most poor and
  progressively increase this coverage with time to
  cover all those identified as being poor.
• Members should have some choice to select their
  service provider
• Recruitment process can borrow a lot from voter
  registration process

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Member Recruitment

• Employ various strategies to disseminate
  information on member registration.,this should
  include
• posters at chief camp and health facilities,
• newspaper advertisement,
• brochures issued in learning centres and at the
  market place.
• Based on available budget consider use of and
  sophistication of the required electronic data
  base, biometrics automated methods of recognizing
  the member recruited will be applied.

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Communication (1)

• Communication will play a critical role in the
  success of the out patient scheme.
• Develop communication strategy to explain SHI
  principles including solidarity
• Important to build consensus in favor of social
  health insurance.
• Stakeholders
• Government
• Health financing stakeholders (GTZ/MOMS/MOPHS/INWE
  NT/health financing strategy taskforce
  members/NHIF)
• Development Partners
• Private sector
• The media
• Members of the general public, the beneficiaries
  of the out patient service
• Service providers
• Local administration
• Community health workers/social health workers 

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Communication Matrix (2)
Symbol Action Function/role
R The Doer The doer is the individual(s) who actually complete the task. The doer is responsible for action/implementation. Responsibility can be shared. The degree of responsibility is determined by the individual with the A.
A The Buck Stops Here The accountable person is the individual who is ultimately answerable for the activity or decision. This includes yes or no authority and veto power. Only one A can be assigned to an action.
C In the Loop The consult role is individual(s) (typically subject matter experts) to be consulted prior to a final decision or action. This is a predetermined need for two-way communication. Input from the designated position is required.
I Keep in the Picture This is individual (s) who needs to be informed after a decision or action is taken. They may be required to take action as a result of the outcome. It is a one-way communication
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Communication (5)

• Communication will happen concurrently and/or
  sequentially as per the need.
• E.g. first communicate to and finalize contracts
  with the service providers/facilities before we
  communicate with the potential beneficiaries
  asking them to present themselves for registration

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Communication (3)

• Channels to be used include
• Above the line- this will be of limited value if
  anything. Examples of this type of communication
  are billboards, newspaper adverts etc
• Below the line- these are brochures, flyers and
  other amphlets. These will be used especially for
  communicating to the beneficiaries of the scheme.
• Public forums eg churches, ghetto radio FM etc.
  this will be used depending on the target
  audience. It will be an important modality since
  it lends credibility to the process and promotes
  understanding of the scheme benefit package.

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Communication (4)

• Key Messages to be Communicated
• Purpose/benefit of insurance
• Recruitment start and finish
• Funding partners
• Benefit package
• Periodic updates on how the project is doing
• Forums for the recruitees to air their views on
  the benefits
• Report- type/frequency and templates to be
  agreed

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Communication (5)

• Other Issues to be considered
• Language to be used in the communications
  materials
• Use of pictorials to enhance effective
  communication to the target audience especially
  the beneficiaries.
• Secretariatcommunication tools such as
  telephones, internet connection, computers etc

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Quality Management

• Quality of service delivery important for the
  success of out patient scheme
• Quality Management Plan will encompass
• Management and Facility Quality
• Ownership and leadership
• Facility infrastructure, plant and equipment.
• Enterprise management systems
• Regulatory and Legal Compliance
• Clinical Quality
• Clinical Standards
• Performance Management
• Client Satisfaction

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Quality Management

• The Quality management will build on existing
  systems such as
• Clinical standard guidelines
• Kenya Quality Model
• The National Hospital Insurance Fund (NHIF)
  Master Check List for outpatient services
  providers
• Various private sector and non-governmental
  organizations quality standards.

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Risk Management

• Should involve
• Risk Identification
• Risk Quantification
• Use the Failure Mode and Effects Analysis model.
  Risk Value Impact x Probability x Detection.
  Where Impact measures the severity of the risk
  on the project Probability measures the
  likelihood of the problem occurring Detection
  is defined as the ability of the project team to
  discern that the risk event is imminent
• Risk Response
• Risk Monitoring and Control Assessment
• Risk management should be iterative and
  participatory

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Risk Management Matrix
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Other Support Systems Commodity Management

• The availability of medical commodities plays a
  critical role in the access of health care
  services and enhancing the quality of health care
  delivery.
• Use of public health facilities is directly
  related to the availability of drugs and other
  medical supplies
• Focus on areas where there are the biggest
  opportunities for improvement that will deliver
  the highest impact on the delivery of health
  services.
• Selection of essential medicines and medical
  commodity list
• Pooling of procurement by private sector
  providers
• Distribution explore Public Private
  Partnerships

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Other Support Systems Refferal System

• OP services usually offered at level 2-3,
  however, recruited members may present emergency
  or non emergency health situations that require
  interventions in health facilities under level
  4-6 for specialized care
• Benefit package to include ambulatory services
• Define refferal protocol
• Consider using PPP
• Use existing networks e.g. St. Johns
• Establish call centre to coordinate refferal
  service

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ME

• ME important for evidence-based decision making.
  ME should include
• Financing options
• population covered
• benefits package
• provider engagement
• organisational structure
• Operational processes
• Monitoring should be continuous
• Need to define indicators
• Do both baseline and tracking surveys

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Challenges

• Big brother influence from GTZ
• Reluctant default champion
• Perceived competition
• Lack of Funding
• CBEH not a legal entity
• Manage fund
• Research Permits
• Time pressure- 1st and last quarter of the year a
  major challenge for most participants- planning
  Budgeting
• Research and writing skills

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Achievements

• NHIF agreed to incorporate capitation as an
  alternative PPM in addition to FFS
• Stakeholder interactions and support especially
  from GTZ
• Increased understanding of PPM and impact on
  success of SHI
• Gained HF knowledge
• Better understanding of the health sector
  documents
• Improved Private Public interactions within the
  group- a better appreciation by both sides

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Acknowledgements

• GTZ Kenya Health Progamme
• KfW, Kenya
• InWEnt Team
• Alice Amayo
• Konrad Obermann
• Norma Lange-Tagaza
• Seynabou Fachinger
• Svetla Loukanova
• Tanja Schwering
• Thorsten Körner
• Ute Schwartz
• Health Financing Stakeholders
• Employers
• Families

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Thank You

• Asante!