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Hospitals struggle with solution to unpaid bills

NAIROBI, Kenya, Mar 3  – "I came here (Kenyatta National Hospital) on December 25 and I had been told I would deliver on 26th. I underwent a caesarean operation on December 28 and was discharged on the 31st but the bill was Sh20, 000 which was too high and I didn\’t have any money."

This is the story Judy Grace gives me from a ward at the hospital two months later. 

The account of this first time mother is fast becoming widespread in Kenyan hospitals with patients being unable to clear their medical bills after receiving treatment.

Although it\’s a sad and painful experience to people who have come to be known as \’long stay patients\’, both public and private hospitals argue that they cannot afford waivers every so often because it puts a strain on the facilities, leaving some of them in a dilapidated state.

And in a country where half the population lives below the poverty line, saving for healthcare is not a priority to many.

"We don\’t want to deny Kenyans treatment but on the other hand we cannot treat for free; of course we will not be able to survive tomorrow if we just allow patients to go," Kenyatta National Hospital (KNH) acting Chief Executive Officer Dr Charles Kabetu states.

Dr Denis Ogolla the Managing Director at Avenue Healthcare, a private health facility, says it is always important to be upfront with patients on the charges.

"One of the problems is that patients come in expecting that the only thing they are paying for are the bed charges. You need to explain to them that in addition to the bed charges, there will be the doctors\’ charges, drugs charges, laboratory charges and so you need to give them a good estimate of what you think the bill will be," the medic explains.

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Currently, at least 372 patients are detained at the Kenyatta National Hospital, which is the largest referral hospital in the country, due to non-payment of their medical bills.

"It has affected our operations because once we have an increased number of patients who we have discharged but cannot leave, they are eating, they are using our facilities and this has negatively impacted on availability of beds," the KNH boss says.

According to the Secretary of the National Economic and Social Council (NESC) – Kenya\’s top advisory body to the government on policies required to accelerate social and economic development – retaining patients in hospitals long after discharge is a misallocation of resources. 

"If you look at the fact that the hospital has to cater for this person who is not paying the bill, you are kind of like providing accommodation services for a person who has already been treated and who should have left the hospital and the hospitals are not meant to be hotels," Mr Julius Muia says.

And although KNH is currently working out a plan to release these patients, they are still very careful not to give the wrong impression.

"Some of the patients are tutored to adopt a wait-and-see attitude so they lie that they cannot afford to pay the bill," Dr Kabetu says but adds that there are those patients who are identified from admission that they cannot afford to pay especially the street families.

Dr Ogolla of Avenue Healthcare says there is need for all hospitals to set up mechanisms to avoid detaining patients after discharge.

"If they can\’t pay today and they can\’t pay tomorrow the likelihood will be that in one month they will still not be able to pay. So you are detaining them and the hospital bills are obviously increasing and at the end of the day, you will still have to make the decision to release them," he says.

But both public and private health facilities are losing hundreds of millions of shillings in bad debts annually stemming from failure by patients to pay their medical bills.

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KNH is now looking at mobilising patients to enrol in the National Hospital Insurance Fund (NHIF) as a possible solution to the problem.

"What we will be doing is that on admission if you are not a member of NHIF you will be required to join and since we have an NHIF office here it will be easy. That way we know that even if we don\’t benefit during that admission, if that patients gets sick again, the bill will be catered for," Dr Kabetu says.

On the other hand Avenue Healthcare has adopted a strategy where they negotiate with the patients who are unable to immediately clear their bills and agree on the mode of payment.

"We usually tend to allow the patients to go home after they sign a document stating that they owe the hospital," the hospital\’s CEO says.

"We then leave it up to the patient to give us a proposal of when they think that they can pay us. If there is any form of security it makes it easier like a log book or title deed which gives them an incentive to come back and pay the bills," he adds.

According to the National Economic and Social Council, only 600,000 Kenyans are covered under comprehensive private insurance. These are mainly those in the formal sector of employment.

Another 13 million are considered to be in the informal sector while 18 million are said to be most vulnerable and require subsidies and direct government support.

The National Social Protection policy has identified 6.5 million Kenyans as living in abject poverty and therefore their health care needs ought to be provided for through government resources.

"Because of that huge number of people, one needs to look back and ask what we can do to make sure that this bottom half of the population is not left out in a sensible medical health care arrangement and this calls for universal plan where every member of the society should belong to a medical plan," Mr Muia says. 

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Other suggestions that have been made to pull out of this dilemma include a move towards social health protection that allows the poor and indigent to access limitless health care services.

The government estimates a 40 percent out-of-pocket health expenditure. These high medical expenses have forced about a million Kenyans to slip below the poverty line annually while many others die because they cannot afford the necessary health care services.

"This is a big issue about people being unable to pay for their medical bills in hospitals. As we try to industrialise in line with vision 2030(Kenya\’s blueprint towards industrialisation) and also in view of the ever increasing population in Kenya, this challenge of people paying for their bills when they go to hospitals is even going to become a bigger problem so we need to go back and address fundamental issues that inform the current situation," Mr Muia goes on to say.

The National Hospital Insurance Fund has a membership of only 11 million which represents slightly above a quarter of the population.

The Manager In charge of Planning and Strategy Chacha Marwa says the scheme offers three different types of contracts for hospitals to choose from. There is the comprehensive cover that caters for the whole bill, contract B where NHIF caters for up to 90 percent of the bill while the patient caters for the rest and contract C where NHIF pays a fixed daily rate to hospitals.

"When you have a mechanism such as the NHIF where you have most people who are in their productive ages contributing, then it cross-subsidizes the ones who are unable to pay for themselves," Mr Marwa says.

"Some of those people who are kept in the hospitals are not necessarily poor. Their problem is that there is inadequate planning. You will find that if they had come to NHIF, the annual contribution for a family is Sh1, 920 but because of that lack of proper planning at the family level then you tend to find that people get into catastrophic spending as soon as they get sick," he says.

A draft strategy on accessible, affordable and quality health care services in Kenya by the National Economic and Social Council has suggested the establishment of a health benefit regulatory authority that will create an enabling environment essential for the spiralling growth in the sector.

It argues that having a strong regulatory authority will avoid the failures of several medical schemes in the past, carry out licensing according to a minimum benefits package and determine how much it would cost to cover the old people.

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"When people are young and growing, they spend a lot of their time chasing wealth but in the process they lose their health which then later in life when they don\’t have that strength, they spend their wealth to chase for their health," the NESC Secretary says.

"So looking for a policy framework that answers the questions of an aging population, a policy framework that answers to a situation of a lot of Kenyans who are below the poverty line requires a lot of work," Mr Muia adds.

Although Kenya is among the African countries considered by the World Health Organisation to be making good progress towards providing universal health care, Health care financing has been under consideration for the last 10 years.

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