Abstract:
Background: Purchasing refers to the process by which pooled funds are paid to
providers in order to deliver a set of health care interventions. Very little is known about
purchasing arrangements in low- and middle-income countries (LMICs), and certainly
not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya,
using the National Hospital Insurance Fund (NHIF) as a case study.
Methods: We applied a principal-agent relationship framework, which identifies three
pairs of principal-agent relationships (government-purchaser, purchaser-provider, and
citizen-purchaser) and specific actions required within them to achieve strategic
purchasing. A qualitative case study approach was applied. Data were collected through
document reviews (statutes, policy and regulatory documents) and in-depth interviews
(n=62) with key informants including NHIF officials, Ministry of Health (MoH)
officials, insurance industry actors, and health service providers. Documents were
summarised using standardised forms. Interviews were recorded, transcribed verbatim,
and analysed using a thematic framework approach.
Results: The regulatory and policy framework for strategic purchasing in Kenya was
weak and there was no clear accountability mechanism between the NHIF and the MoH.
Accountability mechanisms within the NHIF have developed over time, but these
emphasized financial performance over other aspects of purchasing. The processes for
contracting, monitoring, and paying providers do not promote equity, quality, and
efficiency. This was partly due to geographical distribution of providers, but also due to
limited capacity within the NHIF. There are some mechanisms for assessing needs,
preferences, and values to inform design of the benefit package, and while channels to
engage beneficiaries exist, they do not always function appropriately and awareness of
these channels to the beneficiaries is limited.
Conclusion: Addressing the gaps in the NHIF's purchasing performance requires a
number of approaches. Critically, there is a need for the government through the MoH to
embrace its stewardship role in health, while recognizing the multiplicity of actors given
Kenya's devolved context. Relatively recent decentralisation reforms present an
opportunity that should be grasped to rewrite the contract between the government, the
NHIF and Kenyans in the pursuit of universal health coverage (UHC).