Breaking Down Barriers to Health in Bunyala
For many families in western Kenya, the biggest barrier to better health is obtaining the proof of identification needed to enroll in Kenya’s national insurance program.
The national insurer, NHIF, provides a comprehensive health cover for informal sector households at a monthly cost of Ksh 500 ($5 USD) and covers outpatient and inpatient services. The requirements for enrolling individual household members include possessing a national identity card for family members over 18 years, a marriage certificate to prove spousal relationship and birth certificates for children under the age of 18.
“Health insurance covers for medical emergencies and health needs including child deliveries. NHIF is the cheapest health insurance in Kenya and helps many families afford healthcare covering the entire household regardless of the number of dependents in the family,” said Doris Lilungu, NHIF Busia deputy branch manager. She added that increasing health insurance coverage in Busia is a central goal for the Busia branch to offer more households the financial risk protection that health insurance provides while seeking healthcare.
As Busia County and AMPATH embark on a universal health coverage pilot design and implementation in Bunyala, the program draws lessons from previous efforts in other regions to increase health insurance coverage. “We repeatedly ran into challenges of registering some households into NHIF because of the lack of proper documentation. In some occasions, despite the family member’s ability to pay for health insurance, the lack of proper documents became a hindrance to enrolling for NHIF,” said Dr. Jeremiah Laktabai, AMPATH Deputy Director Care-Population Health.
AMPATH’s population health model recognizes the crucial intersection of health and socioeconomic factors. It recognizes and addresses the impact that individual, interpersonal, organizational, community and public policy factors often have directly or indirectly on health.
Stakeholders agreed that the first step to the Bunyala pilot was ensuring that households had the proper documents to enable them to enrol in NHIF. These documents are acquired at a cost from government offices. These costs commonly range from application fees, photocopy costs and transport (which can often exceed other costs due to the distance to government administration offices from far less accessible areas of a county).
Registrar of persons taking Chiefs and their assistants through a refresher course on filling registration forms.
Once applications are completed the civil registration and the registration of births and deaths offices vet applicants and verify the information using various mechanisms that involve local grass root administration such as chiefs and their assistants. Because Busia is a border county, this step requires more rigor so as to only register Kenyan citizens in accordance with the law. The process of vetting applications in Busia is complicated by the porous border between Uganda and Kenya, intermarriage across the two countries, trading and sharing of resources (e.g. the Lake Victoria for the fishing community) and the presence of one ethnic group on both sides of the national boundaries. Essentially, these challenges make it harder to identify and register eligible individuals in the households.
To address some of these challenges, AMPATH teamed up with the separate functions of civic registration and the offices of registration of birth and deaths (vital statistics) to ensure that households are prepared to apply for IDs and birth certificates and also assist by bringing the services closer to them. Working with the local administration, the first step was to understand the gaps in the region by determining the number of individuals who: (a) had attained the age of 18 years and had no national IDs or had lost them (b) were less than 18 years and lacked birth certificates. The next steps include the application and verifications as per the public policy.
Given the high poverty rates in the region and recent hardship caused by floods in the region, it is expected that some vulnerable households will need support to pay for these documents and processes. Partnership support is being sought to help these households that cannot afford to pay for registration documents because they are often the ones that need financial risk protection the most in the form of health insurance. These efforts are not only important for health insurance enrollment, but will also serve other purposes for the households as they are often required to access other services including registering children in schools. These documents are also important elements to a person’s identification as a basic human right.
In a meeting with the Busia county commissioner and other stakeholders, Mr. Joseph Kanyiri, the Busia county commissioner emphasized the need for additional sanitary measures to prevent the transmission of COVID-19 in the registration process that requires contact with finger printing and signatures. He also added that families are encouraged to register children early before six months so as to avoid getting caught up in late registration process that is more difficult because of additional verification processes.
To truly implement a population health program, these experiences have reinforced the importance of addressing financial and structural barriers to health. And once again, these efforts have demonstrated the essential role of partnerships in health and social programs.
Picture (from left): Dr. Rose Ayikukwei, AMPATH's population health socio-behavioral scientist, Dr. David Mukabi, Busia County UHC Director, Benjamin Andama, AMPATH's population health financing lead, Joseph Kanyiri, Busia County commissioner, Jacob Tulet, Civil registrar of persons, Busia county, Cynthia Luyali, NHIF benefits officer, Doris Lilungu, NHIF Busia deputy branch manager and Jacob Ruto, Busia deputy county commissioner.