Systems-Based Healthcare in Lwala

By Chinonso Opara

Being a Nigerian-born American, I have grown to understand that the benefit of living and working in a first world country is not necessarily lifestyle and “Western amenities”. Nor is it the people or culture. I have come to see that the benefit of living in the United States or any other developed country is the relatively available access to healthcare. You can almost bet that when a medical emergency knocks at your door, there will be services to help meet your newly acquired needs. Through a partnership between Vanderbilt and Lwala Community Alliance (Lwala), I was immersed in the Kenyan healthcare system and was able to draw comparisons between Kenyan healthcare and that in the US. I was placed at Lwala’s hospital and observed care provided in this semi-private facility as well as the care provided through government hospitals in the area. I realized more and more that Kenya, and Africa in general, are relatively young countries – only being about half-a-century old. I realized that while Kenya still has a long way to go, it has come far and has potential to grow even more in terms of improving access to adequate healthcare. I had the opportunity to be exposed to the National Health Insurance Fund. I also had the privilege of contributing to the improvement of the KenyaEMR (electronic medical record) system at Lwala, which was originally designed for the care of HIV patients.

One dismaying thing I saw about healthcare in Kenya is that it is based too much on one’s ability to pay. If you come to the emergency room with a medical emergency, such as acute appendicitis, some hospitals will require you to pay first before they touch you, even though your life is in grave danger. While Lwala provides subsidized and free care, patients that are referred to other facilities for acute conditions face cost barriers. At least in the United States, the ER will see you, even though they’ll hand you a hefty bill later.

One particular patient I remember was a young adult with a past medical history of Hepatitis B, undergoing treatment with tenofovir and lamivudine, and who developed cirrhosis of unspecified etiology complicated by a large hepatic mass seen on ultrasound. He had no other known risk factors: no hepatitis C, no smoking, no drinking, one sexual encounter 5 months prior with a condom, no known family history of abdominal disease. The next step in the workup was to refer the patient to another facility for a CT scan, which will cost his family 7 to 9 thousand shillings ($70-$90). This is a hefty price! Especially considering the median income in Kenya is a little above KSh6000/month ($60), and in village life, it is likely much less than this. They will need help from family and good friends in order to come up with the money.

On another day, we had a patient come in with bowel obstruction. She had initially been diagnosed with bowel obstruction secondary to colon cancer in one of the main government referral hospitals. However, her family could not come up with the necessary funds for further workup and therefore took her home. At home her cancer metastasized systemically and she deteriorated. She was brought by her family to Lwala. However, because she required specified diagnostic tests that Lwala’s hospital does not have, we had to tell the family that we could not do much for her. This is another example of how a family’s limited immediate financial resources hinders even the workup of a life-altering disease.

However, we had another patient during rounds who was HIV-positive with nevirapine-induced dermatitis and hepatitis, requiring further workup, including LFTs, and kidney function tests. The difference here is she had health insurance through the National Hospital Insurance Fund in Kenya, and she could therefore afford the further workup of her condition.

The National Hospital Insurance Fund, established in Kenya in 1966, was designed to make access to adequate healthcare more feasible for families, similar to health insurance companies in the US. It is the oldest such insurance scheme in Africa and the pride of the Ministry of Health. It requires a minimum income of KSh1000/month just to enroll and the individual contribution is based on one’s monthly salary. For instance, the following income brackets of KSh1000 – KSh5999 and KSh6000 – KSh7900 must contribute KSh150/month and KSh300/month, respectively. And anyone who is self-employed must contribute KSh500/month. Considering the median Kenyan income of around KSh6000 this is expensive for the most vulnerable Kenyans.

Because of the very vulnerable population Lwala serves, very few patients are enrolled in NHIF.

In fact, in my whole time in Lwala, I only saw one person who had NHIF and that was the patient described above. Even one of the clinical officers, in his whole time in Lwala has only seen three patients with NHIF in Lwala

Lwala provides free services to pregnant mothers, children under 5 and people living with HIV as well as subsidized services to the general population. However, patients needing specialized care above the services provided at Lwala, must navigate the public system.

Lwala is in the process of registering for NHIF and aims to be a full participant in the program in 2017. Once registered, Lwala will begin an ambitious campaign to enroll its population into the insurance scheme. This will mean increased sustainability of the hospital as it receives reimbursement for the free care it provides as well as fuller coverage for patients when they are referred for higher levels of care.

My hope is that the NHIF expands in Kenya to increase coverage for and access to healthcare, but that it does so in a way that retains quality, as is the hope for any health insurance program.

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