An Assessment of Nhif Utilization in Kiwanja Market

AN ASSESSMENT OF THE UTILIZATION OF NHIF BY RESIDENTS OF KIWANJA MARKET, KAHAWA WEST LOCATION, KASARANI DIVISION IN NAIROBI. Presented by: Ann Mwangi Registration number: I30/2160/2006 A research proposal submitted in partial fulfillment of the requirements for the award of the degree of Bachelor of Science (nursing and public health) in the school of health sciences of Kenyatta University. February, 2010. DECLARATION STUDENT’S DECLARATION This proposal is my original work and has not been presented for any academic award in any other University or college.

Signature……………………………………… Date…………………….. Name: Ann Mwangi Registration number: I30/2160/2006 SUPERVISOR’S DECLARATION This proposal has been submitted for review with my approval as a university supervisor. Signature ………………………………….. Date…………………. Name: Mrs. Makworo Department: Nursing sciences. ABBREVIATIONS AND ACRONYMS NHIF National Hospital Insurance Fund MOH Ministry of Health CAP Chapter

HMOs Health Management Organization UNICEF United Nations Children’s Fund KIPPRA Kenya institute for public policy research activities and analysis OPERATIONAL DEFINITIONS Health care- Goods and services used as inputs to produce health. In some analyses one’s own time and knowledge used to maintain and promote health are considered in additional to conventional inputs. Used synonymously with Medicare in this study.

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Health maintenance organization (HMOs) –It is a managed care plan that integrates financing and delivery of a comprehensive set of health care services to an enrolled population. HMOs may contract with or directly employ health care providers. Social insurance – It’s a government insurance programme in which eligibility and premiums are not determined by the practices common to private insurance contracts. Premiums are often subsidized and there is typically redistribution from some segments of the population to others. Health care financing- Refers to paying or funding of health care services provided or to be provided.

It is not Medicare per se that consumers want but health itself. Medicare demand is a derived demand for an input that is used to produce health. Health care consumers do not merely purchase passively from the market, but instead produce it, spending time on health improving efforts in addition to purchasing Medicare input. ABSTRACT The National Hospital insurance Fund (NHIF) is an important aspect of healthcare financing through social health insurance in Kenya. It was established by the government of Kenya (GoK) in 1966 as a social insurance fund.

At its inception, the NHIF was meant to assist GoK employees to gain access to higher quality private hospitals, thereby relieving congestion in the free public hospitals. The NHIF has mainly focused on the formal sector employees in the past around four decades. This has left those employed in the informal sector. This study is attempts to analyze and understand the demand for social health insurance of the informal sector workers in Kiwanja market by assessing their perceptions and knowledge of and concerns regarding National Hospital Insurance Fund.

It will serve to explore how more informal sector workers could be integrated into the NHIF scheme. The research design to be used will be a descriptive cross-sectional study. The area of study is Kiwanja market in Kahawa west location. The study population will include Kiwanja residents above 18 years of age, and employed in the informal sector. The sample size will be 76 as determined using a standard statistical formula and the respondents selected through cluster sampling. A structured questionnaire will be used to collect data. Pretesting of the data collection tool will be done in Kihunguro area in Ruiru.

The data collected will be entered, coded and keyed into variables using SPSS version 12- computer software and excel computer packages. Quantitative data will be analyzed using SPSS version 10 computer software. Presentation of quantitive information will be done using statistical packages (graphs, charts, tables and pie charts). The findings, conclusions and recommendations of this study will be very important in formulating awareness campaigns and educational materials that will enable the residents of Kiwanja in the informal sector of employment to realize the significance of NHIF programmes in financing their healthcare.

TABLE OF CONTENTS DECLARATIONii ABBREVIATIONS AND ACRONYMSiii OPERATIONAL DEFINITIONSiv ABSTRACTv CHAPTER ONE1 1. 0 INTRODUCTION1 1. 1Background to the study1 1. 2Statement of the problem4 1. 3Justification of the study5 1. 4 Research questions5 1. 5 Objectives of the study6 1. 5. 1 Broad objective6 1. 5. 2 Specific objectives6 1. 6 Research assumptions6 1. 7Significance of the study6 CHAPTER TWO7 2. 0 LITERATURE REVIEW7 2. 1 Social health insurance7 2. 2 Healthcare financing through health insurance in Kenya9 2. 2. 1 The National Hospital Insurance Fund (NHIF). 10 2. 2. 2 Membership to NHIF10 . 2. 3 Mode of Payment11 2. 2. 4 Benefits and cover11 2. 2. 5 How to access benefits11 2. 2. 6 Accredited hospitals12 2. 2. 7 Milestones12 2. 2. 8 The future of NHIF12 2. 3 Factors influencing utilization of social health insurance services. 13 2. 3. 1 Feasibility analyses of social health insurance14 CHAPTER THREE20 3. 0 RESEARCH METHODOLOGY20 3. 1 Research design20 3. 2 Study area20 3. 3 Study population20 3. 4 Inclusion and exclusion criteria20 3. 4. 1 Inclusion criteria20 3. 4. 5 Exclusion criteria20 3. 5 Sampling technique and sample size21 3. 5. 1 Sample size determination21 . 5. 2 Sampling technique22 3. 6 Data collection procedures22 3. 6. 1 Research instruments22 3. 6. 2 Pre testing22 3. 6. 3 Data collection process22 3. 7 Data management23 3. 8 Limitations of the study23 3. 9 Ethical considerations23 REFERENCES24 WORK PLAN FOR THE STUDY. 26 BUDGET27 APPENDICES28 INSTRUMENT FOR DATA COLLECTION (QUESTIONNAIRE)28 CONSENT FORM31 MAP OF STUDY AREA32 CHAPTER ONE 1. 0 INTRODUCTION 1. 1Background to the study The concept of National Hospital insurance Fund (NHIF) is an important aspect of healthcare financing through social health insurance in Kenya.

In a developing country like Egypt, the Health Insurance Organization (HIO) is prominent among many health institutions involved in health financing and provision, and a key player in the country’s health sector reform programme. It was established in 1964 as the institution in Egypt responsible for social health insurance, providing compulsory health insurance to workers in the formal sector (Abd et al. , 1997). One of the overall goals of the Government of Kenya is to promote and improve the health status of all Kenyans by making health services more effective, accessible, and affordable.

Therefore health policy in the country revolves around two critical issues, namely: how to deliver a basic package of quality health services, and how to finance and manage those services in a way that guarantees their availability, accessibility and affordability to those in most need most health care (Kimani, Muthaka, and Manda, 2004). On achieving independence in 1963, the Government of Kenya (GoK) committed itself to providing “free” health services as part of its development strategy to alleviate poverty and improve the welfare and productivity of the nation (GoK press, 1965).

This pledge was honored in 1964 with the discontinuation of the pre-independence user fees, and the introduction of free outpatient services and hospitalization for all children in the public health facilities. Services in the public health facilities remained free for all except those in employment whose expenses were met by their employers (Owino, W. and Were, M. , 1998). Through financial support from the central government, strategies were developed to expand the health infrastructure and support the entire health system. The GoK established NHIF in 1966 as a social insurance fund.

At its inception, the NHIF was meant to assist GoK employees to gain access to higher quality private hospitals, thereby relieving congestion in the free public hospitals. The NHIF has mainly focused on the formal sector employees in the past around four decades. This has left those employed in the informal sector. Structural reforms and poor economic growth have increasingly pushed labor into the informal and small scale agriculture sectors where livelihoods are often insecure and incomes are low and uncertain (Kimani, Muthaka, and Manda, 2004).

As a way of reaching out to those in the informal sector and the poor, the government plans to transform the current NHIF to National Social Health Insurance Fund (NSHIF). The aim is to ensure equity and access to healthcare services by the poor and those in the informal sector, who have been left out for the last forty years that the NHIF has been in existence. It is also expected that the new scheme will increase healthcare services utilization, which has suffered under cost sharing, by extending benefit package to also cover outpatient care.

The current cost sharing will be replaced by pre-paid contribution into the new scheme (Kimani, Muthaka, and Manda, 2004). The principal choices for financing a health care system are: general revenues, social insurance funding, and private insurance financing and out of pocket payments. General revenue financing here refers to a system of revenue collection through a broad based tax. All or portion of this tax may be dedicated to the health care system . general revenues may be raised at the federal, state, provincial, or local levels.

According to the United Nations system of national account, 1993, Annex IV par. 4. 111, an insurance programme is designated as a social insurance programme if at least one of the following three conditions is met: a) Participation in the programme is compulsory either by law or by conditions of employment. b) The programme is operated on behalf of a group and is restricted to group members. c) An employer makes a contribution to the programme on behalf of the employee. National Hospital Insurance Fund (NHIF) is therefore a social insurance financing in Kenya.

NHIF’s core function is to collect contributions from all Kenyans earning an income of over Ksh 1000 ($12) and pay hospital benefits out of the contributions to members and their declared dependants (spouse and children) Whilst ensuring that Kenyans of all walks of life have access to quality and affordable healthcare, NHIF operates under the social principle that "the rich should support the poor, the healthy should support the sick and the young should support the old. 2. Statement of the problem The GoK established NHIF in 1966 as a social insurance fund. At its nception, the NHIF was meant to assist GoK employees to gain access to higher quality private hospitals, thereby relieving congestion in the free public hospitals. The NHIF has mainly focused on the formal sector employees in the past around four decades. This has left those employed in the informal sector (Republic of Kenya, 2003a). There exists an information gap on informal sector Kenyans utilization of NHIF services, in instances where studies focus on informal sector employees, NHIF is a social health insurance and an important aspect healthcare financing in Kenya that is often neglected or not fully explored.

Majority of studies carried out; focus on utilization of NHIF services across general Kenyan population irrespective of the employment sector. This has led to formulation of healthcare financing programmes that do not address the specific needs of Kenyans in the informal sector. More so, tools of analysis by most relevant studies are limited to univariate and bivariate analysis falling short of examining the net effect of selected background and intermediate factors negatively impacting healthcare accessibility and utilizations by workers in the informal sector of employment.

The study is designed to assess the level of knowledge and utilization of NHIF in Kiwanja market because it is an area whose majority of residents are in the informal sector of employment. 3. Justification of the study Taking into considerations the existing information gap on utilization of NHIF services by informal sector employees, it is important to undertake this study in Kiwanja market to establish the awareness level and its use. Kiwanja market is a densely populated area behind Kenyatta University. Majority of Kiwanja residents are in the informal sector.

The study is designed to identify the potential hindrances of utilization of NHIF services in Kiwanja residents in the informal sector and ways of how to remove them. The study seeks to explain and provide a systematic body of knowledge that can be explored for appropriate policy formulation, to act as an eye opener and reminder to both the NHIF management team, and other stakeholders to raise the utilization of NHIF services by the informal sector in Kenya. Knowledge deficit regarding NHIF benefits and use to finance health care contributes greatly to the high mortality and morbidity rates due to poor health seeking behavior (Inke et al. 2004). Provision of information and raising awareness on NHIF benefits and use will reduce significantly the number of pregnant women delivering at home due to lack of funds to pay for hospital delivery. 1. 4 Research questions The research questions for the study will be: a) How informed are the members of Kiwanja market about NHIF benefits? b) What percentage of Kiwanja market residents use NHIF services and are in the informal sector? 1. 5 Objectives of the study 1. 5. 1 Broad objective To assess the awareness on NHIF benefits and utilization of NHIF services by Kiwanja market residents. . 5. 2 Specific objectives a) To find out the knowledge level of Kiwanja residents about NHIF. b) To determine the number of Kiwanja residents who are NHIF beneficiaries. 1. 6 Research assumptions The residents of Kiwanja market are knowledgeable about health care financing, they are aware about NHIF benefits but they do not use it because they think it is only meant to benefit those people in the formal employment sector. 7. Significance of the study This study aims at finding out if Kiwanja residents utilize NHIF services.

In addressing the objectives, the study will identify the level of utilization of NHIF services, factors influencing its utilization and come up with ways of addressing any shortcomings that will be identified and help in improving NHIF services utilization. The findings, conclusions and recommendations of this study will be important in formulating awareness campaigns and educational materials that will enable the residents of Kiwanja in the informal sector of employment to realize the significance of NHIF programmes in financing their healthcare.

This study attempts to find out the awareness on NHIF benefits and use by residents of Kiwanja market. It will therefore benefit the residents of Kiwanja and empower them to acquire their human right of health care. CHAPTER TWO 2. 0 LITERATURE REVIEW 2. 1 Social health insurance The concept of health insurance was first proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance.

This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II (Weber, 1994).

A health insurance scheme is social when it subsidizes the poor, the elderly and the sick, and when it promotes equity and access to everyone and not for profit. The core values in social health insurance embody a concern for the plight of the poor. In social insurance financing, health services are paid for through contributions to a health fund. The most common basis for contributions is payroll, with both the employer and the employee paying a percentage of the salary. In general, membership to a social health insurance schemes is mandatory, although it can be voluntary to certain groups such as the self-employed.

The health fund is usually independent of the government but works within a tight framework of regulations. Premiums are linked to the average cost of treatment for the group as a whole, not to the expected cost of care for the individual (Conn , 1998). While there is no universally accepted definition of what “social insurance” is, Kraushaar and Akumu (1993) outline some broad characteristics, which are generally agreed upon. These are: a) Coverage is generally compulsory by law ) Eligibility for benefits is derived from contributions having been made to the programme c) The benefits for one individual are not usually directly related to contributions made by that individual but often those benefits aim to redistribute income between different income groups. This redistribution is usually from the rich to the lower income groups or from those with few to those with many dependants. Equity of benefits regardless of payment is the rule. d) There is generally a plan or the financing of benefits that is designed to be adequate in the long term. ) Governments manage nearly all such social insurance organizations. f) Revenues go fully and unchallenged to health and are not controlled by the treasury in a given country. Conn and Walford (1998) explain the rationale for health insurance in a low-income country with the following three arguments: a) Attracting additional money for health. This is so because health insurance is perceived as an additional source of money for healthcare. Consumers are more enthusiastic about paying for health insurance than paying general taxation as benefits are specific and visible. ) Getting better value for money because consumers are more able and prefer to pay regular, affordable premiums rather than paying fees for treatment when they are ill. c) Improving the quality and targeting of healthcare. Historically, HMOs tended to use the term "health plan", while commercial insurance companies used the term "health insurance". A health plan can also refer to a subscription-based medical care arrangement offered through HMOs, preferred provider organizations, or point of service plans. These plans are similar to pre-paid dental, pre-paid legal and pre-paid vision plans.

Pre-paid health plans typically pay for a fixed number of services. The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (Weber, 1994) 2. 2 Healthcare financing through health insurance in Kenya Health insurance in Kenya has been provided by both private and public systems. The main objectives of the he health systems have been to insure Kenyans against health risks that they may encounter in future.

Health insurance is considered private when the third party (insurer) is a profit organization (Republic of Kenya, 2003a). In private insurance, people pay premiums related to expected cost of providing services to them. Therefore people who are in high health risk groups pay more, and those at low risks pay less. Cross-subsidy between people with different risks of ill health is limited. Membership is usually voluntary. Public health insurance in Kenya is provided by the National Hospital Insurance Fund (Kimani, Muthaka, and Manda, 2004). 2. 2. The National Hospital Insurance Fund (NHIF). The NHIF was established in 1966 under chapter (CAP) 255 of the Laws of Kenya to be run by an Advisory Council appointed by the Minister of Health. The NHIF was established in 1966 under CAP 255 of the Laws of Kenya to be run by an Advisory Council appointed by the Minister of Health. It catered for salaried employees earning Kshs. 1, 000 and above per month, making a monthly contribution of Kshs. 20/= . In 1972 an amendment was made to incorporate voluntary members (self-employed) at a monthly contribution of Kshs. 0/=. In 1998, Cap 255 was repealed and replaced by the NHIF Act No. 9 of 1998 which transformed the fund to a State Corporation managed by an all inclusive Board representing various stakeholders and interest groups (Republic of Kenya, 2003a). 2. 2. 2 Membership to NHIF Membership to NHIF is open to all Kenyans aged 18 years and above earning a monthly income of kshs. 1000 or an average yearly income of kshs. 12, 000. There is no upper ceiling for the age. 2. 2. 3 Mode of Payment Employers effect deductions and remit to the fund by cheque or cash, and E-banking.

Members in the informal sector pay in any of the NHIF offices Kshs. 160 per month for informal sector members. Members in the informal sector pay in any of the NHIF offices. All payments should be received by the 9th of the following month. For retirees/self employed persons payment for the year may be paid upfront; quarterly, semi-annually and/or annually. 2. 2. 4 Benefits and cover a) It covers all admission cases with few exceptions such as circumcision with no medical checkup required. b) Covers member, spouse and children under the age of 18 year. ) Children over 18 yrs and in learning institutions are also covered d) It covers for 180 days of hospitalization in a year. NHIF pay a daily rebate which ranges from Ksh. 400/= to Ksh. 2, 200/= Foreign claims. The number of other spouses is not limited and depends on the ability to pay for them. 2. 2. 5 How to access benefits Through presentation of the following to hospital on admission: Current NHIF Card- both manilla and photo card, Certificate of Contributions Paid (CCP) receipt and the national Identity card. The accredited hospitals deduct the daily rebate X number of days of hospitalization from the incurred bill.

While for the contracted hospitals under category A, the entire bill is made by the Fund, the Fund reimburses member for costs incurred to the extent of the daily rebate if for one reason or another he /she is unable to use the card in Hospital. All claims should be received within 90 days after hospitalization. 2. 2. 6 Accredited hospitals Four hundred and fifteen health care providers have been enlisted across the country to provide services to NHIF beneficiaries under various contracts. Accreditation by NHIF is based on certain set standards and criteria for purpose of NHIF benefits.

Quality Assurance and Standards Department consistently monitors the quality of services. 2. 2. 7 Milestones Increased rebates up to a maximum of 2,200 depending on hospital accreditation. It has an extensive branch network with 27 branches, satellite and window offices. It offers decentralized services, computerized operations and services and has a quality assurance and standards department in place. 2. 2. 8 The future of NHIF NHIF in future will use magnetic stripe card in hospitals to access benefits, introduction of diversified product lines, and further expansion of branch network.

The ministry of health has designed a mandatory social health insurance scheme which seeks to transform the NHIF into a National Social Health Insurance Fund (NSHIF) to provide health insurance cover to both outpatients and inpatients. The main objective of the fund is to facilitate the provision of accessible, affordable and quality healthcare services to all its members irrespective of their age, economic or social status (Republic of Kenya, 2003c). 2. 3 Factors influencing utilization of social health insurance services. In most economically advanced countries, adequate social security laws are basically taken for granted.

However, it often took many decades for social security systems to benefit all or major parts of the population in those countries. In the area of social health protection, for example, it took Japan 36 years to move from the enactment of the first health insurance law to the final law establishing nation-wide social health insurance. In the United Kingdom, a similar time period was needed to achieve its universal tax-based system (Inke et. al. 2004) Social Health Insurance (SHI) is not a widely adopted health financing mechanism in Africa.

While there are many countries that operate a health insurance scheme for civil servants and/or private sector employees only some of these include features of a SHI, its appeal to cover larger parts of the population has been growing. Countries including Ghana, Nigeria and Rwanda have passed SHI laws. Earlier on, Kenya investigated the feasibility of SHI and Lesotho and Swaziland are doing so now. One distinct feature is that it does not call exclusively on public finance, but instead spreads the responsibility of health care financing among households and the private sector as well.

From that point of view, tax-based systems in Africa are particularly challenged: the overall tax base may need to be strengthened, tax compliance may require improvement, and then a sufficient allocation towards health would have to be called for. Still, social health insurance is not a panacea either. It requires that an important organizational apparatus be put in place and that many actors in society shoulder critical responsibilities, such as the willingness and ability to contribute to the SHI scheme and then to comply with its regulations, thereby accepting a certain degree of financial solidarity (Kimani Muthaka ,and Manda, 2004).

Aiming at universal health coverage for its 9. 5 million populations, Rwanda has spearheaded the development of a number of schemes that together constitute its SHI system. The three most important ones are the Rwandaise d'assurance maladie (RAMA), the Medical Military Insurance (MMI) and the Assurances Maladies Communautaires (AMCs). The RAMA social health insurance is compulsory for government employees and voluntary for private sector employees. Its contribution rate is 15% of basic salary (shared equally etween employee and employer). MMI covers all military personnel, who pay a contribution rate of 22. 5% of basic salary (5% paid by employee and 17. 5% by government). AMCs are community-based health insurance schemes whose members are mainly rural dwellers and informal sector workers in both rural and urban areas. They make up the majority of the population; by the end of 2007 about 5. 7 million Rwandans were covered by AMCs. Members usually contribute 1000 Rwandan Francs (1. 5 US$) per person per year which is matched by the government (Stilglitz, J. E. , 2000) 2. 3. 1 Feasibility analyses of social health insurance Since 2002, the WHO has been involved in technical advisory work especially on assessing the feasibility of SHI in Kenya, Lesotho and Swaziland in collaboration with national experts from those countries. In each country we analyzed the financial, organizational and political feasibility. Below we present some of the highlights of this work that should help us in formulating general guidance (Inke et. al. 2004) In Kenya, one basic financial scenario was that of gradual implementation of universal health coverage: coverage by a possible National Social Health Insurance Fund (NSHIF) would reach 62% of the population after 10 years, with further expansion in the second decade of SHI implementation. An important feature is that such a scenario would only be conceivable with sizable government subsidies. Without such subsidies, access to health care among low-income households would be jeopardized, as the contributions From formal sector employees and civil servants would be insufficient to cross-subsidize the needed health care of the poor.

External donors' financial support, however, could alleviate this extra financial burden on government. In fact, a variant of the basic scenario assumes that external donors would finance the provision of antiretroviral therapy, which would reduce the required government subsidies by about 20%. As far as the organizational aspects are concerned, it was studied whether the existing National Hospital Insurance Fund, a mandatory hospital insurance scheme for the formal sector with a small part of voluntary insurance for informal sector workers, might be transformed into the NSHIF.

The latter would then be governed by a Board of Trustees with representatives from civil society. It is also interesting to note that the proposed NSHIF would include a Department of Fraud and Investigation in order to check the fund's financial activities. Civil society groups and enterprises such as the Post Office would also be given a role, especially in the collection of contributions from households in the informal sector (Inke et. al. , 2004) Concerning its political feasibility, consultations were held with a great number of stakeholders and interest groups, and most were supportive of the proposed NSHIF.

Only Kenya's private Health Maintenance Organizations were very critical and had doubts about NSHIF feasibility. Finally, in 2004, the Kenyan Parliament passed a law on the NSHIF. However, President Kibaki judged it still needed amendments and returned it to Parliament for further debate that is still ongoing. Nonetheless, with a long-term vision, the existing National Hospital Insurance Fund is undertaking a number of institutional changes to increase membership and extend benefits so as to be better prepared should SHI take off (Inke et al. 2004) Factors which influence the use of NHIF services in Kenya include: ignorance, socio-economic factors, cultural factors, and demographic factors. Services information availability and accessibility also determines the utilization of social health insurance. Owino and Were (1998), in their study of enhancing healthcare among the vulnerable groups in Kenya ,found out that higher levels of awareness on health insurance, was associated with greater use of social insurance and thus better healthcare among the vulnerable people.

In another study , a poverty survey by the UNICEF and overseas development Agency in 1995/96,it was found that user fees in Kenya made visits to government facilities prohibitively costly as the poor were required to make payments to reach the registration table, instead of using social insurance rebates. Worse, after the payments, the patients were asked to provide paper for record purposes. These costs could have been covered less difficultly by NHIF or more so NSHIF were they well informed of the benefits and the ease of membership.

The study by Mwabu and Wang’ombe (1995) showed that the introduction of outpatient fees in Kenya’s public hospitals reduced the demand by a large proportion, and concluded that introduction of fees, or any upward revisions should be preceded by investments to raise quality of services and a well worked system of health insurance. The people should then be well sensitized on the benefits of joining into health insurance schemes. Huber (1993) did a systematic assessment of outpatients requiring exemptions, based on data from surveys in three districts in Kenya. The calculation was based on information on the household’s ability to pay.

The study established the criteria for determining ability to pay on the assumption that households do not need to pay more than 5% of their annual incomes on healthcare from their pocket fees. As a result, households with cumulative health expenditures greater than 5% were assumed to qualify for the exemptions. The main conclusion from the study was that, it is not possible to tell who cannot pay fees by personal characteristics and so all people of the entire population should be enlightened on social insurance schemes such as NHIF and be encouraged to be members even when they are self employed.

In a study carried out in Kenya (coast province) by Inke Mathaue (2007), on assessment affecting health services demand: extending social health insurance to informal sector in Kenya. Inke found out that, in the sum mix of the demand-side determinants can be addressed with a well designed strategy, focusing on awareness raising and information, improvement of insurance design features and setting differentiated and affordable contribution rates. In another study done by Mwangi W. M. and Mwabu, G.

M (2006) on health care financing in Kenya: simulation of welfare effects of user fee, they found out that the introduction of user selective contribution charges would improve social insurance programmes such as the NHIF. The National Hospital Insurance Fund is the most important health insurance program in Kenya. Membership is compulsory for all civil servants. As of 1990, contribution levels proved insufficient to meet hospital costs and the government was planning to broker private health insurance policies. The government is continually improving and upgrading existing health facilities and opening new ones.

Private health institutions account for 60% of total medical equipment and supplies (import value). Kenya also has a well-developed pharmaceutical industry that can produce most medications recommended by the World Health Organization (republic of Kenya, 1999) In order to increase the utilization of NHIF services, we need to raise the awareness on NHIF benefits to the people of Kiwanja market majority of who are struggling to pay for healthcare from their pockets. This study therefore, sets out to assess the utilization of NHIF services and identify factors that hinder its use by Kiwanja residents.

The Government of Kenya has addressed the issue of inequalities and poor performance in a number of policy documents. The efforts made under the First Health Sector Plan (1999-2004) did not contribute towards improving Kenya’s health status. In 2005, the Second Health Sector Strategic Plan was implemented. This will run until 2010. In order to improve the funding of the healthcare system and to give more Kenyans access to better healthcare, the Ministry of Health is planning to introduce a National Social Health Insurance Fund (NSHIF).

This is a social insurance scheme to which everyone will contribute, without exception. CHAPTER THREE 3. 0 RESEARCH METHODOLOGY 3. 1 Research design The study will be a cross-sectional descriptive study which will assess the awareness of the residents of Kiwanja market on NHIF services and benefits. 3. 2 Study area The research will be carried out in Kiwanja market which is located behind Kenyatta University, approximately 2 kilometers from the Nairobi –Thika dual carriage highway. 3. 3 Study population

The study population will include Kiwanja market residents who are in the informal sector employment, who have attained the age of 18 years and earn an income of at least one thousand shillings per month. Kiwanja market has a total population of approximately 28,000 and about 5600 households as per the records in the chief’s office of Kahawa west location. 3. 4 Inclusion and exclusion criteria 3. 4. 1 Inclusion criteria The study will include Kiwanja market residents, who are self employed or employed in the informal sector.

The respondents to be included must have attained the age of 18 years and consented to be used as respondents in the study. 3. 4. 5 Exclusion criteria The study will exclude students of Kenyatta University residing in Kiwanja market, residents under 18 years of age, and those who will decline to give consent. 3. 5 Sampling technique and sample size 3. 5. 1 Sample size determination The sample size will be determined by using the standard sample size calculation formula by Mugenda and Mugenda, 2003. nf = [pic](Mugenda & Mugenda, 2003) Where: nf =desired sample size (If the target population is 10,000) =the proportion of the target population estimated to be in the informal sector taken as 50% z =Standard normal deviation which is 1. 96 at 99 % level of confidence q=1 – p=1-0. 5=0. 5 d=Degree of accuracy desired is 0. 08 (Fischer et al, 1998) n=the desired sample size (when the target population is ;10,000) N=the population of Kiwanja resident households which is 5600 n =1. 962 ? 0. 5 ? 0. 5 0. 082 =76. 64 nf= 5600=75. 60 therefore sample size=76 1+ (5600/76. 64) 3. 5. 2 Sampling technique Cluster sampling technique will be used till an adequate sample size is achieved.

Kiwanja market area will be divided into four clusters of approximately 1400 households each. There will be cluster A, B, C, and D. cluster A will be on the eastern part of the safaricom booster, cluster B will be on the western part of the safaricom booster while clusters C and D will be north and south of the booster respectively. Each cluster will contribute 25% of the sample size thus 19 respondents will be issued with the questionnaires. 3. 6 Data collection procedures 3. 6. 1 Research instruments A structured questionnaire will be used to collect data during the study. 3. 6. 2 Pre testing

Pre testing of the study tool will be done at Kihunguro area in Ruiru town. 10% of the sample size will be used to test the data collection tool. 3. 6. 3 Data collection process A structured questionnaire will be issued to the respondents after an informed consent is given. The first respondent per cluster will be identified through simple random sampling technique and the next subjects will be selected by snowball sampling until a sample of 19 is obtained. Field editing will be done to the raw data obtained. . 3. 7 Data management Data categorization and coding will be carried out during preparation of the questionnaires.

The data collected will be entered, coded and keyed into variables using SPSS version 12- computer software and excel computer packages. Quantitive data will be analyzed using SPSS version 10 computer software. Presentation of quantitive information will be done using statistical packages (graphs, charts, tables and pie charts). 3. 8 Limitations of the study Time will be limiting factor as the time frame for the study is short compared to the workload that will be involved in the study. Due to inadequate time and limited resources, it will be impossible for the study to be carried out in the entire Kahawa west location.

This therefore will make generalization impossible because of using only one locality for the study. The researcher will also be disadvantaged in terms of personnel in that the researcher will be the only one carrying out the study with no assistants involved. 3. 9 Ethical considerations The researcher will ensure the following ethical considerations: i. Introductory letter from Kenyatta University, Department of Nursing Sciences. ii. Letter of authorization from chief of Kahawa west location.. iii. All respondents will give informed consent before being interviewed. iv. Confidentiality will be maintained.

The researcher will provide feedback to the gatekeepers in the community (chief) and Kenyatta University, Department of Nursing Sciences REFERENCES 1. Abd El Fattah, H. I. Saleh, E. Ezzat, S. El-Sahaty, M. El Adawy, A. K. Nandakuma, C. Connor, H. Salah(1997). The health insurance organization of Egypt: An analytical review and strategy for reform. Technical report No 43. Bethesda, MD: Partnerships for health reform project, Abt Associates Inc. 2. Arrow, K. J. (1963). ”Uncertainty and the welfare economics of medical care. ” American Economic review. 3. Inke Mathauer, Guy, C, Doetinchem, O. , Joses, K, Laurent, M. (2004).

Social health insurance: how feasible is its expansion in the African region, ISS, Rotterdam. 4. Kraushaar, D. (1994). ” Health insurance: what is it, how it works. ” Financing districts Health Services international workshop 5. Kraushaar. & O. Akumu (1993). “Financial sustainability of health programmes: the role of the national hospital insurance fund. ” Nairobi: Government of Kenya. 6. Manda, Kimani. D. , (2004) Healthcare financing through health insurance in Kenya: the shift to a national social health insurance fund. Kenya Institute for Public Policy Research Activities and Analysis (KIPPRA), Nairobi, Kenya. . Republic of Kenya (2003a). The National Social Health Insurance Strategy. Prepared by the Task Force on the Establishment of Mandatory National Social Health Insurance. 8. Republic of Kenya (1999). Kenya Gazette supplement, Acts, 1999. The national hospital insurance fund Act, 1998. Nairobi: government printer. 9. Republic of Kenya, (1997). Economic survey. Nairobi: government printer. 10. Shaw, P. (1998) Financing healthcare in the sub-Saharan Africa through user fees and insurance. World bank 11. Stliglitz, J. E. (2000). Economics of the public sector (third edition). W. W.

Norton 12. World Bank (1993). World development report 1993: investing in health. Oxford university press. 13. Techlink International (1999). A renewed NHIF: final report manual. WORK PLAN FOR THE STUDY. |Task | Months | | | |January |February |March |April | | | | | | | | | | | | |Preparation, and approval of proposal |Wk 1 | |Purchasing stationery |500 | |Transport |1500 | |Proposal preparation |2,000 | |Data collection |3,000 | |Data processing and analysis |2,000 | |Lunch |1500 | |miscellaneous |1500 | |Total |12,000 | APPENDICES INSTRUMENT FOR DATA COLLECTION (QUESTIONNAIRE) Instructions Please tick ( ) in the brackets representing the most appropriate response. Additional informational can also be given in the provide spaces or at the back of the questionnaire. 1 a) How old are you? (In complete years) 18-24years ( ) 25-34 years ( ) 35-44years ( ) 44years and above ( ) b) What is your gender? Male ( ) female ( ) 2.

What is your highest level education? Never gone to school ( ) primary school ( ) secondary ( ) post secondary education ( ) 3. What is your religion? Christian ( ) Muslim ( ) Baha’i ( ) other (please specify)………….. 4. What is your marital status? Single ( ) married ( ) divorced ( ) separated ( ) single parent ( ) widowed ( ) other (please specify)……... …….. 5 a) what is your main occupation? Self employed ( ) civil servant ( ) ? 6. Have you ever heard about NHIF? YES ( ) NO ( ) b) How many dependants do you have? ...................................... 7. IF Yes in question 6 above, where did you hear about it? ) Heard from a friend b) I am a beneficiary or a member if NHIF c) My parents are members of NHIF d) At my place of work 8. Are you a National Hospital Insurance Fund member or beneficiary? Yes ( ) No ( ) 9. If yes in question 9 above how do you rate NHIF services in the scale below out of ten:0-3 poor ( ) 3-5 below average ( ) 5-7 good ( ) 7-10 very good ( ) 10. If no in number 9 above, please tick as appropriate the reason why you are not member or beneficiary of NHIF a) I have never heard about NHIF b) I do not know the benefits of NHIF c) There is no branch of NHIF in Kiwanja market d) I am not employed in the formal sector. 11.

If you are a beneficiary of NHIF, would you like to be a member? Yes ( ) no ( ) 12 If no in number 11 above, please as appropriate the reason why. a) I am not employed in the formal sector. b) There is no branch of NHIF in Kiwanja market. c) I have to think about it first and consult my husband about it. d) The monthly contribution is too much for me. 13. If yes in number 11 above, how many beneficiaries will benefit from your cover? None ( ) my spouse ( ) my children ( ) my parents ( ) other…………………….. 14. Do you think that NHIF services will ease your burden of financing healthcare for you and your family and significant others?

Yes ( ) no ( ) 15. Would like to be an NHIF member? Yes ( ) no ( ) 16. If yes in the above no. 15 do you know what requirements for becoming a member are? Yes ( ) no ( ) 17. If no in number 16 above, why? a) Because I have just learnt about NHIF now. b) Because I have never had a chance of accessing information about NHIF membership before. c) Because I have always thought NHIF is for those in the formal sector. d) I would like some brochures from NHIF on benefits, cover, and how to contribute to the insurance scheme. 18. If you are a member of NHIF have you ever used their services? Yes ( ) no ( ) 19. If no in the above question 18, why? ) I have never been hospitalized. b) None of my beneficiaries have been hospitalized. c) I did not know how to place my claim of cover. d) The process of accessing benefits is too long for me. 20. If yes in the above question 18, where did you use it? a) In a government facility. b) In a mission hospital. c) In a private hospital. d) In a referral hospital such as Kenyatta National Hospital. e) Other (please specify)…………………………………………… 20 if yes in question 18 above how did you find NHIF services? a) Average b) Good c) Very good d) Excellent Thank you very much for being a respondent and for your much cooperation. CONSENT FORM Researcher’s confirmation.

I am Ann Mwangi, a Kenyatta university student pursuing a Bachelor’s of science degree in Nursing and Public Health. I am carrying out a study on utilization of NHIF services in Kiwanja market, Kahawa west location in Kasarani Division. I kindly request your permission to interview you. Confidentiality will be guaranteed. Your names will not be required. Signature of researcher……………………………………….. Date…………. Respondent’s consent I have been fully informed about the nature of the study and I hereby give my consent to any information which is required of me. Signature of respondent……………………………………Date……………. MAP OF STUDY AREA [pic] ----------------------- Kiwanja Market

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