This document discusses challenges and opportunities around achieving universal healthcare coverage in Africa. It notes that over 150 million people globally face financial hardship from health expenses each year. While government and out-of-pocket payments still dominate healthcare financing, countries are undergoing economic and political changes that could impact healthcare. National health insurance programs like Kenya's NHIF cover millions but face challenges in expanding coverage and controlling costs. Adopting health technologies could help address inefficiencies in claims processing and resource allocation to move closer to universal coverage.

1. Health Technology And Innovation For
Universal Healthcare Coverage
Presentation at ACHAP Biennial Conference– 25th Feb 2015

2. Universal Health Care remains elusive despite huge
potential benefit and impact
“Every year health expenses create severe financial hardship for 150 million people
globally and force 25 million households into poverty. This is due largely to the fact that
more than three billion people—many of whom are found in the poorest half of the
world’s population—pay out of pocket for health services. They are forced to choose
between impoverishing fees or foregoing needed services, leaving them at risk of
falling into a downward spiral of sickness and poverty..”
The Rockefeller Foundation, 2010

3. Africa is undergoing various transition that impact
all players in the healthcare industry
Decentralization of
government
Economic
growth
More private sector
focus on development
Increasing literacy
& awareness
• Government services
shifting more to regional
areas e.g. counties
• Counties making different
progress in improving
livelihoods of citizens
• Governors carrying out
various initiatives that are
affecting healthcare
• Major investments in
infrastructure nationally &
regionally
• Growing middle class with
more disposable incomes
• Relative economic and
political stability
promoting economic
activities
• Strong private sector has
evolved under relatively
market friendly policies
• Increasing shift to
emerging markets as
growth in developed
countries slows down
• Private sector investing to
take advantage of the
growing middle class
• More universities coming
up and providing access to
higher education
• Mobile and internet
penetration have
drastically improved
creating more channels
for literacy & awareness

4. Yet healthcare financing in a number of countries is
still mainly by government and out of pocket
expenditure
HEALTHCARE FINANCING BREAKDOWN CHALLENGES FACING HEALTHCARE FINANCING
• High out of pocket expenditure in context
of a weak risk pooling system
• High burden of disease from both
communicable and non-communicable
aspects
• Inefficient and ineffective allocation and
use of scarce resources:
- Promotive & preventative health used on
~12% of total health expenditure while
admin took ~14% expenditure
- WHO estimates ~40% of medical spend
lost through waste
Source: Literature review; Open Capital; Deloitte
Case Point: KENYA

5. Despite challenges in the public sector, it still has
the most facilities
Source: Kenya Service Provision Assessment , 2010

6. For equitable access to health and UHC, all
stakeholders must be engaged
Public
Private
For-profit Not for-profit
Faith Based Organizations
Healthcare financing ( Explore viable models: public/ private/ hybrid insurance?)
Access to healthcare
Quality healthcare (Incentives linked to outcomes)
Efficient allocation & utilization of resources

7. Health IT innovations have offered solutions for
affordable healthcare financing models around the
globe
Leadership / Governance
(Facilitative)
Regulatory Framework
(Interoperability, data security)
Knowledge sharing
( Academia - Industry Collaboration)
Value Based Healthcare System
Collation of Medical
Information
Insights
transformed to
clinical
guidelines
Continuous
medical care
quality
improvement
Continuous
reduction of
medical costs
More affordable and
widespread health
care coverage
e.g.
• Sweden has 90
disease registries
• The registries
cover 25% of total
national health
expenditure
• The registries are
a tool used to
promote
improved clinical
practise
• Sweden’s National
Cataract Register
helps minimize
the incidence of
postoperative
endopthalimitis
• Projected saving
of $ 25 million
p.a. in direct costs
of treating
postoperative
endopthalimitis
• Estimated
reduced direct
healthcare cost of
$ 7 Billion over 10
years
Source: BCG, HBR

8. And we can leverage those lessons to promote UHC
in Africa
• National Hospital Insurance Fund (NHIF)
- Oldest government insurance scheme in Africa
- Largest healthcare risk pool in Kenya
- Mandate is to provide access to quality and affordable healthcare for all Kenyans
- Membership compulsory for all salaried employees
• Premiums
- Calculated on a graduated scale based on income
- Deducted automatically through payroll for salaried employees
- Self employed and other informal sector workers:
‣ Membership is contributory (voluntary)
‣ Fixed premium rate of KES 160 per month
• Coverage:
- ~4.5 million people (11% of Kenya’s population)
- 98% coverage of the formal sector
- 16% coverage for the informal sector – accounts for 80% of Kenya’s population
Source: NHIF; Health Market Innovations; USAID
“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.”
NHIF
NHIF OVERVIEW
Case Point: KENYA

9. NHIF’s contributions have increased and services
cover most of the country
FINANCIAL OVERVIEW COMMENTS
• NHIF has contracts with
about 645 hospitals in the
country for provision of in-
patient services to members
and beneficiaries
• Coverage of 98% of hospital
beds in the country
• Provides services through
contracts specifying coverage
rates or rebate rates with the
providers
• Most comprehensive NHIF
coverage is at public health
hospitals and faith based
hospitals
Source: NHIF; Health Market Innovations

10. NHIF faces various challenges which will limit
Kenya’s ability to achieve UHC
NHIF incurs a lower percentage of
contributions on settling claims…
…and incurs more expenses on
personnel and administrative costs
Other challenges
Source: AKI; NHIF; UAP; Literature review; Expert Interviews
• Allocation of resources towards
more expensive curative services
• Lack of widespread outpatient
cover
• Low pay-outs per claim limiting
access to healthcare
• Financial sustainability
- Growth in the formal sector
saturated at ~98% coverage
- Dependent on informal sector and
government contribution for
growth

11. Current process of managing claims creates
several challenges along the value chain…
Pre-authorization
challenges
Manual, labour intensive, inefficient and prone to error process
Inconsistencies due to systems challenges
Difficult for hospitals to track
what was paid / rejected
Patient
visits
hospital
Hospital
submits
Paper claims
Paper claims
digitized
Coding of claims
into backend
system
Claims
analysis
Claims
settlement
Inconsistencies detection is costly and in-efficient
Lack of good quality data and analytics to drive to better decision making
Source: Literature review; AKI; Expert interviews

12. Challenge
• Insurers need to ensure that
the right beneficiary receives
care so as to reimburse
• Current process consists of:
- Phone calls
- Cross checking of Excel files
with beneficiary details
- Biometrics
• Paper based and in-efficient:
- Hospitals have to submit paper
based claims to insurers.
- They do not have a way of
tracking which claims are
processed and refunded
• Inconsistences in claims is a
common concern across the
health insurance sector:
- ~20%-40% of claims are deemed
inconsistent
- There has been need to have
nurses and medical investigators
to follow up
• Paper based and in-efficient:
- Claim details are entered
manually into backend systems
- Systems don’t integrate with
hospital EMRs
- Errors likely to occur in data
entry
Solution
• Point of care
pre-authorization
- Connects to an online database
and provides hospitals with
beneficiary details and cover
limits
- Better visibility into what
individual benefits and
applicable sub-limits
• Online claims submission:
- Streamlines and provides
visibility into the entire billing
process
- Minimizes paper work and
avoids the situation of ‘boxes
full of claims’
- Creates an audit trail of every
transaction which enables
follow up
- Enforces standardization of care
which improves health
outcomes
• Claim inconsistencies
algorithms:
- Based on disease management
protocols
- Flags claims which are likely to
be inconsistent
- Pro-active management of those
inconsistencies of claims helps
control claims costs leading to
profitability
- Automation increases efficiency
• Improved productivity &
efficiency:
- Automation increases efficiency
and productivity
- Audit trail increases
accountability
• Improved revenue cycle
management for providers
- Better payment allocation and
reconciliation
- Faster transaction time and
claim settlement times
That can be improved through technology to improve
processes, support decision making and move closer
towards UHC
Online claims
submission
Pre-authorization /
patient identification
Inconsistencies flagging
engine
Claims
processing

13. Thank you
Beatrice.Murage@savannahinformatics.com
Savannah Informatics provides tools to the healthcare industry to
enable better decision making