Every resident in Kenya can access healthcare services through the Primary Healthcare Fund(PHF) as outlined in the Primary Health Care Act of 2023. By following the guidelines provided in the Act, individuals will receive the necessary care, ensuring universal access to essential health services across the country. This system aims to streamline healthcare delivery and promote equitable access for all.

Purposes of the Primary Healthcare Fund in Kenya

The Primary Healthcare Fund in Kenya plays a crucial role in enhancing healthcare services through several key actions:

  1. Purchase Primary Healthcare Services:
    The fund actively buys primary healthcare services from Primary Healthcare facilities, making sure Kenyans can access essential and affordable healthcare.
  2. Pay Healthcare Facilities:
    The fund compensates healthcare facilities for delivering quality care. It follows the tariffs prescribed under the Primary Health Care Act, ensuring transparency and fairness.
  3. Create a Central Fund Pool:
    The fund establishes a central pool to manage the collection and distribution of money allocated for primary healthcare services., streamlining financial processes for better healthcare delivery.

Accessing Healthcare Services Under the Primary Healthcare Fund

  1. Residents in Kenya Access Healthcare Services:
    Every resident in Kenya can access healthcare services through the Primary Healthcare Fund, as outlined in the Primary Health Care Act of 2023.The services are in Level 1( Community Health Services), Level 2( Dispensary or Clinic) and Level 3 (Health Centre)
  2. Register for the Social Health Insurance Fund:
    To access these services, individuals must register as members of the SHIF.
  3. Follow Referral Procedures:
    If a person using the social health insurance cover is referred for further treatment from a primary health facility to a level 4, 5, or 6 health facility, they must comply with the provisions of the Act. A beneficiary under the SHIF shall also be entitled to the Emergency, Chronic and Critical Illnesses fund too

Services Offered Under the PHF

  1. Access to Primary Healthcare Services:
    Individuals registered with the Social Health Insurance Fund can directly access primary healthcare services provided under the Primary Healthcare Fund, as specified in the Primary Health Care Act, 2023.
  2. Healthcare Facilities:
    People will receive these services through level 2 or level 3 health facilities that the Authority has empaneled and contracted.
  3. Purchasing Healthcare Services:
    The Authority actively uses funds from the Primary Healthcare Fund to purchase primary healthcare services from contracted health facilities. The benefits package, as outlined in the Second Schedule of the regulations, includes:
    • Promotive services example; Health Education, Healthy Lifestyle Campaigns, Community Health Outreach, School Health Programs, Workplace Wellness Programs
    • Preventive services for example: Vaccination Programs, Screening Tests, Antenatal Care, Health Check-ups, Family Planning Services
    • Curative services for example : Medical Treatment for Infections, Surgical Procedures, Hospital Care
    • Rehabilitative services for example : Physical Therapy for Injury Recovery,
    • Palliative care services for example : Pain and Symptom Management, Emotional and Psychological Support
    • Referral services for example : Referral from Primary Health Facilities to level 4,5 or 6, Patient Transportation to referral hospitals,
  4. Provision of Services
    Health facilities deliver these services according to the tariffs set under Section 32 (2) of the Act, ensuring consistent pricing across facilities.

Payments from the Primary Healthcare Fund

  1. Claim Submission:
    To access funds from the Primary Healthcare Fund as outlined in Section 22 of the Act, which states that an employer must deduct the contribution of a salaried contributor and submit this contribution to the Authority on behalf of the employee at the rate specified in Regulation 16 by the ninth day of each month, a health facility must submit a claim to the Claims Management Office for any facility-based primary healthcare service provided.
  2. Claim Payments:
    The Authority will pay the submitted claims based on the tariffs prescribed in Section 32 (2) of the Act.
  3. Claim Processing:
    According to Part VIII of these Regulations, a healthcare provider or health facility must lodge a claim with the Claims Management Office or a medical insurance provider and claim settling agent, where applicable, within seven days from the date of the patient’s discharge for review and processing of the claim.

The medical insurance provider and claim settling agent referred to in this regulation must:

  • (a) Be registered by the Insurance Regulatory Authority as a medical insurance provider and a claim settling agent.
  • (b) Have a valid license issued by the Insurance Regulatory Authority.
  • (c) Employ at least two qualified and experienced medical doctors.
  • (d) Be registered with the Office of the Data Commissioner established under the Data Protection Act, 2019.
  • (e) Comply with the provisions of the Data Protection Act, 2019 and the Digital Health Act, 2023.

Financing

In line with the objective outlined in Section 20 of the Act, the Authority will mobilize resources for the Primary Healthcare Fund to purchase primary healthcare services from designated health facilities. According to Section 20, the fund will be financed through multiple sources, including appropriations by the National Assembly, grants, gifts, donations, bequests, fees, levies, and other relevant funds.

Unlike the NHIF, the SHI aims to broaden coverage by removing restrictions on specific medical expenses, such as pre-treatment blood work and certain CT scans. It also extends coverage to include congenital conditions and preventive measures, which were not previously covered.