HOW THE EDU AFYA SCHEME WORKS
Registration of beneficiaries
The EduAfya scheme offers comprehensive medical insurance coverage for students in public secondary schools registered with the National Educational Management Information Systems (NEMIS)
The number of NEMIS registered students was estimated at 2.2 million by the NHIF as part of its EduAfya sensitization materials (NHIF and Ministry of Education 2018).
RELATED NEWS:
MINISTRY OF EDUCATION: CLAIM FORM FOR SECONDARY SCHOOLS MEDICAL SCHEME.
NHIF Cover For Secondary School Students, Edu- Afya (Full details)
EDUAFYA – THE COMPREHENSIVE MEDICAL INSURANCE COVER FOR PUBLIC SECONDARY SCHOOLS
However, this appears to be out of a projected population of 3 million
public school students targeted by the program as was initially set out in the Presidential announcement (PSCU 2018). It is unclear if the difference in estimated students presents a real gap.
Based on stakeholder interviews in the four counties, all health care providers indicated that they had a proportion of their claims disapproved due to the lack of a valid NEMIS number and that this continued to be an ongoing issue.
From county education counterparts, the reasons provided for the lack of a NEMIS number included:
- network issues,
- the lack of internet technology (IT) and/or IT “savvy” to register students on NEMIS;
- lack of birth certificates for some students;
- keying errors resulting in invalid NEMIS numbers;
- transmission lag of NEMIS numbers due to student transfers; and, ultimately,
- Low motivation on the part of school heads to lead registration of students to NEMIS.
This varied by school and was largely dependent on the motivation of the head teacher.
To ensure improved enrolment, MoEST has pegged the student capitation reimbursements to schools on the enrolment of students on NEMIS from May 2019.
NEMIS registration as a means of accessing health services was intended to be a stop gap measure.
Originally, students were to be issued with a NHIF card for EduAfya.
However, according to all stakeholders interviewed, students had not received NHIF cards a year into the program in the visited counties.
Additionally, many health care providers indicated that they require letters from the head teachers in order to attend to students.
Although the official purpose of these letters is to ensure that students without NEMIS numbers have access to EduAfya (NHIF 2020), this additional step has implications for access during holiday periods, when students return to their homes from boarding facilities.
The letter, or other form of teacher approval, also has implications for student privacy and confidentiality as students need to state the reason for seeking health care before they can get permission from the school to access services. In the sites visited, most of the students were aged 11-19 years and the schools varied in terms of day, boarding, boys only, girls only, and mixed secondary schools.
Some of the schools maintain a clinic or sanitarium -using their budget from MoEST – to cater for medical emegencies by engaging a nurse or clinical officer.
These facilities are not included within EduAfya nor are they registered with the NHIF. Some also engage a school matron or a senior teacher from whom students in need of health services must seek permission to go to an EduAfya facility for treatment.
Some of the schools are located near health facilities, while in other cases students have to travel some distance to the health facility.
Benefit package
The EduAfya scheme offers a comprehensive benefit package. It was reported at the launch of EduAfya that “the comprehensive medical Insurance cover for the students has been negotiated between the Education ministry and NHIF, taking into account the uniqueness of the population to be insured” (PSCU 2018).
In practice, it is unclear how unique the insurance coverage is as it has been modelled on the civil servants’ scheme.
EduAfya, in accordance with the civil servants’ scheme, includes outpatient services, inpatient services, daycare surgical services, local road ambulance, and emergency air rescue services.
Cases that require overseas air evacuation, general and specialized services, overseas management for cases not treated in the country, funeral expenses, and group life are also part of the package.
Optical and dental benefits are covered only in public facilities as a cost containment measure (NHIF 2020).
Contracted facilities
Health facilities with existing NHIF contracts are eligible to provide services to students.
No separate contract is issued for EduAfya. NHIF guidance indicates that outpatient services are provided on a choice-basis at any contracted facilities.
Students access ward bed facilities for inpatient services in any accredited facilities. This includes accredited mission/faith-based healthcare providers and accredited private hospitals, except for high-cost private facilities.
Inpatient care is on a referral basis from the selected outpatient care
facility. It is assumed that all referral health facilities are included within the EduAfya scheme, as they are NHIF accredited.
Initial challenges with the selection of facilities have since been addressed. Originally, selection of health facilities was done by the head teachers of the approximately 9,000 secondary schools in the country.
Head teachers would then forward the selected health facilities to the
NHIF branch through the CDoEs. While this was the initial practice, it proved problematic as enterprising facilities vied for contracts with schools, even if this did not make geographic sense.
Implied in this arrangement were backhanded deals between the schools and health facilities. This situation seems to have corrected itself as there are no longer limitations on which health facilities schools may send students to, which has reduced the likelihood
of gatekeeping.
While in all counties there were some, mainly private, providers with a lot of schools attached to their facility, these were within their catchment area.
In cases where they were not and the facility was offering outreach services to the schools, these were justified on the basis that there
were no participating EduAfya facilities nearby, in ‘interior’ locations of the four counties.
The level of engagement of providers in EduAfya varied by county and by facility type and level. The differences in engagement were mostly seen in public providers, whereas all private providers
visited were active under the scheme.
The level of engagement in the public sector was largely attributed to the public financial management arrangements in place.
Specifically, this related to whether a public facility could retain NHIF
reimbursements and had the authority to incur expenditure, i.e. pay expenses or make improvements to their facilities/services.
In Counties A and C, PHC facilities and some hospitals received NHIF reimbursements directly and had the authority to incur expenditure, using reimbursements from EduAfya and other NHIF schemes.
In response, these facilities had employed additional casual workers, e.g. young people with IT and accounting skills, to follow
up NHIF reimbursements and promote their facilities within their communities (schools in the case of EduAfya and pregnant women in the case of Linda Mama).
There was a palpable sense of teamwork and active engagement
around the schemes, and a recognition that EduAfya clients were a benefit and not a burden to the facility.
In contrast, in county D, there was less active and more mixed engagement on EduAfya. For example, only two of six public health centers visited were participating in EduAfya despite being located near schools.
As this county had a lower number of private providers, schools
tended to use the hospitals for EduAfya in lieu of public health centers.
In County B, lower level public facilities were not participating while higher level facilities were.
The youth-friendly centres visited were standalone facilities located on the grounds of larger health facilities but accessed separately.
These were constructed with USAID support. attending to students but not claiming for services, despite the same facilities being active
on the Linda Mama scheme.
This county used a common software in hospitals that allows facilities to track the payer for each service offered, a practice that is useful in promoting coherence in the use of funds at the facility level under universal health coverage (UHC) and strategic purchasing for PHC.
There is increasing awareness about the importance of offering youth-friendly services among facility managers, but their readiness to do so is mixed.
In county A, for example, all three adolescent- and youth-friendly centers2 visited were either closed or found to not have any staff, youth, or adolescents in attendance.
These sites attend to students in the outpatient department, mainly for common ailments.
This suggests that the youth friendly centers may not be working optimally, nor is there effort to connect youth-friendly centers
with EduAfya, despite having the same target population.
In all counties, it was found that some providers, both public and private, were trying to be more adolescent-friendly by giving students priority attention, including hiring additional health personnel so that students could be seen quickly.
Payment to facilities
EduAfya services are reimbursed on a fixed-fee-forservice basis. This ranges from KES 1,000 to KES 1,500 for out-patient and KES 1,500 to KES 4,000 daily rebate for in-patient services depending on the
size of health facility and the NHIF contract.
Through discussions with providers, there was a sense that EduAfya rates were generally fair and better than what is provided for under other NHIF schemes, such as the national scheme’s capitation rate.
However, there were concerns voiced that reimbursement rates were not transparent between facilities and that the NHIF had reduced rates for some facilities abitrarily.
For example, some facilities visited in County A noted that their rate was reduced from KES 1,500 per out-patient service to KES 1,000 without any prior communication or
These were contracts for NHIF in- and out-patient schemes as no separate contract is in place for EduAfya. The reimbursement schedule indicated the change in EduAfya rates.
