Abstract:
Background Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the
absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included
NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to
households with persons living with hypertension and/or diabetes in Kenya.
Methods We carried out a prospective cohort study, following 888 households with at least one individual living
with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in
the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study
participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE)
as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse
the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic
inequality in CHE was examined using concentration curves and indices.
Results We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household
budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled
in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE
compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-
poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline
but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the
share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%.
Conclusion We did not find strong evidence that the NHIF national scheme is effective in providing financial risk
protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be
explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF