The Daily Nation in Kenya recently raised concerns about the increasing numbers of births which are being delivered by c-section, now estimated to be 50%. This is very much higher than the rate thought ideal by the WHO, 10% – 15%. Apart from the high rate, the piece also discusses the financial pressure which this places on the national insurance fund, NHIF.
Whilst noting, and agreeing, that a delivery should only be by c-section when it is medically indicated, I am not at all surprised that this rate is so high – especially when insurance-funded.
Maternity hospitals can either be midwife-led, providing BEmONC services or doctor-led providing CEmONC services, which of course include c-sections. The latter approach has a much higher fixed-cost base, a doctor costs more than a nurse/midwife and there are additional staff and equipment costs for the operating theatre, eg in the provision of anaesthesia.
In Kenya, a doctor’s salary can be approx KES 250,000 per month, and participating facilities are reimbursed 30,000 by NHIF for each c-section provided. A maternity facility only needs a doctor on staff if it is providing c-sections, normal vaginal births can be managed by a midwife. It needs at least eight c-section reimbursements to cover this additional payroll cost, never mind all of the other additional costs. A facility which has just one doctor, and wants to maintain an indicated c-section rate within the ideal range, 10%-15%, needs to be providing ~55 deliveries each month, to justify taking on the extra cost of this one doctor, and more than this to fully recover the other costs of the operating theatre. Note that an OB/GYN consultant costs twice as much as a medical officer (doctor), and so the resulting pressure to increase the c-section rate for revenue purposes is even greater.
Here are 3 interventions which could reduce the moral hazard of increasing the rate of non-indicated c-sections under NHIF in Kenya:
- Lobby the Government of Kenya to increase the NHIF reimbursement rate for each c-section, this should take full account of the added operating theatre payroll and equipment costs;
- Change the client segment mix to favour those paying out-of-pocket, and set c-section prices at full cost-recovery, which will most likely be higher than the current NHIF reimbursement rate;
- Diversify services for which we can deploy the doctor and theatre staff to defray these high fixed costs, eg provide gynae services and minor surgery.