BACKGROUND Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. METHODS We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. RESULTS The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. CONCLUSION While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

中文翻译：

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审查肯尼亚国家医院保险基金针对全民健康保险的购买改革。

背景 肯尼亚优先考虑通过国家医院保险基金（NHIF）扩大健康保险覆盖范围来实现全民健康覆盖（UHC）。2015年，NHIF对保费缴费率、福利方案和提供者支付方式进行了改革。我们研究了这些改革对 NHIF 采购实践的影响及其对战略采购和卫生系统公平、效率和质量目标的影响。方法 我们以 NHIF 为案例，以改革为嵌入分析单元进行嵌入案例研究。我们通过对卫生融资利益相关者、设施管理者和一线提供者进行 41 次深度访谈，收集了国家层面和有意选择的两个县的数据；与 51 名 NHIF 成员进行 4 次焦点小组讨论；以及文件审查。我们使用框架方法分析了数据。结果 新的 NHIF 改革的特点是购买行动疲弱。首先，新的保费缴费率沟通不充分，某些公民群体无法承担。其次，虽然据报道新的福利方案是基于民众的服务需求、偏好和价值观，但这些福利方案沟通不充分，而且在不同公民群体之间分配不均。此外，公共医疗机构中服务提供基础设施的差距以及合同医疗机构的亲城市和亲私营分布也影响了这些新服务的提供和获取。最后，新的提供者付款方式和费率被认为是不够的，延迟付款以及与财务问责机制的联系薄弱，损害了他们激励医疗保健服务的公平性、效率和质量的能力。结论 虽然 NHIF 试图通过新的改革扩大人口和服务覆盖范围并减少自付费用，但改革设计和实施中的弱点限制了 NHIF 的购买行动，对卫生系统的公平、效率和质量目标产生了负面影响。为了加快国家全民健康覆盖的改革进程，NHIF 以及国家和县政府的政策制定者应刻意努力，使此类改革的设计和实施与旨在改善卫生系统目标的战略采购行动保持一致。