7/31/2019 Nhif Board

1/4

To

The NHIF Board,

Thro

The Chairman,NHIF Board

P.O. Box 30443-00100,

Nairobi, Kenya. October 16, 2012

Dear Sir,

Ref: Our meeting held at Afya House on 11th

October 2012

Kindly refer to our meeting held under the Chairmanship of the Minister of Medical Services and

attended by representatives of the fund where you were also present.

It was resolved that the allegations on misappropriation and mismanagement of the Civil Service Medical

Scheme be addressed directly by the board.

We have previously addressed these issues via our letters Ref. UKCS/NHIF/VOL.I/14 dated13th June

2012, Ref. UKCS/NHIF/VOL.I/ (24)dated13th September 2012 and Ref. UKCS/NHIF/ VOL.1/

(26)dated 26th

September 2012 attached for the ease of your reference.

We do appreciate the fact the NHIF is guided by the Act but we also submit that the civil servants medical

scheme should not be treated by the social scheme that is governed under the Act. The civil servants

medical cover is a comprehensive cover but facts from some of the facilities that are rendering service

clearly proves that there is a total misconception of the way the scheme is supposed to operate.

In a letter to the Moi referral dated October 2, 2012, (Copy attached) the Eldoret branch Manager wrote in

part, As communicated earliercivil servants in job groupA-M should be admitted in the special wing of

the general ward and the NHIF will pay the rebate Kshs. 2300 plus 200 amounting to Kshs. 2500. This

is in total contravention of the contract signed between the government and the NHIF. And in further

disregard of the contract, the Moi referral hospital in a memo to its Finance department dated September

27, 2012, it is evident that the service provider does not understand the scheme, or is misinformed.

This and many more of the problems that are still dogging the scheme can be resolved if the UKCS and

the NHIF can partner to ensure the success of the scheme. You are aware that the Universal health care is

pegged on the success of the Civil servants scheme. I believe we all want the introduction of the scheme

so as to finally reduce the load of the Kenyans on medical bills.

SCOPE OF MEDICAL SCHEME FOR CIVIL SERVANTS:-

On perusal of the contract, some areas are grey which need revision but the facts on the scheme are clear.

The scheme covers outpatient, Inpatient, Group Life and Last Expense for Member, Spouse and Three

Children.

7/31/2019 Nhif Board

2/4

KEY FEATURES OF THE SCHEME

Out- patient on choice based In patient on referral based on Job Group Overseas treatment for all Members (M+4) Ambulance services-Transfer between facilities. Special clinics in Government Hospitals. Dental & Optical services on referral and on family shared limits. Cover without exclusions Group Life and last expenses benefits with limits. Additional premiums for additional dependents. Medical checkups once in a year. New entrants join without waiting period. All facilities should provide services which include consultations, diagnosis, drugs among other

things without incurring out of pocket expenses as in cover for 100%,

CURRENT MAJOR ALTERATION OF THE SCHEME

Membership has changed from M+4 to M+3 in contravention of the contract. Members Job Group A-M being forced to go to general wards in Government Hospitals, while

queuing with other general patients. No special clinics for civil servants in Government hospitals

Continued payment for out and inpatient services by scheme members without refunds. Members of Higher job group forced to go to specific hospitals that bill equivalent to member

limit for one visit.

Unconfirmed reports of overseas treatment for dependents having been stopped. Only principalmembers are catered for.

Payment of Last/ Funeral expenses yet to be paid to majority of families who lost their insuredloved ones in January.

Change from capitation to fee for service for outpatient for Job Group N-T, an action that hasseen most of the beneficiaries even in lower cadres being subjected to the same in facilities they

have been allocated to.

No portability of services to cater for families who do not live in the same geographical location(especially disciplined services)

No portability of services for members whose jobs entail travelling, frequent transfers and specialassignment of duties by government.

Choice of outpatient facilities abdicated by the NHIF where they arbitrarily allocate and movemembers without their consent.

Denial of quality service to the beneficiaries following an arbitrary termination of contract tosome of the facilities that were known to deliver quality service to members. There was a general

outcry, especially in Nairobi following the sudden termination of Meridian and clinix service

providers.

7/31/2019 Nhif Board

3/4

FACTORS THAT HAVE CONTRIBUTED TO THE ABOVE:

The NHIF has not developed a policy on the administration of the Civil servants scheme but haveinstead applied the policy of the statutory scheme, thus failing to distinguish between the

comprehensive scheme and the social scheme.

Lack of standard information on the scheme which has resulted in lack understanding by seniormanagers thus leading to poor administration of the scheme.

Poor or no sensitization of the facilities. It would be expected that an informed facility would beable to guide the beneficiaries who also happen to have little or no information.

It is important to note that team that negotiated the scheme had clear objectives that led to the signing of

the contract. Incidentally, the scheme is today being handled in a very amorphous way with disregard to

negotiated positions by not being guided and managed in a coordinated way by a team of experts as it was

done earlier.What is becoming clear is the struggle to control the health facilities with disregard to quality

of service.

It is evident that the general attitude of the NHIF employees is that the scheme is one and the same hencethey deal with it just like the statutory scheme.

Based on all the facts shown above, the scheme is faced by numerous challenges which include:-

The arbitrary changes made in total disregard of the effect it will have on the beneficiary willresult in serious financial implications that will impact negatively on the sustainability of the

scheme hence the Fund.

There is a very high likelihood that some of the changes including introduction of capitation ofspecialized services are red flags for misappropriation and fraud. Not all beneficiaries require

specialized services and as such these can be left to referral services.

By lack of having proper quality healthcare services controls is likely to affect development ofhealth infrastructure in government facilities and Poor services to members.

This will also ultimately drastically impact negatively on the Universal health care provision asenvisaged in Vision 2030 and millennium development goals as this scheme was designed to be a

pillar for universal health.

CONCLUSION:-

The Union of Kenya Civil servants being the mouth piece of the beneficiaries of the scheme will not

relent in its quest to ensure the survival of the scheme. Thereisanurgentneedtoaddressthe

disquietamongstourmembersoverthepoorservicesbeingofferedbyespeciallythepublic

facilities.Popularizingtheschemewhiletheproblempersistswillnotaddanyvalue.

Any which way, the beneficiaries of the scheme will have to receive the quality service as is provided for

in the contract. In view of this, the Union hereby wishes to state that for it to support the continued

administration of the scheme by the NHIF,

i. TheNHIFshouldfullyrecognizetheUKCSanditsroleinthesuccessofthescheme.

7/31/2019 Nhif Board

4/4

ii. TheNHIFboardshouldapprovetheformationofacommitteetooverseetheadministrationoftheschemeaswehadindicatedinourearlierletter.(attachedforease

ofreference)

iii. TheNHIFBoard,theUKCS,MSPSandtheMMSshouldcomeupwithapolicydocumentontheadministrationofthemedicalscheme.

iv. TheGeneralManagerscurrentlycreatingconfusionintheAdministrationoftheschemeshouldbetotallydelinkedfromtheschemewithimmediateeffectandofficerswhowill

administertheschemeinaccordancetothecontractbeidentifiedforthwith.

v. Alloutpatientfacilitiesthatarecurrentlycontractedtooffertheservicearere-assessedtoestablishtheircapacitiestooffertheserviceundernewterms

vi. AnynewfacilitiestobeincludedshouldbeprocuredinaccordancetotheprocurementAct,approvedbytheUKCS

vii. Memberswhohavebeenforcedtoprocureservicesshouldberefundedalltheirexpenseswithoutanyfurtherdelay.

viii. Thenumberofdependentsshouldberestoredimmediatelytoavoidanyproblems.ThecontractsaysM+4andthatiswhatitshouldbe.

ix. Membersshouldbeallowedtoretainthefacilitiestheychoseinitiallyandthosewhohavebeenmovedwithouttheirconsentrevertedtotheirfacilitiesofchoice.

x. Facilitiesthathavebeengiventwocodesshouldbefurtherinvestigatedtoascertainhowtheyendedupwithtwocodesanddifferentnamesforthesamefacility.

xi. Thegrouplifecoverandthelastrightsshouldbeavailedimmediatelyandabetternotificationmethodadopted.Allpendingcasesshouldbedispensedoffwithoutany

furtherdelays.As stated in our earlier communication to you, the scheme is about our lives and management of the same

is paramount and that we should have a more active role in its administration if the Insurer is desirous to

maintain a strong relationship with the organization and in extension the beneficiaries.