By ISAAC ONGIRI
A storm is brewing over the new multibillion-shilling health insurance scheme for civil servants, teachers and members of the disciplined forces.
Members of a parliamentary committee are questioning the National Hospital Insurance Fund’s (NHIF) choice of service providers and whether those accredited can offer the services needed. Two private healthcare chains have signed up more than 40 per cent of the 221,730 eligible civil servants.
Also raising eyebrows is the NHIF’s decision to pay accredited hospitals and clinics in full even before they deliver their services. More than Sh1.08 billion has already been sent out to 1,170 hospitals through capitation.
MPs are worried unscrupulous operators may take advantage of the pre-payments by diverting funds to other purposes or lodging fictitious claims. The legislators point out that some service providers have begun ambitious expansion plans using the pre-payments instead of spending the funds on medical services for beneficiaries. The Sh1.08 billion in advance payments, referred to as capitation, is supposed to benefit some 221,730 public servants for the first quarter beginning January 2012.
Fraudulent claims
Parliament’s Health Committee has summoned NHIF officials next week to respond to queries over the scheme, which is expected to grow after the courts sanctioned higher deductions to employees’ pay. The lawmakers are also planning a national tour of all accredited facilities to assess their capacity.
"This is a great idea and we insist that the NHIF must get it right," says Nyaribari Chache MP Robert Monda, who chairs the Health Committee. "As a watchdog we are going to scrutinise some of the underlying issues to ensure it works for the beneficiaries. That is why we have invited the board to come and answer some developing questions."
NHIF is preparing to collect an estimated Sh80 billion annually from contributors in formal employment to deliver an ambitious universal health insurance.
The Sh4.3 billion-a-year scheme for civil servants is expected to expand after the Teachers Service Commission signed a separate Sh4.5 billion deal with NHIF to provide cover for some 260,000 teachers.
For the civil servants, Sh1.3 billion will be spent on in-patient cover, Sh2.3 billion on outpatients, Sh646 million on group life cover while Sh84 million will cater for last expense claims and another Sh2.8 million will be spend on other levies per year.
Some MPs now fear that the NHIF may run into trouble with the experimental scheme unless standards are set for the service providers to avoid fraud or theft of billions of State funds meant to benefit Government workers.
Investigations by The Standard on Saturday established that 1,170 health facilities have been enlisted to provide services through the scheme.
Eyebrows have been raised on how some clinics are opening up small facilities all over so as to attract huge membership in order to bid for high advance payments from the fund.
"It is important that this service be put on hold so as to ensure that issues of concerns which may lead to loss of funds are dealt with," said Public Accounts Committee chairman Dr Boni Khalwale.
Beneficiaries were required to select a health provider of choice in any of the nation’s 47 counties. Two healthcare chains have signed up more than 40 per cent of the 200,000-plus civil servants signed up. Documents in our possession indicate that the Clinix Health Care Ltd has taken the largest share of those under the cover (27 per cent) after being selected by 56,747 members followed by Meridian Medical Centre with 32,824 members (15.5 per cent). The other providers have only enrolled between two to 2,000 members.
NHIF has already paid out Sh635 million to cover out patient services for the first three months since the cover took off. Another Sh79 million will cater for in patient claims while Sh366 million carter for life insurance and last expenditure. Another Sh452,225 has been spent on administrative needs.
NHIF Chief Executive Officer Richard Kerich said measures are being put in place to deal with cases of fraud and misuse of the fund should they arise. He warned those scheming to lodge fraudulent claims will be arrested and prosecuted.
"This is a noble idea that should not be allowed to go to waste by careless people who may want to misuse it. NHIF is prepared to deal with any cases of misuse and providers who do not strictly adhere to the code of conduct will be deregistered and legal actions taken," Kerich said.
He added that the programme is attracting criticism from some insurers in the private sector who fear loosing business.
A document seen by The Standard on Saturday reveals that a consortium of private health insurers had proposed a whopping Sh12 billion to provide the same services before the Government opted for NHIF.The team had, however, failed to secure the tender when they refused to share joint liability and insisted on a clause to limit their losses by cancelling the contract, instead of seeking a review of the premium.
Kerich also said NHIF should not be drawn into protests that two service providers got the largest share of membership. He argued that beneficiaries had made voluntary choices and the fund manager has no option but to pay.
"We suspect a lot of business rivalry in some of the rising questions, but we want to make it clear that NHIF had nothing to do with who got what number. For us all we do is to pay the service providers according to the number of members they have," the NHIF boss said.
He said that the implementation of the expanded medical cover for Kenyans in formal employment will roll out immediately. He added the increased contributions would be deducted from employees at the end of this month.
Kasipul Kabondo MP Oyugi Magwanga, a member of the health committee, claimed that some of the enlisted providers have enrolled non-existent clinics in several towns around the country.
"We are shocked that even well established institutions like Kenyatta National Hospital and Moi Refferal-Eldoret could only attract so little from the fund and that is why we want to go deep into this matter to ensure NHIF doesn’t lose money to fraudsters," said Magwanga.
The MP added that some of the enlisted clinics do not even have the necessary personnel to be able to deliver on the amount of capitation they have claimed. He advised that the TSC scheme should be put on hold until checks and balances are put in place to manage the huge resources.
Chairman of the NHIF board Dr Richard Muga confirmed that the board has been summoned by MPs to appear on 11th April. "This is a new scheme and it is a good scheme if there are challenges on implementation we will deal with them," Muga said.
He further revealed that NHIF has initiated talks with Cotu Secretary General Francis Atwoli to discuss the implementation of the increased medical contributions for employees in the formal sector, which the trade union has opposed.
