Civil servants have been paying for health services from their pockets despite having an elaborate cover under the National Hospital Insurance Fund (NHIF).
According to a report by a team formed to investigate complaints against the NHIF-managed Comprehensive Medical Insurance Scheme for Civil Servants (CMSCS), the scheme offered a raw deal for majority of Government workers.
The investigation also uncovered fraudulent activities by healthcare providers, including impersonation of workers' dependents to lodge fake claims and forcing patients to buy medical supplies provided under the scheme.
Despite the insurer pledging 24-hour cover, a number of civil servants said they were denied treatment at night and made to pay for certain procedures.
These were some of the grievances captured in the report after the Union of Kenya Civil Servants (UKCS) questioned the capacity of NHIF to manage the medical scheme.
The report indicated that despite the Sh4.2 billion special cover, the 130,000 civil servants do not enjoy better services than those under the national cover. Many said delays in pre-authorisation letters for crucial procedures and tests from NHIF forced them to pay from their pockets.
Moreover, the workers cannot access treatment and care for chronic illnesses using the scheme.
According to the report, civil servants cannot also access lifesaving services such as ambulance evacuation as they are not available in some areas, yet this is one of the provisions the insurer promised when the scheme was rolled out in 2012.
For example, the report revealed that there was no ambulance services provided by NHIF for civil servants and their beneficiaries in Lamu County. The nearest ambulance was in Malindi, Kilifi County.
There were also no specialised services such as dental and optical care under the scheme in Kajiado, Kitui, Machakos, Makueni, Mandera and Wajir.
In the same counties, NHIF-accredited facilities turned away the civil servants and their dependents, especially at night.
There are also no accredited facilities offering optical services for civil servants under the scheme in Baringo, Uasin Gishu, Trans Nzoia, West Pokot, Turkana and Marsabit.
In Meru, civil servants were asked to buy supplies such as pressure stockings and crutches, although these were promised under the scheme.
The report indicates that most of the public health facilities where the workers were expected to get treatment were ill equipped and did not have drugs. “Contracting facilities lack the capacity to offer services to members under the capitation, leading to poor quality of services to members and their dependents,” the report read.
The probe was prompted by complaints raised by civil servants.
The complaints prompted the civil servants union to initiate plans to find a new insurance provider and oust NHIF in February this year.
The Government, through the Ministry of Public Service, then set up a committee in to discuss and present a report on the dispute.
The committee members were drawn from the civil servants union, Ministry of Health, National Treasury, Public Service, NHIF, Insurance Regulatory Authority, and Council of Governors.
The report, dated March 2019, revealed that whilst there was awareness of the benefits under the cover, the level of access was minimal.
“Awareness on maternity package, dental cover and optical cover were rated at 84, 81 and 80 per cent respectively. The corresponding levels of access to benefits under these packages was indicated as 38,32 and 34 per cent,” states the report.
Only four per cent of civil servants interviewed for the Monitoring and Evaluation Report of 2017/2018 on Access to Benefits said they had access to both emergency road and air rescue services.
The report cited delayed capitation payments which negatively affected service delivery to scheme members as well as low capitation rates that cannot cater for expensive procedures and treatments that some members and their dependents undergo.
In January, the union opposed the setting up of the Free for Fixed Service treatment model, which the union Secretary General Tom Odege said would introduce limits of as low as Sh1,500 per day, locking out members in need of more expensive specialised services.
The Ministry of Public Service, through the Principal Administrative Secretary Mary Kimonye, in a letter dated June 6, 2019, has detailed a raft of changes to address the grievances by the civil servants.
Among them is that the NHIF should review and reduce the documentation required for identification and verification of dependents at the point of seeking services.
The ministry also recommends that NHIF develops benefit packages and issue clear guidelines on how and where to access treatment for specialised and chronic illnesses.
The NHIF has also been asked to facilitate portability of services by providing a list of standby facilities as well as redistribution of ambulances per county to enhance referral evacuation.
The Council of Governors and Ministry of Health were tasked with tackling the human resource challenge and ensuring medical supplies are available in public hospitals.
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