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Civil servants have a reason to smile after the government moved to address bottlenecks in the provision of the comprehensive medical insurance scheme through the National Hospital Insurance Fund (NHIF).

In a circular, Public Service Principal Secretary Mary Kimonye said civil servants in job group A-K, who have been on capitation model since 2012, have been placed on fee-for-service and assigned limits. 

Notably, civil servants in this group, who form the majority of the workforce, and their dependents, will access both inpatient and outpatient services, dental and optical services in any of the health facilities recognised by NHIF across the country.

According to the circular, the lowest cadre of civil servants in Job A-G will have up to Sh700,000 for inpatient while the highest cadre in Job group Q, R, S and T will have a limit of Sh2.5 million and Sh70,000 and Sh350, 000 respectively for outpatient services. 

“In order to ensure prudent utilisation of the assigned shared family limits, high end health care facilities in various counties will be accessed only on referral basis and emergency situations,” Kimonye said. 

“Specialised services and inpatient discharges will be subject to authorisation by NHIF to ensure appropriateness and safety of specific treatment, sustainability of the scheme and realisation of value for money,” she said.

Fake claims

She also instructed NHIF to conduct biometric registration of principal members and thereafter continuously register individual beneficiaries at the point of service “to improve the scheme’s efficiency and effectiveness.’

The scheme, which came into effect on July 1 and runs up to June 30, 2022, covers the financial year 2021/22 and is intended to address grievances raised by civil servants in the past particularly on accessibility of the NHIF services. 

In 2019, a report compiled by a team formed to investigate complaints against the NHIF-managed Comprehensive Medical Insurance Scheme for Civil Servants showed that government workers were dissatisfied with the scheme. 

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.

And, despite the insurer pledging 24-hour cover, the report captured complaints by a number of civil servants who claimed that they were denied treatment at night or made to pay for certain procedures.

Yesterday, the Kenya Union of Civil Servants deputy secretary general Jerry Ole Kina welcomed the move by the government to improve the provision of  healthcare for its workers describing it as a move in the right direction. 

He said that civil servants will now enjoy NHIF services from any accredited facility in the country adding that workers often faced difficulties accessing services especially when they are transferred from one county to another. 

“Every year there is a review of the scheme. Previously, civil servants used to access services in two different categories, that is capitation model which required them to select a facility to access especially outpatient services,” Ole Kina said. 

“Now all civil servants are under the fee-for-service where you don’t necessarily have to select a facility but you access services in facilities that are accredited to the NHIF,” he explained.

“The only issue here is that each one has been given a limit in inpatient and outpatient,” he stated.

Expensive hospital

According to him, there was need for civil servants to protect their limits by accepting services from facilities that are affordable or by avoiding facilities that would easily drain their limits. 

“For example, if your limit is Sh70,000 for outpatient you wouldn’t go to an expensive hospital where you might exhaust that limit within one day… you look for a facility that is a little better,” he said.

“Access is better. There are a number of challenges we are looking at and slowly by slowly as we engage NHIF we are able to address the emerging issues,” he said, adding that the biometric identification which has been introduced will solve fraudulent activities surrounding identity issues. 

“We welcome the move to put all civil servants on the fee-for-service scheme.

We should expect teething problems because we’re not talking about 1,000 people but 130,000 plus their dependents which comes to around 600,000,” he stated.

He said: “We don’t rule out possibility of challenges that civil servants might experience but they should be able to reach us or use the toll numbers that have been provided,” he said, adding that NHIF has also promised to address any challenges that civil servants might encounter.