To The NHIF Board, Thro The Chairman, NHIF Board P.O. Box 30443-00100, Nairobi, Kenya.

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.

October 16, 2012

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 principal members are catered for. Payment of Last/ Funeral expenses yet to be paid to majority of families who lost their insured loved ones in January. Change from capitation to fee for service for outpatient for Job Group N-T, an action that has seen 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 special assignment of duties by government. Choice of outpatient facilities abdicated by the NHIF where they arbitrarily allocate and move members without their consent. Denial of quality service to the beneficiaries following an arbitrary termination of contract to some 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.

FACTORS THAT HAVE CONTRIBUTED TO THE ABOVE: The NHIF has not developed a policy on the administration of the Civil servants scheme but have instead 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 senior managers thus leading to poor administration of the scheme. Poor or no sensitization of the facilities. It would be expected that an informed facility would be able 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 hence they 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 will result 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 of specialized 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 of health infrastructure in government facilities and Poor services to members. This will also ultimately drastically impact negatively on the Universal health care provision as envisaged 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. There is an urgent need to address the

disquiet amongst our members over the poor services being offered by especially the public facilities. Popularizing the scheme while the problem persists will not add any value.
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.

The NHIF should fully recognize the UKCS and its role in the success of the scheme.

ii. iii. iv. v. vi. vii. viii. ix. x. xi.

The NHIF board should approve the formation of a committee to oversee the administration of the scheme as we had indicated in our earlier letter.(attached for ease of reference) The NHIF Board, the UKCS, MSPS and the MMS should come up with a policy document on the administration of the medical scheme. The General Managers currently creating confusion in the Administration of the scheme should be totally delinked from the scheme with immediate effect and officers who will administer the scheme in accordance to the contract be identified forthwith. All outpatient facilities that are currently contracted to offer the service are re-assessed to establish their capacities to offer the service under new terms Any new facilities to be included should be procured in accordance to the procurement Act, approved by the UKCS Members who have been forced to procure services should be refunded all their expenses without any further delay. The number of dependents should be restored immediately to avoid any problems. The contract says M+4 and that is what it should be. Members should be allowed to retain the facilities they chose initially and those who have been moved without their consent reverted to their facilities of choice. Facilities that have been given two codes should be further investigated to ascertain how they ended up with two codes and different names for the same facility. The group life cover and the last rights should be availed immediately and a better notification method adopted. All pending cases should be dispensed off without any further delays.

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.