TSC response to claims of AON Minet humiliating teachers

TSC response to claims of AON Minet humiliating teachers

RESPONSE TO THE QUESTION BY SENATOR ROSE NYAMUNGA MP, ON MANAGEMENT OF THE TEACHERS’ MEDICAL  SCHEME

The above captioned matter and your letter Ref:SEN/SCE/CORR/2020/40(01) dated 26″ October,  2020 refers.

Enclosed hereto, please  find detailed response to the question by Senator  Rose Nyamunga, MP for your further action.

RESPONSE PRESENTED BY DR. NANCY MACHARIA

1.     BACKGROUND

1  .  1     The Teachers Service Commission is established under Article 237  (1)  of the Constitution  with  the overall  mandate  of teacher management.  Specifically,  Article  237  (2)  of the Constitution mandates the Commission to:

a) Register trained teachers;

b) Recruit and employ registered teachers;

c) Assign   teachers   for  service   in   any  public   school   or institution;

d) promote and transfer teachers;

e) Exercise disciplinary control over teachers;

f)  Terminate the employment of teachers  engaged in  public service.

1.2       The Commission is further mandated Under Article 237 (3) of the Constitution to:

a) Review the standards of education and training of persons entering the teaching service;

b) Review   the  national   demand for,   and  the  supply   of teachers; and

Advise  the National  Government  on matters  relating  to the teaching profession.

1  . 3      On  the  other hand, section   11   of the Teachers  Service Commission Act requires the Commission to:

a) Formulate policies to achieve its mandate;

b) Provide strategic leadership and direction;

c) Prescribe teaching standards and ensure compliance;

d) Manage the Teachers payroll;                                   .

e) Facilitate career progression &  professional development;

f)  Monitor the Conduct and Performance of teachers; and do all such  other things as may  be necessary for the effective discharge of its functions and the exercise of its powers.

1. 4      Further  in  compliance  with  the provisions  of Article  41  of the Constitution the Commission negotiated and signed Collective  Bargaining Agreement 2017-2021  (CBA) with  the  teacher unions.  

The CBA  was   informed  by   a comprehensive Job Evaluation Report which  was conducted jointly by TSC and the Salaries and Remuneration Commission.  The CBA came  into effect on 1″ July,  2017.

1.5       Accordingly, the Constitution of Kenya, the Teachers Service Commission  Act,  the  Code of  Regulations  and Code of Conduct for Teachers,  Collective Bargaining Agreement (CBA)  2017-2021  read together with  other policies forms the legal framework underpinning the Commission’s operations.

2.    THE TEACHERS MEDICAL SCHEME                                                                                             .

2.1   The Teachers  Service  Commission,  in  its  efforts to conform to the National  Policy on Universal  Health  Care for Citizens approached National  Health  Insurance  Fund  (NHIF)  in  July 2019  for the provision  of Medical  Insurance  Cover to all teachers  employed  by  the Commission.  

The NHIF  later submitted a proposed  medical premium cover  for  the 318,000  teachers at  an annual contract price of Kshs. 15 Billion totaling to 45 Billion in three years.

2.2 Consequently, the Commission requested the National Treasury  to   provide an  annual budget  allocation  of Kshs.  15 Billion yearly for teacher’s medical scheme for three years  (2019 –  2022).

2.3  The  National Treasury, in their  response advised the Commission that due to the harsh economic conditions they would not be able  to fund the teacher’s  medical  scheme at the amount of Kshs. 15 Billion annually.

2.4   Due  to lack  of budgetary provisions  to have  a  full-fledged medical  insurance  cover for  teachers  and  based on  the response  from both NHIF  and National Treasury,  the Commission settled for a Hybrid Insurance Model comprising of Capitation Financing Model and Fully Insured components to bridge the budgetary gap and ensure that all  teachers  are medically covered.

2.5   In  compliance with the provisions of the Public Procurement and Asset  Disposal  Act  201 5,  the Commission  engaged Minet Insurance Brokers  (K)   Ltd. through a competitive process  that  resulted  in  the  award   of  contract for  the provision of   Teachers’ Medical Insurance Cover  for 318,000   teachers    as     principal    members    and   their dependents.

2.6  Minet was awarded   a three (3) year framework contract at a contract sum  of Kshs. 35,220,512,500.  The Scheme  is structured  under a consortium of Insurance companies managed and administered by Minet Kenya Insurance Brokers Limited.

2. 7  The Teachers’  Medical  Scheme  is  also  structured  in  two models as indicated below:

a) Capitation Model:  This  is a kind  of healthcare  payment system where  a physician  or hospital is paid a fixed amount per patient for the agreed period  of time.  

In  this  model, the Outpatient,  Inpatient, Dental, Optical and Maternity were all grouped under capitation.

b) Fully Insured:  The following items  were grouped under fully  insured.  They include  Group Life,  Last  Expense, Evacuation Allocations, International Travel and Referrals and Excess of Loss.

2.8  The proposed maximum  family  size per family is 6 members comprising:  –  the Principal  Member,  one legal  spouse,  four ( 4)  Children.  Teachers  who are in  service  from ages  18  to age 65 are eligible for cover.

3.     QUESTION ONE

Low capitation on Outpatient Services with some capped at as low as 900/= inclusive of the doctors consultation fees, tests and drugs.

3.1   Under the Contract,  the Teachers  medical  scheme   has  a benefit structure for all  the teachers employed by the Commission and there is no capping on any Outpatient Limit per day.

3 .2   The  only  capping  for  the  outpatient   component is   the member’s allocation  per year which should not be exceeded.

Appendix  1  shows the Benefit Structure for the Teachers as per the Job Groups.

3. 3   A clear analysis  of the benefits  structure  confirms  that the Teachers Medical  Scheme has superior benefits than most of the public servants in Kenya and the region.

The  cover applies  to  a   wide   range of services  and  the allocations  for each component per year are substantial  to cover the Principle member  plus 5 other dependents. It is one of the  most  comprehensive  medical  schemes  available  in Kenya.

4.    QUESTION TWO

Restrictions on the Hospitals Teachers are allowed to visit for  treatment  some  of  which are ill equipped  and  lack qualified personnel.

4.1   Teachers   Medical   Scheme   provides   accessible   healthcare services to teachers in the 47 counties.  The scheme  has over 500  health  service  providers  country wide  offering  a  wide range of services  from In-patient,  Outpatient,  Dental, Optical, Maternity, Medical Emergency Evacuation and specialized referrals locally and Internationally,  Group Excess of Loss Cover,   Group Life and last expense cover.

4.2  The scheme  operates  under portability without restrictions system  allowing Teachers to access any hospital  in the list of medical service providers at anytime and anywhere within the Republic of Kenya.

4.3    Based  on the feedback  from consultative  forums  on the administration  of the scheme  and the  monthly meetings between CIT   and  Minet,  additional 32  medical   service providers  ranging from  private facilities, faith based institutions as well as some county referral hospitals like Kitui were added to the list of Medical service providers.

4.4  The list of hospitals is available in both the TSC and  Minet website   or   the   same   can  be   accessed   through   the USSD  *340 #.  In coming  up with the list of hospitals, the Commission ensured that the hospitals are spread  across the Country for ease of accessibility to teachers.

4.5  The Commission  has also ensured that the selected  hospitals have the necessary medical infrastructure, equipment and are accredited by NHIF to meet the teacher’s medical needs. The list is hereby attached as Appendix 2

4.6  The allegation  that  most  of these facilities  lack  qualified medical personnel may not be entirely true as it is against the law to station unqualified personnel to run a medical facility. To address such  a  sensitive issue, the Commission requires specific details to avoid any speculation.

5.    QUESTION THREE

Delay in approvals which sometime take up-to one month putting the life of a teacher at risk

5. 1       Teacher’s Medical scheme  like any other medical scheme has pre-authorization  requirements  which entails  consultation, confirmation  of patients’  details,  review and vigilance  billing system to ensure there is value for money.

5.2 It is also important to mention that normally 90% of outpatient cases do not require pre-authorization. However, the  10% cases  that require  pre-authorization are managed through   a  robust online  approval  system  where  cases  are handled on the first come first served basis.

5.3  The rigorous approval  procedures  have been put in  place to detect and deter fraudsters  who have  perfected the  art of defrauding teachers using the medical scheme. Further, this is done mainly  with  a  view  of ensuring  that the  member’s benefit is  protected from misuse  resulting from inflated  bills and unnecessary costs.

5. 4  While  the  elaborate  approval   process  is  appreciated, the Commission is aware of instances where such approvals have taken abnormally long therefore denying teachers their right to expeditious medical attention.

5.5  To militate  against  this  practice, the Commission  activated and improved its complaint reporting mechanisms through TSC Teachers’ Medical Secretariat, CIT and continuous engagement with  Minet to ensure that teacher’s  grievances are received and processed in  a  timely manner. Since these measures were put in  place in January 2020,  I   am happy to report that the complaints related to approvals have reduced to a bare minimum.

6.    QUESTION  FOUR

Teachers experience challenges while lodging claims with Minet.

6. 1        Under the Scheme,  claims related to payments are made by the Hospitals and not individual teachers.

6.2   It  is  only  in  instances  where teachers  or their  families  have been treated in  a facility othe. r than the contracted hospitals when they are required to lodge claims for reimbursement of the expenses incurred. This is only applicable where the visit to  non-contracted  health  facility  is  as  a  result of medical emergency.

6. 3   In  such  instances  Minet  is  required  under the contract to settle  such  claims  within  2 weeks  when all  the necessary supporting documents have been submitted.

6.4   The Commission took up this matter with Minet where it was established  that the major  cause  of the delay  in  releasing reimbursement  to  teachers  has   been lack  of  supporting documents like original doctor’s report ( case note),  receipts, statements etc.

7.    QUESTION  FIVE

Query Five:  Limited Access due to Rigid Operating Hours by health facilities.

7. 1        Some  hospitals  contracted by  Minet  and listed  as  medical service providers for the Teachers’ Medical Scheme are the same  providers  rendering  medical  services  to  the general members  of the public.  Majority of these hospitals including faith based   hospitals,   private   health   facilities   and  some government facilities operate on a 2 4hour basis.

7.2   In an event that one of the medical service provider has rigid operating hours; teachers are advised to seek medical assistance  to the next service  provider  in  the neighborhood which is in the list.

8.    QUESTION  SIX

Limited  Dental  services where only  tooth  extraction  is catered for by Minet.

8. 1        Under the contract, the following are the services available at accredited  dental  facilities within  the list of dental  service providers;

a) Dental consultation and Anesthetist’s fee

b) Dental X-Ray and root canal treatment

c) Tooth extraction

d) Deformation  Surgery

e) Scaling necessitated by a prevailing  medical condition or as prescribed by a dentist

f)  Dentures necessitated by an accident or injury

8.2   Dental services are specialized in nature and may not be found within  some local  neighborhoods.  The Scheme has provided a  list of Dental specialists contracted and available  in every county.  Teachers  are free to access dental  services  from the list of panel of dental specialists contracted  by Minet.

8. 3   The dental component of the scheme incorporates all  dental services  subject to the maximum  cover per member.  The cover is not limited to tooth extraction alone but all services that are clinically  possible  as a dental service.

8.4   In the event that a teacher’s medical need  has been restricted to tooth extraction alone, the same would amount to breach of contract and call  for remedial  action  based on  such   a specific case.

9.     CONCLUSION

9. 1       Pursuant to Section  1  51  ( 1)  of the Public Procurement  and Asset   Disposal   Act   201 5,   the   Commission   has   also established  a  Contract Implementation  Tearn  ( CIT)  whose membership  comprise  officers at the level  of Directors to monitor,  assess   and  evaluate  the  implementation  of the scheme through monthly meetings with the service provider.

9 .2   At the County level,  the Commission  has  also  established County committees  comprising  the  TSC  Director,  Minet Caregiver,  Union  Representatives,  KEPSHA and KESSHA to monitor   and  handle   Teacher’s   Medical   Scheme   issues presented to them.

Further Minet has appointed Care Givers in all the 47 counties who works closely with the TSC County Directors to respond to issues  and difficulties which  may be faced by Teachers while seeking medical services.

9. 3   Further  the Commission  has  been conducting  sensitization programmes to teachers to create awareness  of their rights under the scheme and the reporting mechanisms to enable the Comm. ission take remedial  action whenever our teachers run into problems.

9. 4  While  the implementation  of the teachers’  medical  scheme has been generally successful, the Commission admits that the same has also had its fair share of challenges mainly associated with  the Capitation  Financing Model.  

To this  end, in  the month of September, the Commission’s CIT team carried out a  comprehensive  survey to measure the performance of the Scheme in its first year.

9. 5   Admittedly,   some   of  the  issues   raised   by   Honourable members were  also  raised by teachers and have  been also captured in the Commission’s Survey Report. The Report has been submitted to the service provider for their response.

9 .6   On behalf of the Commission,  I  wish to assure members that all the issues raised  will be taken up with the service provider for immediate redress as  per the provisions of the contract between the two parties. The Commission will not hesitate to invoke its rights under the contract with a view to protecting the interest of its teachers and their dependents.

TSC response to claims of AON Minet humiliating teachers

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