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.
