The Kenya Medical Training College (KMTC) Preservice Training Manual for Cost Sharing

Transcription

1 The Kenya Medica Training Coege (KMTC) Preservice Training Manua for Cost Sharing August 2000 Ministry of Heath, Kenya Kenya: APHIA Financing and Sustainabiity Project Management Sciences for Heath 165 Aandae Road Boston, MA Teephone: (617) This report was made possibe through support provided by the US Agency for Internationa Deveopment, under the terms of Contract Number C The opinions expressed herein are those of the author(s) and do not necessariy refect the views of the US Agency for Internationa Deveopment.

2 Copyright: Kenya Medica Training Coege, Nairobi First Draft: August 2000 Designed by Christopher Frost Sections of this manua may be freey copied and adapted for teaching, private study, research or other purposes provided that such activities are not-for-profit and provided that the source is ceary cited and acknowedged. ii Ministry of Heath, Kenya

3 And with the best eaders When the work is done The task accompished The peope wi say: We have done this ourseves. Lao-tzu, China, 4000 BC Kenya Medica Training Coege iii

4 Acknowedgment The Kenya Medica Training Coege gratefuy acknowedges the technica assistance of the APHIA Financing and Sustainabiity Project through Management Sciences for Heath in writing and editing of the manua; financia assistance of USAID under the terms of Contract No: C for compiing and fina production. iv Ministry of Heath, Kenya

5 Contents Acknowedgment... iv Introduction... vi Purpose... vi Modue one ORIENTATION... 1 SESSION ONE Poicy reform: the need for cost sharing... 3 SESSION TWO Boards and non-moh bodies: Roes and functions Modue two OPERATIONS...17 SESSION ONE Revenue generation: Fees, Exemptions and Waivers SESSION TWO Nationa hospita insurance fund SESSION THREE Expenditure panning SESSION FOUR Accounting SESSION FIVE Quaity of care and pubic information Kenya Medica Training Coege v

6 Introduction The Kenya Medica Training Coege (KMTC) Preservice Training Manua for Cost Sharing was produced by the Division of Heath Care Financing in the Ministry of Heath. The Manua compies a set of simpe but important and usefu heath care financing approaches and activities that seek to strengthen the roe and performance of heath service deivery and outcomes in Kenya. In many deveoping countries, there is a genera consensus that some kind of cost sharing is needed in view of escaating heath costs and the imited capacity of pubic heath networks to finance or deiver subsidized heath care to a citizens. In Kenya the government s abiity to finance and expand heath services has been undermined by poor economic performance, unprecedented rates of popuation growth, and the immense cost that the AIDS pandemic is beginning to impose on pubic heath budget. And due to the critica need to improve heath care financing and deivery in Kenya, it is time to introduce a pre service training modue dedicated to the subject of Cost Sharing. There are severa options for financing better heath care, but user fees and socia heath insurance (NHIF) are emphasized in this manua because they represent the argest percent of tota heath expenditures in Kenya. Purpose The purpose of the Manua is to deveop and refine skis and expertise in broad heath care financing issues at preservice eve so that a KMTC graduates come out with the requisite skis and competencies in Cost Sharing to be immediatey operationa in the fied. Training in the Cost Sharing Program has acquired an important roe in the Ministry of Heath s poicy to decentraize training, disseminate skis and consequenty increase financia resources for heath. The program has a set of poicy, procedures and reporting requirements that must be understood and vi Ministry of Heath, Kenya

7 foowed throughout the heath sector. And it is important that a the staff, both pre service and in service, with responsibiity for Cost Sharing have the skis and knowedge to carry out Cost Sharing activities. Finay, it is envisioned that this Manua wi not ony prepare future heath workers to gain experience in setting, administering and coecting fees but aso in aocating resources more efficienty to promote better heath in the communities that they wi serve. Ummuro Adano AFS Project Training Advisor Management Sciences for Heath Kenya Medica Training Coege vii

8 N1 Modue one O R I E N T A T I O Kenya Medica Training Coege 1

9 Modue one O R I E N T A T I O N Modue one contents SESSION ONE Poicy reform: the need for cost sharing... 3 Aim... 3 A: POLICY REFORM... 4 B: OBJECTIVES AND PRINCIPLES OF COST SHARING... 5 C: ORGANIZATION AND MANAGEMENT... 7 D: LESSONS LEARNED... 9 E: FUTURE CHALLENGES SESSION TWO Boards and non-moh bodies: Roes and functions Aim A: ROLE OF DISTRICT HEALTH MANAGEMENT BOARDS B: ROLE OF DHMB STANDING COMMITTEES C: DISTRICT TREASURIES Handout Ministry of Heath, Kenya

10 Poicy reform: the need for cost sharing SESSION ONE SESSION ONE Poicy reform: the need for cost sharing Aim The aim of this Session is to introduce participants to the broad strategic framework of the Cost Sharing Programme in terms of its poicy, goas and principes, and the management structure. Learning Outcomes At the end of the Session participants wi be abe to 1. Expain the poicy governing the Ministry of Heath s Cost Sharing Programme 2. Demonstrate a cear understanding of the rationae, goas and objectives of the Programme 3. Demonstrate a cear and accurate understanding of the organization and management infrastructure of the Programme Session Summary Time a. Poicy Reform 3 hours b. Objectives and Principes of Cost Sharing c. Organization and Management d. Lessons Learned e. Future Chaenges Materias Resources Fipchart/Chak board Marker pens OHP Handouts/reference materia Orientation Manua Kenya Medica Training Coege 3

11 Modue one O R I E N T A T I O N A: POLICY REFORM Key Information Since independence, heath care in Kenya has been generay free, and in the first two decades great strides were made in improving services, with a positive impact on chid and adut heath. However in the 80 s, the Kenya Government fet it was no onger abe to provide unimited free heath care, owing to insufficient budgetary aocations that continue to decine in the face of rising costs, popuations, the advent of AIDS, and the resurgence of other diseases. At the same time, the Government recognizes the need for every Kenyan to gain access to good quaity, affordabe heath care. It was imperative that some radica heath care financing poicy measures had to be instituted to address the probem. USAID, the Word Bank and other major donors worked with the government to design the heath reforms. Heath financing reform was introduced in ate 1989, athough support was by no means universa, since there remained a strong beief in the phiosophy of free care. A the same, the Ministry of Heath fet it had become necessary to suppement government financing through the introduction of user charges. Fees for services poicy was introduced in Government Hospitas and Heath Centres on 1 st December The existing poicy on heath care financing was again modified in 1992 to convert user charges from a consutation fee to a treatment fee. _ Task In pairs 1. List some exampes of services in other sectors for which Kenyans are sharing costs. 2. How are funds that are generated being used? 3. Are there any usefu essons that coud be earnt and adopted by the Cost Sharing Program of the Ministry of Heath? 4 Ministry of Heath, Kenya

12 Poicy reform: the need for cost sharing SESSION ONE REMEMBER This is not just a user fee programme. The Nationa Hospita Insurance Fund (NHIF) is a big and important contributor to the programme. Over the years contributions by NHIF beneficiaries have grown from Kshs 20/= to 2% of gross monthy wage in The revenues generated from user fees and NHIF reimbursements are retained ocay and are additiona to budget aocations provided by Treasury. These funds are to be used to improve the quaity of heath services in faciities and to support district-eve Promotive and Preventive Heath Care (P/PHC). Athough there is considerabe pressure to do so, cost sharing funds are not to be used to pay for wages, basic operating expenses or deveopment activities. These funds shoud be coected and propery accounted for. B: OBJECTIVES AND PRINCIPLES OF COST SHARING Key Information A Goa coud be described as a shared vision. It is the coective sense of what is important for the future. It aso provides a hoistic sense of what s important and inks the past with the present and future. If you don t know where you are going, any road wi get you there. The Cheshire Cat, Aice in Wonderand The Goa of the Cost Sharing Programme coud be summarized as foows: Increased financia resources from user fees and NHIF reimbursements for the improvement of faciities and the provision of high quaity heath and patient care on an equitabe basis. Kenya Medica Training Coege 5

13 Modue one O R I E N T A T I O N Objectives improved quaity of heath services in faciities enhanced faciity eve revenue coection capacity and panning for use of funds support to and improved district-eve Promotive and Preventive Heath Care (P/PHC) activities _ Task What I want for my hospita Aow yoursef to think freey about your faciity, and identify two ways in which you want it to be better. Describe the hospita as you want it to be in these two respects: Our imagination is very powerfu. It can create compeing ideas of future reaity which are the key to constructive motivation to behave so as to bring the imagined state into being. REMEMBER If your desired goa or vision either for yoursef or your faciity invoves other peope being different than at present, remember that they wi not share your goa. Reaching your goa might then invove finding ways of enisting their support: if they do not share your goa, they have no reason to hep you reach it! 6 Ministry of Heath, Kenya

14 Poicy reform: the need for cost sharing SESSION ONE C: ORGANIZATION AND MANAGEMENT Key Information The Ministry of Heath (MoH) has four broad management eves: Centra (headquarters) Responsibe for: poicy setting, donor coordination, managing the impementation of poicy changes, monitoring and evauation Provincia Provincia Medica Officers (PMOs) are responsibe for: a heath services in a province, apportioning centra resources such as personne and drugs. District District Medica Officers of Heath (DMoH) are responsibe for overa management of a curative and preventive district heath faciities. Faciity Medica Superintendents are responsibe for hospitas, and Cinica Officers in Charge are responsibe for heath centres whie nurses are incharge of dispensaries. Figure Organizationa Structure of the Ministry of Heath Cost-Sharing Management The cost-sharing management was designed to be part of the Ministry s genera management structure. Kenya Medica Training Coege 7

15 Modue one O R I E N T A T I O N Responsibiities for the organization and management of heath care financing in the Ministry of Heath are aso carried out at four eves: Afya House (PS, HCF Impementation Cmttee, DHCF) Responsibiities Poicy setting, NGO/donor coordination, setting user fees, monitoring and evauating impact of poicy changes Province (PMO, PHMT) Responsibiities Guide, monitor and supervise DMOHs and faciity managers, coection performance, approve expenditure pans, issue AIEs, assess impact District (DMOH, DHMT) Boards (DHMB, HMB) Oversee faciity management, supervise, monitor performance. Responsibiities Approve expenditure pans, community oversight Faciity (HMT, HCMT, EEC) Responsibiities Maximise fees coection, prepare and impement expendi-ture pans, monitor waivers and exemptions, maintain reasonabe service quaity, patient care and pubic reations Figure Cost-sharing management responsibiities of the Ministry of Heath 8 Ministry of Heath, Kenya

16 _ Poicy reform: the need for cost sharing SESSION ONE D: LESSONS LEARNED Key Information Cost sharing brings a business approach to heath care, and for it to be successfuy managed and integrated into the MoH system, business attitudes, practices and systems must be adopted. Additionay, the introduction of cost sharing can be a catayst that creates changes that can in turn have beneficia effect beyond cost sharing, such as in efficiency and quaity of care. Task 1.1.3: In groups of six Using the headings beow, discuss in your group and ist some of the main essons or constraints that you have encountered that reate to the impementation and management of the cost sharing programme. 1 Poicy issues 2 Socia Insurance NHIF 3 Management Structure Boards and Teams 4 District Treasuries 5 Fee eves, Fee types 6 Quaity of care 7 Continuing education and training 8 Monitoring and Evauation Pease appoint a Secretary who wi make a poster presentation and report back group findings to the penary. REMEMBER Fu and proper impementation of cost sharing in a districts and faciities wi take severa years. Management skis and motivation vary consideraby amongst staff, and bringing about system and attitude change takes time. Some faciities and individuas wi proceed more sowy than others and inservice training and constant supervision wi be needed for a ong time. Kenya Medica Training Coege 9

17 Modue one O R I E N T A T I O N E: FUTURE CHALLENGES Key Information The forma impementation of cost sharing may be compete, but much remains to be done for the programme to work propery in a faciities and at a eves. The chaenge now is to continue strengthening and deveoping systems in a way that: generates increasing revenues (e.g. the introduction of cash registers at Coast Genera and the subsequent dramatic increase in revenue coection); maintains the principe that these revenues are additiona to Treasury funding; makes a greater contribution to quaity of care; and minimizes the negative impact of user fees on vunerabe groups. Experience so far has shown that a we-managed programme of cost sharing can contribute significanty to the funding of government heath services, without significanty reducing access to the pubic, especiay the poor. However, the resources required to carry out such a major, sustained, ong-term effort are phenomena, and without commitment at a eves, especiay from the poicy makers, the pubic and providers, as we as faciity managers, even a we-designed cost sharing poicy may founder. There is no onger any debate about the need for cost sharing in the funding of government heath services in the future. However, cost sharing aone cannot sove the probems it is not the magic buet; the aocation and use of resources must be improved. Additionay, NHIF fu potentia is yet to be reaized. The additiona revenue generated incuding improved NHIF reimbursements, new business systems and practices being adopted, and the contribution of cost sharing to successfu decentraization wi make it easier to continue the reform process. 10 Ministry of Heath, Kenya

18 Poicy reform: the need for cost sharing SESSION ONE Task 1.1.4: In groups of six The ong-term impact, success and continued pubic acceptabiity of the cost sharing program depends on a number of integrated issues. Some of these factors are isted beow. Discuss in your group and add to the ist: a) Improving NHIF caiming and cash coection efficiency b) Expanding and increasing fees c) Management improvements at faciity eve d) Not reying on cost sharing ony to stem the continuing decine in the pubic heath sector _ e) f) Kenya Medica Training Coege 11

19 Modue one O R I E N T A T I O N SESSION TWO Boards and non-moh bodies: Roes and functions Aim The aim of this Session is to provide participants with knowedge and information on the functions and operation of District Heath Management Boards (DHMBs), Hospita Management Boards and District Treasuries regarding the management of heath services and cost sharing at district eve. Learning Outcomes At the end of the session participants wi be abe to: 1. Demonstrate a cear and accurate understanding of the roe of District Treasuries as we as the DHMBs and their three standing committees 2. Provide support to the work of Hospita Boards to improve management efficiency and promote quaity heath care services in the district Session Summary Time a. Roe of DHMBs 2 hours b. DHMB Standing Committees c. District Treasuries Materias Resources Handouts/reference materias Fipchart/Chak board Lega Notice No.162 The Pubic Heath Marker pens Act (Cap. 242) OHP Guideines for District Heath Management Boards (Green booket), GoK Ministry of Heath 12 Ministry of Heath, Kenya

20 Boards and non-moh bodies: Roes and functions SESSION TWO A: ROLE OF DISTRICT HEALTH MANAGEMENT BOARDS Key Information The District Heath Management Boards were estabished by the government under Lega Notice No. 162 of The Boards have representatives from consumers under other sectors to oversee the provision of heath care in the district, to ensure cient representation and the accountabe use of funds. The members of the Board are appointed by the Minister for Heath and it operates under the broad direction of the District Deveopment Committee (DDC) Boards and their three standing committees need not get invoved in the day-to-day management of heath services and cost-sharing. The emphasis of their roe is primariy one of fisca supervision and poicy monitoring, for exampe to ensure that voted funds are used on activities for which they were panned. B: ROLE OF DHMB STANDING COMMITTEES REMEMBER There have been mixed resuts, from one district to another, regarding the roe and functionaity of DHMBs over the six years that they have been in pace. In most cases, extensive ongoing training wi be required to hep carify their roes and aow them to start supervising and supporting the cost-sharing programme. Most Boards have begun with their expenditure approva roe, but some have moved to a wider roe of supervision and support, representing their communities and acting as a centra ink between the Ministry and the faciities. A Boards sha need to be trained, informed and encouraged to grow and deveop in this direction so that they can make their presence fet. Kenya Medica Training Coege 13

21 Modue one O R I E N T A T I O N Afya House (PS, HCF Impementation Cmttee, DHCF) Responsibiities Poicy setting, NGO/donor coordination, setting user fees, monitoring and evauating impact of poicy changes Finance and Genera Purposes Committee Responsibiities Reviewing revenue targets and expenditure pans Monitoring payments and bankings Monitoring NHIF caiming process Reviewing ong term deveopment pans Arranging for routine annua audit of FIF and specia audits where irreguarities are suspected Quaity of Curative Services Committee Responsibiities Annua review of services and needs assessment Deaing with forma compaints about quaity Pubic Heath Care Committee Responsibiities Annua review of services, needs assessment and setting of priorities for pubic heath activities in the district Monitor P/PHC activities in the district Promote cean towns, cean water suppy operations Get semi-annua reports on heath statistics Figure The roe of DHMB standing committees C: DISTRICT TREASURIES Key Information _ Task In groups of six The DHMB That We Want Discuss and deveop a ist of factors that wi add to the overa effectiveness of your Board. Some of these factors incude: a the dynamism of the Board Chair and the enthusiasm of the members b the number and quaity of training workshops and supervision visits 14 Ministry of Heath, Kenya

22 _ Boards and non-moh bodies: Roes and functions SESSION TWO District Treasuries provide a degree of oca financia accountabiity and management contro of the cost sharing programme. A hospita, heath centre, and P/PHC funds are kept in one bank account, with joint signatory power hed by the District Accountant and the DMoH. The District Treasuries are responsibe for: ensuring that a revenue is coected (using officia cash receipts) and banked overseeing expenditure trends auditing and providing financia advice and support Task In groups of six Effective coaboration with District Treasuries 1. List some of the major difficuties you face in deaing with your District Treasury 2. How can some of these issues be resoved satisfactoriy? Kenya Medica Training Coege 15

23 Modue one O R I E N T A T I O N Handout User Fees The biggest chaenge facing the Kenyan pubic heath network is not whether or not to continue charging user fees but rather how to use cost sharing fees to promote better, visibe, more equitabe heath care and to create a sef-sustaining mechanism for financing heath care. The main goas of user fees are to mobiize oca revenues, promote efficiency, foster equity, increase decentraization and sustainabiity, and encourage the growth and deveopment of the private sector. Key essons earned so far: Ø Kenyan househods are paying for heath care and private out-of-pocket expenditures are the argest singe contributor to heath care expenditures in Kenya. Ø Negative fee effects on service utiization have been overstated. Many factors besides fees incuding distance to heath faciities, staff attitude, and the quaity of care pay an important roe in heath seeking behaviour. Ø Peope wi pay for quaity care, especiay when the introduction of user fees is accompanied by simutaneous improvements in service quaity and heath outcomes. If appropriatey impemented and efficienty administered, user fees can make heath care deivery more equitabe and promote a sef-sustaining financia base for better heath care. The pathway to the successfu impementation of user fees incude: Ø Encouraging the use of fee-based heath care through campaigns and oca pubic information that carify the rationae for user fees Ø Retaining fees at the oca eve and estabishing oca contro over quaity improvements and staff invovement Ø Estabishing methods that improve cash coection and administration efficiency In concusion, time and experience are required to deveop a we-functioning system of fees for heath care services. The actua potentia of user fees is sedom ost, for severa reasons. Poicies mandating these fees tend to be poory administered, faciities are often inefficient in coecting fees and unpaid bis, patients are unwiing to pay for ow-quaity services, and abuses of exemption poicies are widespread. 16 Ministry of Heath, Kenya

24 S2 Modue two O P E R A T I O N Kenya Medica Training Coege 17

25 Modue two O P E R A T I O N S Modue two contents SESSION ONE Revenue generation: Fees, Exemptions and Waivers Aim A: FEE STRUCTURE AND COLLECTION GUIDELINES B: FEE COLLECTION REGISTERS C: EXEMPTIONS D: WAIVERS SESSION TWO Nationa hospita insurance fund Aim A: ROLE OF NHIF B: ORGANISING FOR NHIF CLAIMING SESSION THREE Expenditure panning Aim A: RESPONSIBILITIES FOR FACILITY EXPENDITURE PLANNING 75% 30 B: RESPONSIBILITIES FOR DISTRICT P/PHC EXPENDITURE PLANNING 30 C: GUIDELINES ON USE OF FUNDS D: EXPENDITURE APPROVAL REQUIREMENTS E: PROCUREMENT PROCEDURES SESSION FOUR Accounting Aim A: ACCOUNTING SYSTEM B: LEVELS OF ACCOUNTING PROCEDURES C: BANKING OPERATIONS SESSION FIVE Quaity of care and pubic information Aim A: QUALITY OF CARE Roe of Cost Sharing B: MEASURES TO IMPROVE QUALITY OF CARE C: LOCAL PUBLIC INFORMATION Ministry of Heath, Kenya

26 Revenue generation: Fees, Exemptions and Waivers SESSION ONE SESSION ONE Revenue generation: Fees, Exemptions and Waivers Aim The aim of this session is to provide participants with the knowedge and skis to carry out key revenue setting, biing and coection procedures of the cost-sharing programme by foowing set guideines and other procedura requirements. Learning Outcomes At the end of the session, participants wi abe to 1. List a the different services being offered at the faciity eve and the amount of fee charged in each case 2. Expain the appication of fee coection guideines 3. Demonstrate a cear understanding of the importance and usefuness of different types of fee coection registers 4. Demonstrate a practica understanding and appication of the procedure of granting waivers and exemption criteria Session Summary Time a. Fee Structure and Coection Guideines 2 hours b. Fee Coection Registers c. Exemptions d. Waivers Materias Resources Fipchart/Chak board Marker pens OHP Handouts/reference materia Categories of exemption Kenya Medica Training Coege 19

27 Modue two O P E R A T I O N S A: FEE STRUCTURE AND COLLECTION GUIDELINES Fee Posters Biingua fee posters that are cear, compete and unambiguous shoud be put up in a departments, a waiting areas and at a cash points. Each poster shoud indicate the range of fees charged for services on offer Patient Fow Patients shoud not have to wak far to receive attention or make payments, queue for ong or queue many times Contro Maintain a separate cash coection point for each major revenue generating department. Each cash point must have adequate security proper cash box and adequate ockabespace. Rotate cashiers from one cash point to another periodicay without notice to reduce fraud and broaden experience. Senior staff to conduct periodic surprise cash counts and spot checks. Cash reconciiations to be conducted at the end of each day. Patient satisfaction Periodic patient exit surveys shoud be conducted to assess the eve of patient satisfaction with the quaity of services and payment mechanisms in order to detect any probems such as the charging of additiona fees by staff for granting favours such as queue jumping or corridor consutations. Figure Four Key Steps 20 Ministry of Heath, Kenya

28 _ Revenue generation: Fees, Exemptions and Waivers SESSION ONE Key Information Efficient coection of revenues is an important aspect of user fees. Fees need to be coected in a way that causes minimum inconvenience to patients and staff, ensures maximum coections and can be easiy accounted for. B: FEE COLLECTION REGISTERS Key Information Inpatients and Outpatients are potentiay the argest sources of revenue to a hospita but in practice often itte of that revenue is actuay coected. In order to achieve fu potentia it is vita that proper aid down procedures are foowed and the appropriate financia registers are kept and competed at a times by the various revenue generating departments. In practice, these invove the foowing MUST DOs: You must caim for a patients covered by NHIF You must charge a in-patient x-ray and ab services to their accounts You must ensure that a in-patient bis are either coected or charged to NHIF You must ensure that waivers or exemptions are correcty granted Task 2.1.1: Match Making In each case, draw a ine to match the procedure/roe with the appropriate activity/responsibiities. Procedure/Roe Purpose Inpatient Admissions Inpatient Accounts Office Inpatient Biing Book Pharmacy Revenue Register Medica Superintendent/ Heath Administrator A the inpatient payment detais are competey and correcty entered here It is used to record every issue of drugs, amount charged,receipt number, waiver number or reason for exemption They have authority to grant credit, waive or exempt Papers for a patients (discharged, dead or absconded) eaving the hospita must pass through here where services received are accounted for. A charge sheet is opened here for every patient admitted (inc. exempt, waived and NHIF patients) Kenya Medica Training Coege 21

29 Modue two O P E R A T I O N S C: EXEMPTIONS Key Information The term exemption is used to mean an automatic excuse from payment based on defined status such as being under five years, being a prisoner, having specific communicabe disease such as tubercuosis, STI and AIDS or using a specia service such as prenata care. A compete ist of exemptions is at Handout 2.1A. The main purpose of this feature of the programme is to promote equity and to protect the poor and medicay vunerabe so that they do not fee discouraged from seeking care when they genuiney need to do so. D: WAIVERS Key Information The term waiver refers to a system that invoves a discretionary fu or partia reease from payment based on inabiity to pay. This is another protection mechanism that is avaiabe to the disadvantaged or ow-income earners. However, the waiver system must be managed and impemented with care. If it is too ax, too informa, and too easy to maintain a waiver, then the system wi be abused, revenue wi decrease ad the benefit of user fees wi be reduced. On the other hand, if the system is too rigid, patients are not we informed about the existence of a waiver system, or if it is too difficut to obtain a waiver, then needy heath care seekers wi be turned away.? How do you Grant a Waiver? Granting a waiver is a two-step process: The cinician or nurse seeing the patient recommends a waiver, preferaby with the hep of a socia worker The Medica Superintendent or Heath Administrator makes the decision to authorize the waiver. 22 Ministry of Heath, Kenya

30 _ Revenue generation: Fees, Exemptions and Waivers SESSION ONE And for a waiver cases, a Waiver Appication Form must be competed and approved by an authorized officia. Criteria for Granting Waivers It is important that the information provided on the waiver form shoud be carefuy considered and if possibe verified. The history as we as the socio-economic status of the patient shoud hep you decide whether to grant or not to grant a waiver. In addition, there are other categories of patients who are more ikey to be granted waivers. These incude: Students away from home with no funds of their own; Patients with chronic inesses which are not automaticay exempt; Patients who have spent their money to trave a ong distance to the hospita REMEMBER It is the responsibiity of the Heath Administrator to ensure that the waiver system is fuy impemented at the hospita. Key Actions of Impementation Task designated staff with responsibiity for granting waivers Ensure that Waiver Forms are avaiabe at a times Inform a staff and the pubic about how the waiver system works Task In groups of six Exempt, Waive or Pay Game The trainer wi give each group a pack of six cards which wi be paced on the tabe facing downwards. Each member of the group sha pick one card at random. Each card carries a simpe message describing a specific patient category seeking heath care at a pubic faciity. The members wi take turns to read the message on their cards and the group wi discuss and decide whether the patient member shoud be exempted, waived or asked to pay fuy for the service provided. Kenya Medica Training Coege 23

31 Modue two O P E R A T I O N S! Trainer s Note Exampes of some of the card messages might incude statements such as: I am a Medica Training Centre student from a we to do famiy. I am a nurse from the femae ward I am a weathy entertainer suffering from chronic tubercuosis. I smoke but I don t drink. I am a very poory dressed pastoraist with 100 goats and sheep and famiy of ten I am an exchange student from the Democratic Repubic of Congo I am an iega immigrant in poice custody 24 Ministry of Heath, Kenya

32 Nationa hospita insurance fund SESSION TWO SESSION TWO Nationa hospita insurance fund Aim The aim of this session is to provide participants with information on the roe of NHIF in revenue generation and hep them deveop skis to make caims and receive reimbursements from NHIF in a reguar and timey fashion. Learning Outcomes At the end of the session participants wi be abe to 1. Expain the roe of NHIF in revenue generation under the Cost Sharing Programme 2. Demonstrate a cear understanding of how to organize for NHIF caiming 3. Foow and appy the guideines for caiming from NHIF 4. Conduct effective NHIF ward census 5. Compete a the necessary NHIF reporting forms Session Summary A. Roe of NHIF B. Organizing for NHIF Caiming C. NHIF Ward Census and Reporting Materias Resources Handouts/reference materia Fipchart/Chak board Operations Manua Part 2 Marker pens OHP Kenya Medica Training Coege 25

33 Modue two O P E R A T I O N S A: ROLE OF NHIF Key Information The NHIF was estabished by an Act of Pariament in 1966 with the primary purpose of providing heath insurance cover to members and their isted beneficiaries. The mode in operation is that of a heath insurance fund. Participation in this scheme is mandatory for a saaried empoyees earning taxabe income. Membership contributions are remitted to NHIF which in turn reimburses accredited heath care providers for services provided to NHIF members and beneficiaries. Accredited providers incude GoK hospitas, Mission Hospitas, private hospitas and nursing homes. A contributor or beneficiary can ony derive benefits from NHIF if contributions are up to date. At the moment, NHIF reimbursements cover ony inpatient care using a daiy inpatient care fee rate reimbursement method. NHIF is perhaps the singe most important and steady source of revenue for hospitas. Reimbursements from NHIF are deposited in the cost sharing account aong with fee revenues and are panned for and spent on improving faciity and district services. REMEMBER Your faciity stands to ose hundreds of thousands of shiings each month just through under-reimbursement for NHIF patients And the reasons are simpe: Staff faiure to identify NHIF beneficiaries in the hospita; Staff faiure to compete and submit caims; NHIF faiure to process and pay caims prompty and in fu or Frauduent encashment of NHIF cheques 26 Ministry of Heath, Kenya

34 Nationa hospita insurance fund SESSION TWO B: ORGANISING FOR NHIF CLAIMING Key Information NHIF produces a comprehensive set of guideines for NHIF caiming, incuding exampes of necessary forms, which can be obtained either from NHIF offices or the Division of Heath Care Financing of the Ministry of Heath. The guideines provide detais on procedures and structures that wi hep you to organize for NHIF caiming, a summary of which is provided beow. Actions essentia for NHIF Caiming Caiming from NHIF invoves severa steps: Hod the Heath Administrator responsibe for NHIF Estabish an NHIF Caims Office Set up within or cose to the Inpatient Account Office and staffed with a senior cerk and other cerks who maintain NHIF register and caim forms reporting to Heath administrator in charge of cost sharing Monitor NHIF revenue against NHIF revenue targets Set an annua caims target for HMT approva using this formua: a) % of NHIF patients = No. of NHIF patients identified x 100 No. of patients interviewed b) Target No. of Caims per month = Average No. of Discharges per month mutipied by the % of NHIF patients as per (a) above. c) Target Vaue of Caims per month = Target No. of caims per month (as per b) mutipied by the Average Length of Stay (days) mutipied by the daiy reimbursement rate. Use Cost Sharing revenue to make NHIF caims Funds used for: office stationery, NHIF edgers, photocopies, trave and per diem for a cerk to trave to Nairobi to obtain Certificates of Contributions Paid, stamps and other necessary items. Figure Structures for NHIF caiming Kenya Medica Training Coege 27

35 Modue two O P E R A T I O N S Steps for Caiming from NHIF Caiming from NHIF invoves severa steps: Steps for Caiming from NHIF NHIF Requirements Stationery (NHIF caim forms NHIF 8, MoH invoices, Statement of Account NHIF 18) Identification of NHIF beneficiary (each beneficiary shoud be provided with an NHIF caim form on admission which shoud be attached to the patient s charge sheet. Identification can aso be made on the ward through poite but firm interviews and athough not encouraged at point of discharge) Maintaining an NHIF register and foowing up caims in Nairobi Competing an NHIF Caim A cerk competing a caim sha require the foowing essentia documentation: NHIF Card Certificates of Contributions Paid Member s Nationa ID Card Photocopy of Marriage Certificate of Spouse Photocopy of ID Card of Spouse Chidren under 18 proof of dependent status Finay, competing and submitting a caim to NHIF. Record Keeping and Reporting It is important that NHIF cerks must keep a the necessary records of each NHIF beneficiary identified. Some of these documents incude: Identification Note Book to record patient name, patient number, ward, bed number, NHIF member number and hep the cerks keep track of the caiming status for each beneficiary. NHIF Register to record each caim submitted with detais of reimbursement or rejection and re-submission Fiing System - to maintain adequate records of NHIF caiming, reimbursements and other documentation NHIF Caiming Report to document a monthy summary of the NHIF caims by the faciity for the Heath Administrator. Figure Caiming from NHIF _ Task In groups of six First Things First Re-arrange the foowing NHIF caiming tasks in a ogica order. 1. Foow up caims frequenty with NHIF 2. Identify NHIF beneficiaries at or soon after admission 3. Maintain a good fiing system 4. Compete an NHIF caim 5. Coect and photocopy essentia documentation and don t charge patients 6. Set up and maintain Identification Book and NHIF register 7. Estabish an NHIF Caims Office 8. Appoint a Heath Administrator to supervise NHIF caiming 9. Keep accurate financia accounts 10. Prepare an NHIF Caiming Report on a monthy basis 28 Ministry of Heath, Kenya

36 Expenditure panning SESSION THREE SESSION THREE Expenditure panning Aim The aim of this session is to encourage the participants to deveop and use appropriate skis and systems to ensure that funds are accounted for and expenditures are propery made. Learning Outcomes At the end of the session participants wi be abe to 1. Demonstrate a cear understanding of their roe and responsibiity in the expenditure panning process for both 75% and 25% 2. Set cear priorities and budget for the use of funds 3. List the requirements for the approva of Authority to Incur Expenditure (AIE) requests 4. Foow the oca purchase procurement procedures 5. Deveop costed expenditure pans Session Summary Time A. Responsibiities for Faciity 1 hour 30 minutes Expenditure Panning (75%) B. Responsibiities for District P/PHC Expenditure Panning (25%) C. Guideines on Use of Funds D. Expenditure Approva Requirements E. Procurement Procedures Materias Resources Handouts/reference materia Fipchart/Chak board Operations Manua Part 1 OHP Markers Ease Kenya Medica Training Coege 29

37 Modue two O P E R A T I O N S A: RESPONSIBILITIES FOR FACILITY EXPENDITURE PLANNING 75% Key Information The primary purpose of the cost sharing programme is to improve patient care and the quaity of services at Ministry of Heath faciities. The expenditure panning process shoud be foowed to ensure: revenue is spent in a timey manner and according to expenditure guideines estabished by the Ministry of Heath accountabiity improvements to quaity of care The tabe beow iustrates responsibiities for panning, approva and impementation of expenditures of the 75% funds: Tabe Team Hospita Management Team (HMT) Hospita Executive Expenditure Committee (EEC) District Hospita Management Board (DHMB) Task/ Responsibiity Prepares FIF Annua Pan Confirms FIF Annua Pan; prepares 1/4y sub-aie requests; directs expenditure according to G ok procurement reguations and prepares monthy Payments Report, itemizing a expenditures Reviews, requests modifications and approves annua pans and AIE requests District Accountant Provincia Medica Office (PMO) Certifies avaiabiity of uncommitted funds for the faciity in bank Issues AIEs on behaf of the Accounting Officer B: RESPONSIBILITIES FOR DISTRICT P/PHC EXPENDITURE PLANNING Key Information The other important objective of the cost sharing programme is to strengthen preventive and primary heath care. As outined in the ast session, 75% of the funds generated by Ministry faciities is to be used by the faciity that generated the funds and 25% remains with the district for district P/PHC activities. 30 Ministry of Heath, Kenya

38 Expenditure panning SESSION THREE The tabe beow detais responsibiities for panning, approva and impementation of expenditures of the 25% P/PHC funds: Tabe Team PHC Core Team District Heath Management Team (DHMT) District Hospita Management Board (DHMB) Task/ Responsibiity Consuts with a reevant district heath staff (FP, AIDS, KEPI Coordinators); Prepares Annua Pan and 1/4y AIE requests for use of FIF revenue for P/PHC Confirms FIF Annua P/PHC Pan Prepares 1/4y sub-aie requests Reviews and approves Annua P/PHC Panand sub-aie requests District Accountant Certifies avaiabiity of uncommitted funds in bank Provincia Medica Office (PMO) Issues sub-aies in accordance with current FIF expenditure ru es C: GUIDELINES ON USE OF FUNDS Key Information Expenditure guideines are the basis for determining whether a request for a sub- AIE to spend FIF revenue can be approved by the DHMB and the PMO. The specific guideines and reguations for use of FIF revenue are contained in Ministry of Heath circuars. These guideines and reguations change from time to time. The officer-in-charge of cost sharing at each faciity and in each district is accountabe for having a copy of the most recent circuar on expenditure guideines. This information shoud be communicated to a faciity and district staff invoved in panning for the use of cost sharing revenue. Use of Funds As noted above, cost sharing revenues are meant to improve the quaity of patient care. Treasury aocations are meant to provide for saaries and personne aowances, water and eectricity, patient food, essentia drugs and other basic faciity requirements. The deveopment budget is expected to cater for capita construction, faciity expansion, vehice purchase, and major equipment purchase. Kenya Medica Training Coege 31

39 Modue two O P E R A T I O N S _ Task Individuay and then in pairs Study the foowing ist of expenditure categories and put a tick against those you think are aowabe expenses under the FIF revenue expenditure guideines. Share your responses with a coeague and discuss them further tins of high goss paint to paint wards 8,9 and Expanding the maternity wing 3. Emergency drugs and dressings 4. Laboratory and Xray suppies 5. Essentia stationery - receipt books, inpatient charge sips and registers 6. Basic drug suppies 7. Water and eectricity 8. New engine for the hospita ambuance 9. In-patient drug kits 10. Surgica suppies and goves 11. Posters for pubic information, education and communication 12. Mik for chidren in the nursery D: EXPENDITURE APPROVAL REQUIREMENTS Key Information It is important to understand that sub-aie requests for the use of cost sharing revenue can be approved ony when certain conditions have been satisfactoriy met. Some of these conditions incude: The request is consistent with the rues on Use of Funds The request is consistent with the Specia Requirements isted beow A the routine reports have been submitted and are up to date The Accountant has certified that the necessary funds have been coected by the faciity and are avaiabe in the bank and have not been committed for other purposes The written sub-aie has a the required information Specia Requirements In order to buid in appropriate measures of accountabiity in the use of cost sharing funds, there are certain specia requirements that appy to the panning, approva and use of FIF funds. Some of these specia requirements appy for the foowing categories of expenses: Maintenance of equipment and buidings requests must state expicity the 32 Ministry of Heath, Kenya

40 Expenditure panning SESSION THREE exact buiding or piece of equipment invoved and the type of maintenance or repair that is required. Vehice expenses ist the vehices to be supported with the funds and ceary state the purpose Drugs and dressings a requests must be accompanied by proposed ist of drugs to be purchased, signed by the Medica Superintendent and Hospita Pharmacist; schedued drugs are purchased ony if they are not avaiabe from MSCU within the time required.; the purchase of non-schedued drugs must be approved by the Hospita Drugs and Therapeutics Committee. E: PROCUREMENT PROCEDURES Key Information Cost sharing revenue is generay spent through oca procurement procedures. Hospitas experiencing unwarranted deays due to District Tender Boards, District Treasuries, or other factors shoud immediatey inform the PMO so that corrective action can be taken. The Government of Kenya Suppies Manua (1978), Chapter 6, Procurement and Purchasing, contains detaied descriptions of the reevant procedures for purchase of drugs and medica suppies. Procedures and eves of purchase are notified through circuars as they are updated from time to time. Leves of Loca Procurement For individua hospitas and districts, ordinary oca procurement of drugs and medica suppies is done through: petty cash oca purchase hospita quotation district tender board At Provincia Genera Hospitas the foowing additiona procedures must be used for expenditure of 75% funds: quotations wi be opened by the Executive Expenditure Committee a accountabe documents (LPOs, LSOs) wi be kept safey by the Heath administrator and issued to user points as and when required Kenya Medica Training Coege 33

41 Modue two O P E R A T I O N S The Medica Superintendent of the PGH (and not the MoH) wi sign a approved PGH cost-sharing LPOs and LSOs. The senior Heath administrator wi ensure that a LPOs and LSOs are entered in the respective vote-book before they are signed and sent to the district accountant for signature Emergency Loca Procurement Hospitas provide inpatient and emergency services 24 hours a day. As such there are occasionay ife-threatening emergencies for which specific drugs and medica suppies are needed urgenty. There are two aternative methods avaiabe for emergency oca procurement: 1 Emergency District Tender Board The District Commissioner who is the Chair of the DTB can constitute an emergency DTB meeting to deiberate on emergency procurement within a very short time. The quorum is five members and the amounts invoved shoud be above K shs 30, Authority from the Accounting Officer There are other specia circumstances where an emergency DTB might not be feasibe. For exampe, a mass fata road traffic accident where medica suppies may have to be coected directy and quicky from a oca pharmacy. In such a case, a etter must be obtained from the Accounting Officer (Permanent Secretary). The Permanent Secretary s etter aong with an invoice woud then be presented to DTB for ratification at a ater date. The circumstances surrounding such a procurement shoud be ceary expained to the Accounting Officer. Procurement Limits As mentioned above, procurements of goods and services using cost sharing revenues is governed by the government procurement and tendering reguations that are spet out in specific Treasury Circuars and in force at any given time. 34 Ministry of Heath, Kenya

42 The atest procurement imits are summarized in the tabe beow: Expenditure panning Tabe Leve of Purchase Up to Kshs 10,000 per item per purchase Procedure Petty Cash Purchase against cash from Imprest Account. Fu detais must be recorded in suppies records. Kshs 10,000 to 30,000 Loca Purchase Purchase on Loca Purchase Order (LPO, S20) of urgenty needed items avaiabe ocay. Verba quotations must be obtained and recorded on S20. Order must not be spit to keep them under Kshs 30,000 imit. Kshs 30,000 to 200,000 Hospita Quotation Purchase on Loca Purchase Order, S20. Written competitive quotations on Request for Quotations, S10 needed and is adjudicated departmentay. Kshs 200,000 to 1miion District Tender Board Quotation quotation raised and adjudicated by the District Tender Board. Kshs 1m to 5 miion District Tender Board Open Tender submitted to DTB for adjudication and approva Over Kshs 5 miion Submitted to Centra Tender Board adjudication and approva Kenya Medica Training Coege 35

43 Modue two O P E R A T I O N S SESSION FOUR Accounting Aim The aim of this session is to inform and encourage participants to rise to their own best eve of performance and capabiities to ensure that revenues are maximized, funds are accounted for, and expenditures are propery made. Learning Outcomes At the end of the session participants wi be abe to 1. Demonstrate a cear understanding of the various eves of accounting procedures aid down for accounting for cost sharing funds 2. Describe the operations of the cost sharing (FIF) bank accounts 3. Compie and anayze accounting reports Session Summary Time A. Accounting System 2 hours B. Leves of Accounting Procedures C. Banking Operations Materias Resources Fipchart/Chak board Marker pens OHP Handouts/reference materia Exchequer and Audit Act 36 Ministry of Heath, Kenya

44 Accounting SESSION FOUR A: ACCOUNTING SYSTEM Key Information Cost sharing revenues are deposited at the district in specia Bank accounts and are NOT returned to Treasury or MoH headquarters. Accounting for both coections and expenditures is, however sti made to District Treasury, who post transactions into the MoH edger accounts. Accounting is done through a Heath Care Services Fund in accordance with the requirement of the Exchequer and Audit Act, Cap 412. A copy of this Act is avaiabe as Handout 5.1 Under the Heath Care Services Fund, separate account codes are used for the foowing transactions under cass 4 (Funds and Deposits) of accounts: 75% portion of the coections for each faciity P/PHC funds used for the 25% portion of a coections made in the District Expenditures made by each faciity Expenditures made for P/PHC activities B: LEVELS OF ACCOUNTING PROCEDURES Key Information In order to encourage and maintain maximum financia management contro of cost sharing revenues it is important that certain accounting procedures and requirements are accompished at various eves. The tabe on the next page presents a summary of some of these important procedures: Kenya Medica Training Coege 37