CHAK is seeking to dispose some of its motor vehicles. Interested bidders can find details of the vehicles here. 

It is nearly 10am in Olasiti Village in Narok County and most people are already busy with their daily chores. Today is, however, not an ordinary day. By 10:30am, the men begin trickling into the AIC Olasiti Church compound. By 11am, the crowd is sizeable, and goat meat is boiling away merrily in a large pot set on an open fire.

As the men arrive, they sit on plastic chairs under a huge tree in the Church compound. Soon all the plastic chairs are filled and the late comers either lean on something, perch on rocks, logs or whatever is available to be used as a seat.
The Clinical Officer In Charge at AIC Olasiti Dispensary, Julius Pion, locally known as Daktari Pion, calls the meeting to order and the men quickly heed his calls to pay attention.

Daktari Pion has organized a male dialogue day where the men in Olasiti Village will discuss reproductive health and other health challenges facing their community. Daktari Pion holds the male dialogue forums at least one day every month in different villages within the health facility catchment area. With 16 villages in his facility catchment area, he has a lot of ground to cover.

The male dialogue forums are part of CHAK efforts to strengthen community-based interventions towards increasing demand for essential reproductive, maternal, newborn, child and adolescent health services such as Antenatal Care (ANC) and Skilled Birth Attendance (SBA). This includes rallying men to support the continuum of maternal and child health services.

The AIC Olasiti male dialogue forum is one of over 50 such meetings supported by the CHAK RMNCAH Programme in the four counties of Narok, Turkana, West Pokot and Marsabit over the past two years of implementation, reaching over 2000 men. The counties were selected for support due to poor maternal and newborn health outcomes, inadequate access to maternal health and newborn services and information, cultural practices such as Female Gentile Mutilation (FGM) and early marriages leading to increased dangers during pregnancy and childbirth, thus contributing to Kenya’s high maternal mortality rate.

Data shows that the performance of Narok County is lower than the national average for most reproductive health indicators.
Comparison of Narok County and national reproductive health indicators (KDHS 2022)

In organising the male dialogue forums, Daktari Pion works closely with the Sub County Community Health Assistant (CHA), Community Health Promoters (CHPs), area chiefs, faith leaders and other health care workers. The CHPs begin mobilizing the men to attend the meeting three days prior to the arranged date. Religious leaders support in dissemination of messages to the men in the local community to attend the dialogue days. The chief provides security and encourages the men to attend the meeting, including informing the village elders of the intended forum.

The health topics discussed during the men dialogue forums that on average last two to three hours are quite diverse and include early ANC attendance, attendance of eight ANC contact visits, preparation for Skilled Birth Attendance (SBA), child immunization, nutrition for pregnant women, breast feeding, postnatal care, post partum family planning, personal hygiene, relationships, child spacing and family planning, female genital mutilation and its risks, early pregnancies and sexually transmitted infections. The men are also given information on and screened for diabetes, hypertension and HIV.

As evidence of progressive change, Daktari Pion says AIC Olasiti Health Centre currently sees 50 plus ANC cases and does 15-22 deliveries monthly, compared to one delivery when the health facility began offering maternity services in 2018.
Today, Daktari Pion will be giving information on modern family planning methods to the men to address myths and misconceptions and encourage uptake of the contraceptive methods. Support from the men, who are the heads of their families, can go a long way in improving uptake of the methods.

The Clinical Officer also hopes to encourage the men to actively participate in their partners’ pregnancy journeys by giving financial assistance for health care and nutrition, taking a keen interest in the health of the mother and baby and ensuring adequate rest for their pregnant and lactating wives.

The men listen keenly as Daktari Pion goes skillfully through each topic, nodding in agreement with some of his statements but completely disagreeing with others. Many of them disagree that they should accompany their wives to the health facility for ANC visits, but they are united in agreeing that girls should be allowed to complete schooling before being married. Daktari says that although the men are reluctant to accompany their wives to ANC and PNC visits, most of them give financial support and even follow up on their wives’ visit to the health facility through phone calls to him.

Addressing myths and misconceptions about family planning 
Moving swiftly to the discussion on modern contraceptives, Daktari explains each method in detail. The CHAK team, led by RMNCAH Programmes Coordinator Jane Kishoyian, are present in today’s meeting and have carried with them samples of each contraceptive method. The samples are circulated among the men who get to see them up close and touch them.

While 99.5 per cent of the men have seen a condom, other modern contraceptive methods such as the IUCD, implant and female condom attract a lot of attention from the men, many taking time to examine the samples closely and exclaim at their appearance.

Many of the men admit to having used the male condom but believe modern contraceptives have serious side effects on the health of their wives and negative implications on their fertility. Some of the men say modern contraceptives cause pain to the male during sexual intercourse. However, the CHAK team and Daktari Pion are on hand to give the correct information about modern contraceptives to the men.

The older men have a hard time accepting the use of modern family planning methods, while the younger ones are more interested in establishing whether the myths and misconceptions are true. Acceptance of modern family planning methods is still very low in the Olasiti community although this is changing slowly as more people get information from reliable sources, including health care workers in the CHAK RMNCAH programme which began in 2022. Short term methods (depo) are preferred by the women who are currently using modern family planning methods.

The CHAK RMNCAH programme has trained health workers from the 60 implementing health facilities on Focus Antenatal care, Adolescent and Youth friendly training, NCDs (Diabetes and hypertension) in pregnancy, essential newborn care, post-natal care and management of pregnancy related complications and baby friendly health initiatives (BFHI). Additionally, Community Health Promoters from 15 counties have been trained on community package of care.

The programme supports the male dialogue meetings by ensuring the men have something to eat on the day of the meetings. The programme also provides the health care workers and Community Health Promoters with transport and lunch on the day of the event. The CHPs mobilise the men to attend the event and provide blood pressure and diabetes screening services for the men who attend the event. The CHPs are equipped with a kit containing a digital blood pressure machine, a glucometer machine and 50 strips as well as a thermometer. The CHPs are well trained to screen for these conditions. Men suspected to have any of these conditions are reviewed at a later date and if the readings remain abnormal are referred to the nearest health facility.

At the end of the discussion, the men sit together, each with a piece of boiled meat in his hand, using a traditional Maasai knife to cut meat held at one end by the teeth.

The age-old Maasai practice of men sharing goat meat continues but some things are slowly changing. Despite challenges the of poor transport infrastructure, especially felt during the rainy season and long distances to health facilities, a large majority of the men are ensuring their wives and babies receive antenatal and post-natal care and births take place in a designated health facility. They also ensure that their women get nutritious food and children are immunized. Additionally, the men are slowly being convinced of the need to adopt modern family planning methods.

With the change over from the National Hospital Insurance Fund (NHIF) to the Social Health Insurance Fund (SHIF) less than one week away, CHAK member health facilities have raised concerns over lack of clarity on some operations of the new health financing scheme. The CHAK MHUs have also asked the Government to settle all their pending NHIF claims which run into millions of shillings.

In a meeting held last week with SHA, the CHAK member health facilities said they remained in the dark about fundamental operational issues of the fund including the contracting process, client registration, tariffs and claims system. The health service providers sought clarification on how the SHA referral system would operate as levels 4-6 health facilities were not allowed to receive walk-in patients under the new system.

The CHAK MHUs said they were unable to register patients in the SHA system and requested to be allowed to use portable devises to reach as many people as possible. Additionally, the health service providers sought clarification on the scope of emergency services to be offered by level 2 and 3 health facilities vis-à-vis those to be offered by levels 4-6 facilities under the new scheme, saying this was not clear.

Another question arose on when the health facilities would begin blocking patients on NHIF to SHA and exactly how the transition would happen. The SHA informed the health service providers that direction would be issued on the issue and transfer of patients from NHIF to SHIF would be seamless. It is worth noting that Kenyans are required to register afresh under SHIF although the deductions of 2.75 per cent of gross pay for salaried people are compulsory.

Source: SHA presentation to CHAK MHUs by Dr Joyce Wamicwe 

During the meeting, the CHAK member health facilities were also briefed on expected digitization of the health sector. Although most Level 4-6 CHAK member health facilities have end-to-end health information systems and would most likely adapt well to a national system, few primary health care facilities (Level 2 and 3) are utilizing technology in health care. All health facilities in Kenya are required to have the web-based SHA portal by October 1, 2024, to facilitate claims processing after seeing patients. Digitization of Kenya’s health system has been provided for in the Digital Health Act 2023. Digitization would also ensure that health workers remained up to date with their licenses.

During several meetings with SHA, the CHAK member health service providers have consistently complained about long-standing NHIF payments, some of them several years old. The NHIF/SHA assured the health facilities that any NHIF payments not made by the roll over date of October 1, 2024, would be taken over by SHA. The CHAK member units asked SHA to issue them with a commitment letter, confirming the debts would be paid but were assured that all genuine pending NHIF claims would be honored by SHA.

The MHUs expressed concern at the time taken for claims to be moved from one stage to another in the NHIF system, saying some of the stages were taking an unnecessarily long time. Additionally, the CHAK MHUs said some claims were over seven years old and sought to know if these would be brought under SHA, urging their prioritization. Further, the CHAK MHUs pointed out that there were unable to view the status of their claims in the new SHA/NHIF system. The CHAK members demanded timelines for payment of the pending claims.

The MHUs added that pre-authorization for surgeries continued to take a long time, yet some patients required the service urgently. Some of the CHAK health facilities complained that they were unable to submit their claims to their local NHIF branches for processing as the system seemed to have a blockage.

In response, SHA told the meeting attendants that the blocked claims could be specific to certain NHIF branches and would be followed up once official complaints were received. Where the claims were already within the NHIF system, the CHAK MHUs were assured they had been captured as part of SHA debts and would be paid out.

Further, the CHAK MHUs were informed that it was impossible to view the stage at which their claims were in the new system. The CHAK members were asked to check for claims that had been returned but were yet to be acted on. It was noted that letters of claim rejection were yet to reach the health facilities in some instances and appeals could therefore not be lodged with SHA/NHIF.

SHA informed the CHAK health facilities that training on the use of its e-claim management system provider portal would be done beginning the third week of September 2024. The e-claims hardware would be provided by SHA.

SHA also informed the CHAK members that contracting would be done electronically and was anticipated to take a short time. Verification of data given during contracting would be done at a later date with consequences for fraud. The process of contracting would be continuous, giving service providers an opportunity to upgrade their services.

Under SHIF, empaneling of health service providers would being done by the Kenya Medical Practitioners and Dentists Council (KMPDC). A list of already empaneled health facilities was available on the SHA website. A total of 734 mission hospitals, both CHAK and KCCB, were already on the SHA list and empanelment was ongoing. The SHA pledged that SHIF tariffs wiould be gazzetted.

The Government has assured CHAK health facilities of a smooth transition to the Social Health Authority (SHA/SHIF) whose implementation will kick off in July 2024. The assurance comes in the wake of heightened engagement between CHAK facilities and NHIF to address delayed claims payments.

Delegates at the CHAK Annual Health Conference 2024 were informed that every Kenyan would be required to register afresh for SHA/SHIF. Bio metric registration would be done for all beneficiaries while every child would be registered within 14 days of birth.

The SHA/SHIF is mandated by the law to:

• Register beneficiaries
• Manage funds received under the Social Health Insurance Act 2023
• Receive all contributions
• Empanel and contract healthcare providers and healthcare facilities
• Make payments to contracted healthcare providers and healthcare facilities out of the relevant fund as provided in the Act.

According to Julia Ouko who delivered a presentation on behalf of Dr Samson Kuhora, a law on empanelment and contracting would be formulated and a body put in place to run this function. A benefits panel would review benefits after every two years in consultation with CS-Health.

The delegates were further informed that although empanelment was not guaranteed, licensed health facilities in the country would be central to the implementation of the new policy direction.

Claims management would be done through claim settling agents and medical insurance providers. A tribunal would be set up to settle disputes although any decision could be appealed in law.

Speaking at the Annual Health Conference, Mr Chrisostim Wafula, Manager, Claims Management, NHIF/SHA told representatives of CHAK health facilities and other delegates that a multi-disciplinary team has been formed to support high volume hospitals in the claims reconciliation process as the transition process continued. The reconciliations were expected to be completed by June 30 with the process coordinated from NHIF/SHA head office.

Surgical claims flagged in 2023, some of which were way above the contract rates, had already been released to NHIF branches for processing and would follow the normal payment routes while old e-claims would be released at the end of April 2024 for processing.

Further, NHIF had received money from Government and would be processing Linda Mama claims. Capitation would be paid to the health facilities in the month of May.

Some CHAK member health units confirmed that they had received NHIF payments during the third week of April. However, the facilities continued to express reservations at the slow pace of claims payments, especially given the short time period left before the start of SHA implementation.

According to the delegates, some claims had been pending for over seven years and there were cases of capitation being paid using a wrong formula. The health facility representatives termed this unfair given that the capitation was already too low for the services offered.

The challenges had further been compounded by the on-going doctors’ strike that had pushed huge numbers of patients, especially those critically ill, to the CHAK facilities, given that county health services had ground to a halt.

Further, lower level health facilities were struggling with claims and there was no guarantee they would be empaneled for SHIF due to challenges with internet connectivity. Although the Government had embarked on installation of fibre optic cables, this was mainly serving county and sub county offices and adjacent areas. Lack of internet connectivity would greatly impact Level 3 health facilities which served a large number of clients.

The CHAK member health units also expressed concern that many clients were unaware of the NHIF benefits package and called on the Government to address this shortcoming during the SHA/SHIF implementation. The delegates were informed that there was a plan to communicate the SHA/SHIF package through the division of benefits.
Further, the delegates were briefed on the referral system in the new system. Patients would be referred to Level 4 and 5 health facilities from Level 2 and 3.

The Social Health Insurance Act 2023 establishes three new funds, namely, the Primary Healthcare Fund (PHF) which will be accessed in Level 2 and 3 health facilities upon registration to SHIF, the Social Health Insurance Fund (SHIF) which will be accessed in Level 4, 5 and 6 health facilities upon registration and up to date premiums, and the Emergency, Chronic and Critical Illness Fund (ECCIF) to be accessed upon depletion of SHIF cover.

As Kenya moves rapidly towards actualization of radical policy changes in health, including a shift to the Social Health Insurance Fund (SHIF) by July 2024, CHAK Member Health Units have expressed profound disappointment over poor handling of medical claims by Medical Administration Kenya Limited (MAKL).

The health facilities have accused MAKL, which handles medical claims for the police, prison officers and teachers, of unfairly rejecting medical claims reimbursements, disinterest in stakeholder engagement and wanting public relations practices.

The CHAK network members expressed their deep frustration during a plenary session at the Annual Health Conference 2024. Delegates at the conference representing hospitals, health centres, dispensaries, churches, church health programmes, Medical Training Colleges and universities from 45 counties condemned MAKL for what they see as blatantly unfair practices in handling medical claims for patients treated in CHAK facilities.

Delegates shared deeply troubling experiences which they said had disadvantaged the firm’s clients as it had become difficult to continue providing services with no guarantee of claims reimbursement.

Key grievances expressed by the CHAK Member Health Units against MAKL included:

• Full payments are rarely made for services rendered. The MHUs added that even the very little money that had come through had been paid very late.
• Engagement and communication with MAKL leadership has been quite difficult. The firm does not respond to emails and calls and where a response is made, it often comes late.
• They accused MAKL of rejecting a disproportionate number of claims without plausible reasons, adding the firm seemed to have set claim rejection targets.
• It was especially difficult for the health facilities to get authorization to admit a patient despite some of the cases being emergencies.
• The requirement to refer patients through the MAKL system had proved difficult to implement.
• Different contracts for health facilities that are at the same level. The MHUs demanded uniform contracts for similar level facilities.
• MAKL has to reapprove payments after the initial approval. During the reapproval process, money is deducted and payments delayed.
• The health facilities also accused MAKL of asking for arbitrary discounts for services rendered to patients, saying this was especially difficult as reimbursed costs were already extremely low.
• Sometimes payments are signed off by MAKL and not paid.
• MAKL was also accused of declining admission extensions for very sick people, even when it was apparent such a person could not be discharged.
  

The CHAK members, while citing limited revenue streams, added that they were inclined to guard the little income they got jealously and called upon MAKL to improve service delivery and respect the agreements signed with the health facilities.

Pointing out that they were at the front line in health service delivery and often had to deal with disappointed and disillusioned MAKL clients, the health facilities said they were faced with the dilemma of saving a life and accepting inadequate reimbursements, which was akin to being stuck between a rock and a hard place. Out of desperation, many clients were opting to pay out of pocket despite having an insurance cover paid for by the Government.

The CHAK MHUs resolved to remain resilient and fight the unfair practices by MAKL. They were adamant that despite the challenges, being people of faith, they would embark on prayers and aggressive lobbying and advocacy to ensure their grievances were heard and addressed. They proposed a multi-tiered approach with incrementally bold steps to ensure the situation was reversed.