The Supreme Audit Chamber (SAC) reviewed the results of the state audit of the effectiveness of NJSC "Social Health Insurance Fund" (SHIF) for 2022-2023.
According to the press service of the department, the audit covered funds and assets worth 3.8 trillion tenge and involved 13 organisations.
It has become known that to date, the compulsory social health insurance (CSHI) system covers 16.2 million people. Of these, 12 million are beneficiaries, for whom the state pays contributions. About 2 million are civil servants and employees of budget organisations and the quasi-public sector.
"The financial burden on the state, excluding private expenses (paid medicine), is at least 76%. In this regard, one of the key conclusions of the audit is that, despite the introduction of CSHI, there is still no noticeable reduction in the burden on the state due to the shared responsibility of citizens," the statement says.
It is reported that during the monitoring, experts identified the non-disbursement of National Fund funds. In 2022-2023, over 50 billion tenge were allocated to the Fund as part of guaranteed and targeted transfers. However, 13 billion tenge, or 26%, remained unspent.
Furthermore, the auditors found that the Fund does not pay due attention to monitoring the quality of medical services.
"In Astana, an inspection was carried out of two of the largest providers under CSHI, which collectively cover 179,000 people. As a result, a lack of own production premises and medical equipment was identified, with a practice of hourly rental observed. In a number of clinics of these LLPs, licenses for certain types of activities and ramps for receiving non-mobile citizens were absent," the SAC reported.
At the same time, the audit revealed cases of double payment for medical services at the expense of both SHIF and citizens, although according to existing rules, medical institutions should not charge for those types of medical care financed under the Guaranteed Volume of Free Medical Care (GVFMC) and CSHI.
"Thus, for inpatient care, cases of double payment were established amounting to at least 1.7 billion tenge, and for outpatient care – 27.6 billion tenge. At the same time, the Fund does not conduct monitoring of this aspect," the statement says.
Among other things, auditors identified cases of double payment by SHIF for services in dental clinics. It became known that the cost of anaesthesia was already included in the health insurance tariff, but dental clinics charged the Fund an additional 2.1 billion tenge for it.
Also, as a result of reconciling data from the Ministry of Health, the Ministry of Internal Affairs and the Ministry of Justice, cases were established of prescribing medications to citizens who had moved abroad for permanent residence.
Along with this, SHIF monitoring showed that by March of this year, 109 medical organisations had overdue loans totalling 19 billion tenge.
In turn, the Chairman of the SAC, Alikhan Smailov, emphasised at the meeting that SHIF is obliged to ensure high-quality monitoring and control over the targeted use of budget funds.
"And this should be done not manually, but automatically. The Fund must have its own risk management system, on the basis of which it must conduct monitoring and quality control of services provided, the availability of a production base, equipment, relevant medical licenses and permits," said Smailov.
Overall, based on the audit results, it was established: procedural violations amounting to more than 32 billion tenge, as well as ineffective planning and use of funds – totalling 31.1 billion tenge. The amount of financial losses and lost profits amounted to 11.8 million tenge.
It is reported that materials regarding the facts of double payment for medical services and false reporting will be forwarded to law enforcement agencies.