Hope and hurdles: Patients hail SHA, but upfront costs remain a barrier

Shardack Ouma, 69, from Ndhiwa in Homa Bay County, remembers the fear when he was diagnosed with prostate cancer. He had been unwell since 2019, moving between health facilities for treatment and screenings.

By the time his illness was identified in 2021, it was already at a terminal stage. He started treatment at Kisumu County Referral Hospital and was later referred to Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH).

Ouma recovered in 2022, finally regaining enough strength to get out of bed. Though now a survivor, he still visits JOOTRH monthly for injections and medication.

During his illness, he used the now-defunct National Health Insurance Fund (NHIF) before transitioning to the Social Health Authority (SHA) last year. He appreciates SHA but finds the upfront payment requirement difficult.

“It’s very hard because I’m not working. I had to beg from well-wishers to raise Sh3,600. My monthly premium is supposed to be Sh300,” he says.
Although this is cheaper than NHIF’s Sh500 monthly (Sh6,000 yearly), he recalls still being asked to pay cash under NHIF. With SHA, he hasn’t paid a cent out of pocket.

“I urge the government to consider people like me—elderly and unemployed. SHA is good, but they should revise the annual payment rule,” he adds.
Even when medication is out of stock at JOOTRH, he is referred to government-licensed facilities where he gets drugs via SHA. “For example, at Salama Cancer Care, they just check my name and process everything through SHA.”

Elijah Otieno, from Kano Kolwa in Kisumu, started feeling unwell in August last year. After seeking help from a village missionary hospital, he was referred to JOOTRH and began renal dialysis—two sessions weekly, each costing Sh10,500.

“I come here twice a week. I haven’t had any issues. SHA has been covering all my hospital bills,” he says.
Otieno and Ouma’s cases highlight how SHA has transformed access to life-saving care, even as debates around its sustainability and accessibility continue.

Public opinion about the Social Health Authority (SHA) and the new Social Health Insurance Fund (SHIF) is mixed; while some see it as a lifeline, others point to significant barriers.

Following the phasing out of the National Hospital Insurance Fund (NHIF) last year, all Kenyans in both the formal and informal sectors are now required to register with SHA and contribute to SHIF, which was created under the Social Health Insurance Act 2023 as part of President William Ruto’s Universal Health Coverage (UHC) reforms.

Upfront payments

At Siaya County Referral Hospital, 58-year-old Philster Akinyi has battled heart and lung conditions since 2014. She has been hospitalised for two months, surviving on oxygen support. “I’ve not used any of my own money, except for a top-up. I’m fully compliant and told I’ll top up again in November,” she says.

Akinyi pays Sh450 monthly to SHA. Though lower than NHIF’s Sh500, she had to pay for the full year upfront to access services.

“If we had to pay out of pocket, my husband might have sold land or cows. I’ve been here over two months—it would have been very expensive,” she adds.

Doctors now plan to discharge her with an oxygen cylinder, covered by SHA.

Grace Nekesa, 30, from Karapul in Alego Usonga, Siaya County, recently gave birth without complications. Her discharge and care for the baby have been fully covered by SHA.

Still, she’s frustrated by the upfront Sh6,000 required to benefit from the scheme. “Paying the whole year at once is very hard, especially for unemployed people like me. Monthly payments would help. Raising Sh500 a month is already difficult,” she says.

JOOTRH CEO Richard Lesiyampe says that in the last year, they have seen 255,000 patients, and almost 80 per cent of them are registered with SHA.
Lesiyampe says they have also seen 150,000 patients in their consultant clinics, with 80 per cent of them using SHA.

He says they deliver about 400 babies every month, and all those mothers are on SHA. “As we speak, I have 600 patients admitted in the wards, all of them are on SHA except five, and those five are underage. The other two are from street families. That gives you the indication,” he says.

Lesiyampe notes that 99 per cent of their current resources as a facility come from SHA. “Therefore, it plays a critical role in ensuring we provide healthcare and services to patients. SHA has supported us from last year to date. Though they have not fully paid all our claims, at least 80 per cent have been paid. This is unlike what used to happen under the NHIF scheme,” he adds.

He says that while they occasionally experience delays in reimbursements from SHA, sometimes the fault lies with the facilities. “We submit incorrect claims or fail to attach the requisite documents. These are small teething issues, but generally, SHA has been on top of things. From October last year, we have received Sh800 million from SHA,” he says.

When asked whether he would recommend changes to SHA, he acknowledges it is a new system — a model being tested, and appreciates the progress so far.

“Any new healthcare system has challenges, and some of those are being addressed. We have seen a lot of progress. There are a few areas that need to be looked into, for instance, last expense support for those who pass on, and the ambulance system. I also think after one year, we can review which benefits need to be increased or reduced,” he adds.

All facility levels

According to Alfred Onyango, Head of Insurance Administration at JOOTRH, SHA works at all levels, from level two dispensaries to level six hospitals.
He says the greatest challenge is that many patients avoid the lower-level facilities.

“We have three types of funds under SHA that people should understand. First, there is the Primary Healthcare Fund, which is funded by the exchequer as per the Act of Parliament and is used at level two and three facilities,” he explains.

“When you go to level two or three, you need to register for SHA, and your card will automatically work. The fund is directly paid by the government. At these levels, treatment is offered free of charge,” he adds.

He notes that the Social Health Insurance Fund (SHIF) — the premium paid by an individual after a means assessment — operates from level four to level six facilities. “When you go to the hospital, you’ll be expected to have paid your contribution so the card can be activated. There is also the Emergency, Critical and Chronic Illness Fund, also funded directly by the exchequer, which supports emergency and chronic cases,” he says.

“For instance, if you are brought to the hospital after an accident, you’re supposed to be treated under this fund. You just need to be registered for SHA, and even if not, you’re still eligible for care.”

He explains that some illnesses are managed at level two or three hospitals, but most people believe only higher-level hospitals offer SHA services.

“But the problem is that most people believe SHA is only working effectively at level four, five, or six facilities — and this is where the challenge lies. Level five and six facilities are not supposed to handle outpatients under SHA, which is why patients are advised to visit level two or three facilities to be seen by doctors there,” he explains.

He notes that any illnesses that cannot be managed at levels two, three, or four are meant to be referred to levels five or six. There are specific treatments available at level six that are not offered at the lower levels.

“For example, a CT scan service — all you need is a referral letter from the facility where you first sought treatment, along with a request from that level. My advice is that our people should follow the proper channels, and SHA will work as intended,” he says.

He adds that reimbursements from SHA to health facilities have increased in comparison to those from NHIF.

“For instance, when JOOTRH was a level five hospital before it transitioned to level six, NHIF paid Sh3,500 per day for a hospital bed. Now, with SHA in place at level six, we are charging Sh4,480 per day — that’s an increase.

For a CT scan, NHIF paid Sh6,000; under SHA, it’s now Sh6,900. Renal dialysis used to be covered at Sh9,500 per session by NHIF, but SHA now pays Sh10,600 per session. For surgical procedures like hip replacement, NHIF covered Sh300,000 — SHA now pays Sh336,000, inclusive of implants,” he adds.

As part of the Universal Health Coverage (UHC) agenda, President William Ruto directed that all outpatient services at public dispensaries, health centres, and sub-county hospitals be offered free of charge, under the Primary Healthcare Fund. “This applies to all PHC services at public level two to four hospitals and SHA-contracted private and faith-based facilities,” said Ruto.

The free services include consultations, diagnosis, treatment, lab tests, X-rays, ultrasounds, drug dispensing, health education, management of chronic and acute illnesses, maternal and child care, and immunisation.