SHA: Patients' one-year pain, scandals and unpaid claims

The tribulations of Phyllis Mandela capture the failings of Kenya Kwanza’s much-touted universal health coverage (UHC) plan, one year on.

Unable to clear her bill after giving birth, the mother was detained at the Thika Level Five Hospital for two months.

It took the intervention of lobby groups to have Ms Mandela released, a victim of a system that, as late as Tuesday, President William Ruto described as the best for mothers and their babies.

Detention of patients and broke hospitals due to unpaid claims, and broken systems have been the norm one year after the Social Health Authority (SHA) was rolled out.

Many public and private hospitals remain understocked, understaffed and overwhelmed, with patients forced to buy basic drugs out of pocket.

And the scheme, billed as the answer to the fraud-riddled National Hospital Insurance Fund, has also been flagged for fraudulent claims estimated at about Sh10.6 billion, according to reports by the Ministry of Health, with at least 31 hospitals under the Directorate of Criminal Investigations (DCI’s) microscope.

And as the government continues to defend the plan, patients and their families have been left on their own.

In fact, Mandela’s case mirrors many across the country, where patients are being locked in hospitals for failing to settle bills, or simply turned away.

In a recent video clip allegedly from the Maragwa Hospital in Murang’a, several mothers are seen holding their newborns pleading with the government to free them after being detained for their inability to pay.

“I’m Mary Wanjiru, I came here in July,” says one woman.

Another adds: “I’m Ruth Nekesa. I delivered on September 7, 2025. My husband does not visit me-God help me.”

The detention contradicts President Ruto’s pledge that access to healthcare would no longer depend on the ability to pay. The President has often re-affirmed his commitment to ensuring all Kenyans access quality healthcare through the UHC, anchored in the Social Health Insurance Act, 2023.

But the pledge has remained just that, an empty pledge as the sick endure more suffering, families struggle to foot bills from their pockets, and medical facilities cry for funding as unpaid claims pile.

For example, the scrapping of Linda Mama under SHA has drawn sharp criticism, including from retired President Uhuru Kenyatta, who said the initiative improved maternal health indicators.

At least 21 women die every day in Kenya from pregnancy-related complications, a figure experts fear may rise.

But on Tuesday, Ruto and his Health CS Aden Duale defended the change, insisting the Linda Jamii plan is an upgrade because it targets the whole household.

“We must accept that we learnt lessons from Linda Mama, and that is why we designed a better Linda Jamii programme. We did not stop it, we progressed it to UHC, where we are now looking after the whole Kenyan community,” the President said on Tuesday.

But according to the Act, every expectant woman must register as a member of Social Health Authority Fund (SHIF), and pay annual premiums capped at 2.75 per cent of their income, to enjoy antenatal clinic services, delivery and post-delivery care.

Hospital stay is restricted to 48 hours for normal delivery and 72 hours for C-section. Mothers with complications pay out of pocket for the longer time.

“In case a woman develops complications after delivery, SHA does not pay for her bills. We strictly discharge a woman after three days, and while still on same bed, we re-admit her, under medical cases because SHA only reimburse three days,” said an official in one of hospitals in Nairobi, who did not wish to have the facility named, due to fear of intimidations.

Big numbers but no money

Ministry data shows at least 26.5 million Kenyans have registered with SHA, which replaced NHIF on October 1, last year. The Digital Health Agency has digitalised 3,386 of the targeted 6,500 public health facilities.

Duale says so far, 17.5 million Kenyans have visited over 10,000 health facilities. Of these, 12.5 million accessed free primary care paid by the government.

“They went to dispensaries, health centres, sub-county hospitals as outpatients and went home without paying a coin,” he said on Monday during a meeting with faith-based organisations.

But even as Kenya Kwanza administration prides in high registration numbers, only 4.5 million Kenyand are remitting their premiums.

Health CS maintains SHA has collected Sh70 billion, three times what NHIF used to collect.

This is, however, not true. SHA’s granular data shows from November, 2024, to August this year, SHA collected Sh64.3 billion, of which Sh58.8 billion is from the formal sector, while 10-month verified data is Sh85.8 billion.

The government had projected to collect Sh160 billion annually, with Sh38 billion from salaried workers and Sh122 billion from the informal sector.

Of this, Sh70 billion was earmarked for the Emergency, Chronic and Critical Illness (ECCI) Fund and Sh45 billion for the Primary Healthcare Fund (PHC). SHA operates the three funds namely SHIF, ECCI, and PHC.

The collection is low compared to what NHIF used to collect. For example NHIF raised Sh80 billion in 2023/24. Contributions of 2.75 per cent go to the SHIF kitty, whereas ECCI and PHC rely on allocations from the Exchequer.

The total requirement to fully finance UHC stands at Sh275 billion. Failure to collect enough has left  public, faith-based and private hospitals starved of Sh76 billion.

“We are basically spending more than we are collecting,” said a senior official at SHA. “From political angle, SHA is serving more people, but from financial perspective, you are absorbing a risk that you cannot finance.” 

Experts warn that low collection might collapse the scheme, if no action is taken.

XN Iraki, a professor of Economics at the University of Nairobi, observes that SHA’s biggest miss is skepticism, and that many Kenyans lack trust in it.

“It (SHA) is evolving and Kenyans ask about it. It is over marketed,” he says. “Many are still nostalgic of NHIF. We should link pay to services.” 

Nevertheless, he admits SHA is a great idea if implemented to the letter.

According to Prof Iraki, to guarantee quality care to all, the Authority should take care of those who cannot afford.

The Social Health Act, 2023, and its accompanying regulations require the National Treasury and county governments to allocate funds to support vulnerable households.

Last month, President Ruto announced that the government had committed Sh4.4 billion to SHA to cover 2.2 million indigents, representing about 558,000 households.

But these beneficiaries are yet to be identified. And a budget is yet to be set aside, raising questions about how enrollment into the scheme aimed at providing quality care to all would be managed.

The scheme has also been dogged by what it was said to cure; fraudulent claims. DCI is investigating suspected false claims amounting to Sh10.6 billion. But the investigations have been shrouded in secrecy, and no updates have been given since Duale spoke about it a month ago.

Meanwhile, section of private hospitals have been forced to withdraw SHA services. The Rural Private Hospitals Association of Kenya (Rupha) has cautioned that unless collections improve, the scheme could fail.

“SHA as a pillar, we now have experience with it. Is it working? Kenyans are told to register and get free services. It sounds good and might win elections, but if things continue as they are, SHA could collapse in three to four months,” warns Rupha Chairperson Brian Lishenga.

Shifting the focus

Dr Lishenga attributes the crisis to accumulated liabilities, financially distressed facilities, and severely depressed contributions from the informal sector.

He argues that instead of focusing on registration, health officials should shift the narrative to remittance of premiums.

Beatrice Kairu, a health economist, notes that when SHA was unveiled, it was touted as Kenya’s boldest attempt yet at delivering universal healthcare. 

But a year into its rollout, SHA “looks less like a rescue plan and more like a revenue collection machine”.

For many Kenyans, the deductions are real, but the benefits remain imaginary. 

Kairu says to its credit, SHA was built on sound theory, pooling health resources under one roof, and aligns Kenya with countries like Ghana and Rwanda’s Mutuelles de Santé, which have made impressive strides. Rwanda, for instance, boasts over 90 per cent coverage.

According to her, emphasis on primary care, if properly implemented, could also help reduce the reliance on tertiary hospitals for minor illnesses.

“SHA’s dream is quickly souring. Hospitals remain understocked, underfunded, and overwhelmed. Patients still buy basic drugs out of pocket. Families still pool money for emergencies. In effect, Kenyans are paying more but receiving less,” says Kairu.

Unclear subsidies

Subsidies also are unclear, enforcement is weak, and many of the vulnerable remain locked out.

“Instead of lifting the burden from the poor, SHA risks widening inequality by squeezing formal sector workers while offering little relief at the point of service,” she argues.

Despite health being a devolved unit, the county-run facilities remain ill-equipped and understaffed, unable to cope despite receiving primary healthcare funds.

Some counties are also not ring-fencing money for primary healthcare as entailed in Facility Improvement Fund.

For example in the recent SHA payment of Sh3.1 billion last month, the Level Five facilities received more allocations. The Rift Valley Provincial General Hospital in Nakuru received the biggest share of  Sh96,553, 620. 

Despite the pay, the facility has, for example, reported non-functional CT-scan machines, forcing patients to queue on a single functional one. It lacks drugs, with overworked human resource. Sharing of beds is also common.

And as Kenyans cry out, governors remain mute.

John Nyangi, a health financing expert, says the county administrators  have remained an extension of the national government Executive, instead of coming up with policies to improve health in the grassroots.

“Money goes to county revenue fund, and the governors are using the money for their operations and run other roles like construction of roads, yet SHA is not sending money. What do we expect? This is why mwananchi continues to suffer,” says Dr Nyangi.

“Governors have failed Kenyans. The spirit of devolution was to make county governments independent so that they can address issues of people within their respective counties independently away from influence of national government and decisions made in Nairobi,”

In a recent interview, Murang’a Governor Irungu Kang’ata defended his colleagues, blaming delays in reimbursement of money to counties, making it hard to run Level 2 and 3 hospitals where majority of Kenyans seek basic healthcare.

“SHA should reimburse money that we rarely get. There is likelihood that health at level 2, 3 is not good because of SHA,” he said.

SHA, including claims from NHIF, owes Murang’a Sh200 million.

Claims from the new health scheme are also lower compared to NHIF, according to the Governor.

Delayed reimbursements

For example, Murang’a Hospital used to receive reimbursement of Sh15 million monthly from NHIF, an amount that has reduced to Sh5 million under SHA.

“There has been no clear explanation of delayed pay to hospitals, and when we ask, we are taken round in circles,” he said.

This limits purchase of essential commodities from the Kenya Medical supplies Authority.

Kisumu Governor Anyang’ Nyong’o says delays agreed. “The government should address its functions in the new SHA that is causing a lot of unnecessary problems,” said Prof Nyong’o.

For its sustainability, Kairu says transparency and credibility is key. “Without strong oversight, SHA risks becoming a giant cash cow for bureaucrats, not a lifeline for patients. Global experience shows that health insurance schemes thrive only when three conditions are met built on trust, equity, and service delivery.” 

Already, the Office of the Auditor General has raised red flags over SHA funds not passing through the Treasury’s Consolidated Fund as required by law.

The bypass, she says, does not only undermine transparency but also fuels suspicion that SHA is a reincarnation of NHIF’s corruption-prone model.