Two years of SHA: Big promises, mixed fortunes for patients

Brenda was rushed to a private hospital in Kitale with severe abdominal pain.

Doctors diagnosed her with an ectopic pregnancy, a potentially life-threatening condition that required emergency surgery.

The 35-year-old underwent surgery and left the hospital without paying a penny.

Her Sh250,000 bill was cleared by the Social Health Insurance Fund (SHIF), administered by the Social Health Authority (SHA).

She had expected to pay out of pocket and was surprised when the bill was settled.

“I left hospital a happy person. Initially, though the surgery was a success, I was worried because I was uncertain if SHA was going to offset the bill. At the time, I was struggling financially,” says Brenda.

Her experience persuaded some of her friends and neighbours to register with SHA and begin making contributions.

But Bernard* has a different account.

On September 30, his 35-year-old son was rushed to a private hospital with acute abdominal pain after being referred from Kenyatta National Hospital (KNH), where a doctor had diagnosed him with pancreatitis, an inflammation of the pancreas.

Although his son’s SHA premiums were inactive, Bernard paid Sh32,000 to reactivate the cover before admission.

He was shocked when SHA paid only Sh4,000 of the Sh320,000 hospital bill.

“My son’s SHA account was dormant, but I activated it. I was shocked to learn that SHA only paid Sh4,000,” he says.

When contacted by The Standard on Thursday, Bernard was depositing Sh100,000 through an M-Pesa agent towards settling the bill.

“I do not know what SHA catered for. What is Sh4,000? I wish I just had this money to clear part of the bill. All in all, my son is safe, and I am happy. SHA has not been of use,” says the father.

The contrasting experiences capture the mixed realities of SHA, two years after it replaced the National Health Insurance Fund (NHIF).

While some patients report substantial financial relief, healthcare providers continue to raise concerns over claims, reimbursements and the adequacy of payments.

SHA chief executive Dr Mercy Mwangangi says the authority is strengthening claims processing, provider payments, digital systems and member support to improve access to care.

It is also promoting public awareness and regular contributions to sustain coverage.

Since its rollout on October 1, 2024, at least 33.4 million Kenyans have registered with SHA.

“With the milestone achieved, we continue strengthening access to affordable, quality healthcare for all Kenyans,” says Dr Mwangangi.

But experts have sharply criticised the registration, saying numbers alone do not guarantee access to treatment.

“The main test is whether people can now get care they need without financial difficulties,” says Allan Maleche, executive director of KELIN.

Former Kenya Medical Association (KMA) president Dr Samuel Kigondu says SHA has made important strides in registration, financing some healthcare services and establishing a new institutional framework.

However, he says outstanding debts, delayed reimbursements, concerns over financial sustainability, exclusion of vulnerable households and interruptions in service delivery remain serious challenges.

“My position has always been that UHC must protect both the patient and the healthcare provider,” says Kigondu.

“We must stop confusing the announcement of healthcare benefits with their actual delivery. We must also stop confusing the registration of Kenyans with sustainable insurance coverage.”

According to the doctor, the scheme's success should be measured by whether Kenyans can obtain quality care when they need it without being pushed into poverty.

“Two years later, the promise of SHA remains important. But the promise must now be converted into reliable services, financial protection and sustainable healthcare financing,” he says.

In response, Dr Mwangangi says access to services has increased alongside registration, with significant resources flowing to healthcare facilities.

Through the Primary Healthcare Fund alone, SHA has disbursed approximately Sh29.7 billion to providers.

The Facility Improvement Financing framework also allows public facilities to retain and use eligible revenue to improve services, including purchasing essential medicines and supplies and acquiring equipment.

“These are not just statistics. Behind these numbers are mothers delivering safely, cancer patients accessing life-saving treatment, renal patients receiving dialysis, and families receiving healthcare services that would otherwise impose a significant financial burden,” says Dr Mwangangi.

She says SHA has financed more than 30 million primary healthcare visits, 1.3 million deliveries, over 545,000 surgical procedures and care for 53,000 cancer patients.

The authority also funds emergency care for up to 24 hours and has established a national ambulance centre, accessible through the 922 helpline, according to the CEO.

Other gains include an expanded network of contracted healthcare facilities, increased sponsorship for vulnerable households and stronger digital systems.

Former Rural and Urban Private Hospitals Association of Kenya (RUPHA) chairperson Brian Lishenga acknowledges improvements in SHA's information technology systems, saying patient authentication has stabilised and hospitals receive payments monthly.

However, he says the payments cover only about 15 to 30 per cent of claims submitted.

He also raises concerns over the settlement of outstanding NHIF debts, saying some providers were forced to write off a substantial portion of the money owed to them.

“NHIF bills were only partially settled for those owed less than Sh10 million. Most wrote off more than 60 per cent of claims,” says Lishenga.

He says primary healthcare facilities are particularly affected by unpredictable payouts that do not match the services provided.

As a result, patients continue to incur out-of-pocket expenses for outpatient services, while facilities struggle to finance service improvements.

Lishenga also cites high rejection rates for inpatient claims, particularly maternity services, with some facilities reporting rejection rates of up to 50 per cent.

“ The rejection rate is not accompanied by explanation in most cases and an internal dispute resolution mechanism does not exist for appeals on these rejections,” says Lishenga.

On the issue, Dr Mwangangi says SHA continues to strengthen claims processing, provider payments, digital systems and member support to facilitate timely access to care.

Beyond payments, Lishenga questions the emphasis on expensive specialised services, such as cancer treatment and dialysis, arguing that primary healthcare deserves greater attention.

According to Lishenga, a national social insurer must prioritise common health needs and early treatment, particularly among vulnerable populations, rather than concentrate resources in a few large hospitals.

“A few hospitals account for over 70 per cent of SHA payout. These hospitals are concentrated in large cities and towns. The average rural Kenyan is left behind,” he says.

But Dr Mwangangi dismisses the claims that SHA disproportionately benefits large urban hospitals, saying its financing model is designed to promote equitable access.

Through the Primary Healthcare Fund, SHA finances essential services at Level 2, Level 3 and selected Level 4 facilities, many of which serve rural and underserved communities.

Access to primary healthcare, she adds, does not depend on whether members are up to date with their SHIF contributions, allowing vulnerable households to obtain essential services.

The aim, she says, is to promote prevention, early diagnosis and timely treatment, reducing the need for more expensive specialised care.

“SHA’s objective is to strengthen healthcare delivery at all levels, ensuring that healthcare needs are addressed close to home while specialised services remain accessible when required,” says Dr Mwangangi.

Nevertheless, Lishenga argues that the benefits package must be reviewed to reflect the actual cost of providing care, including rising salaries, medical supplies and equipment.

“What SHA pays for services is basically what NHIF used to pay seven to eight years ago. But you know costs change; inputs have become more costly-inflationary pressure. Salaries have changed. Cost of implants has gone up,” he says.

Kigondu echoes the concern, arguing that the cost of providing treatment is often confused with the price at which SHA purchases a service.

“Costing has not been done. Costing is often confused with purchase price,” he says.

He cites deliveries as an example.

Under SHA's gazetted tariffs, facilities receive Sh10,000 for a normal delivery and Sh30,000 for a Caesarean section, regardless of whether they are public or private, urban or rural.

Kigondu argues that these rates do not necessarily reflect the cost of staffing, infrastructure, supplies and other resources required to provide safe maternity care.

“Let us assume the cost of a safe delivery is Sh50,000. Kigumo will charge Sh10,000 because the cost of labour is subsidised by the government, and costs of supplies are subsidised by KEMSA; the government does not pay rent,” he says.

“Most patients are forced to top up. The real cost of normal delivery is definitely not Sh10,000,” he adds.

SHA CEO, for her part, explains that SHA tariffs are determined through a structured process guided by clinical standards, healthcare costs and service utilisation.

“Standardised tariffs promote consistency, equity, and efficient financing of healthcare services across contracted facilities,’ explained the CEO.

She highlighted that, with the ongoing review of the benefit package, the authority is engaging stakeholders: patients, lobby groups, provider associations, drug manufacturers, and equipment vendors.

“SHA works closely with the Benefits Package and Tariffs Advisory Panel (BPTAP), which provides independent technical advice on the review of healthcare benefits and payment rates,” said the CEO.

The review, she added, also draws on feedback from patients, healthcare providers, and other stakeholders to ensure benefits respond to Kenyans' healthcare needs while remaining affordable and sustainable.

mkahenda@standardmedia.co.ke