NHIF to SHA: A year marked by reforms, strikes, and health sector controversies

Fresh allegations about funds that Kenyans are contributing to the Social Health Authority to the effect that they could be going into private accounts serve to make the year 2024, a most dramatic one in the health sector.

Even as the Social Health Authority yesterday dismissed the claims permeating new media, what they join Kenyans in taking stock of, as the year draws to a close is that the health sector has experienced a whirlwind of moments making it a most dynamic one of all sectors of the country's basic services sectors

Kenya's health sector has been marked by sweeping radical reforms, contentious policy changes and industrial unrest.

The transition of health scheme from the highly popular National Health Insurance Fund (NHIF) to the Social Health Authority (SHA) emerged as one of the most polarizing topics in the country.

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Billed as a cornerstone of universal health coverage in accordance with the Kenya Kwanza administration’s agenda, SHA reforms sort to overhaul the financing of healthcare by introducing a centralized system. That aimed to pool resources and reduce inequalities in the access to quality healthcare.

The implementation of the scheme, however, quickly sparked heated debates involving the Ministry of Health, stakeholders, and ordinary Kenyans, many of who raised concerns about difficulties in accessing health services.

Kenyans also criticized the benefits offered under the new scheme, arguing that they did not align with the deductions that were being made.

SHA was officially actualized on October 1, 2024, with NHIF ceasing operations on November 22, 2024.

Amid implementation, policy analysts and civil society groups continued to question the practicality of SHA reforms, highlighting challenges such as weak infrastructure at national and county levels, corruption, and the government's track record of mismanaging public health funds.

On the other hand, proponents of the reforms, including top government officials, maintained that SHA would improve efficiency, reduce fraud, and ensure equitable access to healthcare services.

Despite general distrust from Kenyans, Medical Services Health Principal Secretary, Harry Kimtai maintained in an interview with The Standard that SHA will serve all Kenyans unlike NHIF that he said was discriminatory - it mostly targeted the employed.

On his part, Presidential advisor on health, who is also a health economist, Daniel Mwai, told The Standard in an interview that healthcare financing has been a major challenge in the country, a matter that has now been corrected with the launch of SHA.

Mwai said the system is a creation and improvement of the disbanded one and was informed by past systemic failures.

“Insurance has people with diseases subsidized by those who do not have" He said and added "The rich subsidize the poor, and young subsidize the old, and therefrom come up with a healthcare system that is stable,” said Mwai, also a lecturer at the University of Nairobi.

SHA is governed by the Social Health Insurance Act.

The SHA Act was signed on October 19, 2023, replacing the National Health Insurance Fund Act, and established the Social Health Authority (SHA) that oversees three essential funds; Primary Healthcare Fund, Social Health Insurance Fund and Emergency, Chronic and Critical Fund.

In SHA, the exchequer caters for Primary Healthcare Fund and Emergency Chronic Critical Illness Fund (ECCIF), whereas individual contributions are made to SHIF.

Patients who deplete SHIF access care with ECCIF.

The new scheme also does not have premiums, with standardized services devoid of the amount contributed.

“SHA has to be uniform to all Kenyans. It is for all Kenyans. We are pulling resources together as Kenyans. Every Kenyan, rich or poor, will be entitled to the service,”  Kimtai said.

Under SHA health services across all hospitals in the country have been standardized, with tariffs for charges offered in private, public and faith-based hospitals being uniform.

For instance, hospital deliveries are capped at Sh11,200 for normal births and Sh32,000 for Caesarian Section (C-Section). The charges tcut across all hospitals.

Dialysis was allocated Sh10,650 per session, and peritoneal dialysis allocated Sh18,000 per month.

In the scheme, mental health services include rehabilitation for substance related addictive disorders, screening, management and referral of behavioural disorders, affective and psychoactive disorders, and mental health education.

In-patient service for mental illnesses will be allocated Sh1,200 per visit, in addition to Sh125,00 for rehabilitation.

With increased cases of cancer, the cover will remit Sh5,000 for administering chemotherapy, Sh53,500 for PET Scan, Sh40,000 for brachytherapy and up to Sh3,600 per session for radiotherapy.

Mortuary fee of Sh500 has also been included in the new scheme, a service that was not under NHIF.

Other services covered under Primary Healthcare Fund include end-of-life services and medical inpatient services.

The scope under end-of-life services include preparation and storage of a body in a mortuary, a service the cover will pay Sh500 per day capped at five days.

Controversy

Despite the ambitious scope of SHA, its rollout has not been without controversy. The issuance of a Sh104.8 billion Integrated Healthcare Information Technology System (IHTS) tender raised questions in Parliament.

The tender, initially awarded through direct procurement to a consortium led by Safaricom, was later canceled in favor of a local firm, Savannah Informatics.

The contract, which has since been dropped was signed by the Ministry of Health to digitalise health services for a period of 12 years comprises Safaricom Limited, Apeiro Limited and Konvergenz Network Solutions Limited, with Apiero, linked to Adani Group being the largest shareholder.

Safaricom, was the lead consortium in the project issued through a direct procurement.

In the tender, Safaricom was to provide infrastructure that include connectivity and servers while Konvergenz Network developed payment systems which entailed the Afya Yangu portal.

Additionally, Safaricom, Apeiro and Konvergenz were to deliver a health information that was to allow hospitals to share patients records.

The consortium was dropped following wrangling in favour of a local firm-Savannah Informatics, intended to provide a portal to process claims by private hospitals.

Implementation debate to continue in the new year

As the year closes, health experts acknowledge that  transition to SHA remains work in progress, emblematic of the broader struggles and aspirations that define Kenya’s health sector today.

The scheme requires all Kenyans to register, with deductions capped at 2.75 percent. Lowest pay to the scheme is Sh300, a drop from Sh500- what used to be paid to NHIF.

The SHA reforms require substantial funding. The Primary Healthcare Fund received Sh50 billion from the government, while SHIF is expected to raise Sh148 billion annually through member contributions. ECCIF requires Sh 75 billion annually.

However, the 2024/25 budget allocated only KSh 6.1 billion for the Primary Healthcare Fund, Sh4.1 billion for ECCIF, and Sh2 billion for SHIF.

Transition to SHA remains work in progress, emblematic of the broader struggles and aspirations defining Kenya’s health sector. Over 15 million Kenyans have registered for SHA, including 5.8 million who migrated from NHIF.

Kimtai announced the establishment of County Multi-Sectoral Steering Committees aimed at overseeing implementation of SHA.

The committee include representatives from National Government Administrative Officers (NGAOs), County Executive Committees (CECs) Faith-Based Organizations (FBOs), the Kenya Health Federation (KHF), and SHA, CECs from respective counties expected to chair in ensuring efficient operations of the scheme at grass-root level.

The committees according to the PS will monitor service delivery at registered hospitals to ensure access to quality healthcare for everyone, maintaining importance of collaboration between national and county governments.

In his State of the Nation address on November 21 President William Ruto reaffirmed his commitment to ensuring that all Kenyans have access to quality and affordable healthcare through implementation of UHC.

Ruto acknowledged immense financial burden facing majority of Kenyans, a challenge he said his administration is committed to addressing head-on.

“UHC is a cornerstone of our transformation agenda and a matter that touches on every Kenyan family,” he re-affirmed.

Troubled sector in the year (strikes)

The sector witnessed multiple strikes ranging from doctors, clinical officers and laboratory technicians.

Though not national, a number of nurses across respective counties went on strike demanding promotions, medical cover and medical covers.

Doctors  downed their tools for 56 days, whereas clinical officers and laboratory technicians were on strike for more than 90 days.

Key issues at the heart of the impasse across the cadres included the harmonization of salaries, promotions and provision of medical cover

Clinical officers on their part demanded finalizing of the 2017 Collective Bargaining Agreement (CBA) that has since stalled.

The clinical officers’ strike began on April 1, 2024, a week into the doctors' strike.

Doctors demanded implementation of the 2017 CBA. With key issues being posting and payment of intern doctors, a role the Kenya Kwanza government was accused of ignoring for about two years.

At the height of the doctors strike, Ruto directed his Chief of Staff and Head of Public Service, Felix Koskei, to find a solution to the strike. A mediator from the Labour Ministry one Linus Kariuki was appointed Chair of the negotiation committee.

The young doctors scaled up the strike spending a cold night at the Ministry of Health headquarters, in what they dubbed #OccupyMoH. 

The doctors demanded sacking of the then Health Cabinet Secretary Susan Nakhumicha accusing her of failing to find solutions to the issues disturbing them.

The strike haunted Nakhumicha who opened up during her handover of the docket to Deborah Barasa a Medical doctor.

“I really regret the time the doctors were on strike" She said "It was quite a low moment for us as a ministry. Seeing patients who need to be served and doctors are not there to serve them. I must say that that was one of the things that really was a low moment for me as I worked here,” recalled Nakhumicha.

As a solution to the numerous strikes, President Ruto appointed a task force to formulate comprehensive strategies and policies on human resources.

In his appointment, the president admitted to existing need to “assess and address current challenges and gaps in the recruitment, placement, training, and retention of healthcare professionals”.

The Prof Khama Rogo-led task force comprises of a membership of 24 and is expected to address Human Resource challenges facing the Health sector. The team is charged with identifying legal, policy, administrative and operational constraints impeding performance of the health sector in Kenya.

KMPDU welcomed establishment of the task force, having been part of a return-to-work formula that followed 56 days nationwide-strike.

“We are fully supporting the task force. We have a plethora of pending issues, and we asked for a task force in our return-to-work formula” KMPDU Secretary-General, Dr Davji Atellah told The Standard in an interview.

Doctors last week threatened another strike to commence this week. They accused the government of failing to actualize a past CBA and a return to work formula that ended the 56 days strike.

It took the intervention of Deputy President Kithure Kindiki, on Thursday December 19, for doctors to cool down their fresh anger. 

It was agreed to have intern doctors receive a pay of Sh206,000 as per the 2017 CBA. After being posted in August this year, the government had slashed their pay from Sh206,000 to Sh40,000.

Kindiki also signed to a promotion formula and  in addition to payment of Sh1.75 billion basic salary arrears.

However, Dennis Miskellah KMPDU deputy secretary general told The Standard in an interview that the strike shall be “suspended once monies hit the account”.

Diseases outbreak in the year

Kenya also reported outbreak of M-Pox, a new variant declared by World Health Organisation (WHO) as a public health emergency of international concern, is more lethal, spreads fast and causes more fatalities.

Cases of the disease are still being reported in the country, with Nakuru leading in number of infections.

The country also reported shortage of childhood vaccinations, an issue that was a concern to new borns, shortage that was attributed to a ct in budgetary allocation to the vaccination program.

Some of the vaccines reporting stock out include Bacillus Calmette-Guérin (BCG), Measles, Polio, rotavirus and tetanus vaccine.

The vaccines are given to newborns under the Kenya Expanded Programme on Immunization (KEPI) to provide immunization against six killer diseases of childhood, namely tuberculosis, polio, diphtheria, whooping cough, tetanus and measles.

It was however not all gloomy, as Kenya was commended globally for achieving viral suppression in HIV treatment and adherence, at International AIDS conference in Munich, Germany.

The United Nations Aids (UNAIDS) targets of 95-95-95 epidemic control progress report launched in Munich show that Kenya has achieved 97-97-94 against a target of 95-90-86.

The targets ensure that at least 95 per cent of the population know their HIV status, 95 per cent are put on treatment and 95 per cent have their viral loads suppressed.

In 2023, 1,378,457 Kenyans were living with HIV of whom 1,336,681 were on treatment, a gradual increase from 1.2 million in 2022.