Sick nation: Crisis as private and mission hospitals halt SHA services

The country is on the brink of a health crisis if private and mission hospitals make good on their threat to suspend services today over Sh30 billion pending bills.

Private and mission hospitals across the country have vowed to deny patients services, except for emergency cases requiring life-saving intervention.

The facilities are demanding payment of National Health Insurance Fund (NHIF) arrears amounting to Sh30 billion. The debt dates back to 2017 and is owed to public, private, mission and faith-based hospitals.

There are at least 650 hospitals across the country under this umbrella.

According to a notice issued by the Rural and Urban Private Hospitals Association of Kenya (RUPHA), the suspension of services follows the halting of Social Health Authority (SHA) and Medical Administrator Kenya Limited (MAKL) schemes, which cover police officers and teachers.

After being stabilised, emergency patients relying solely on their SHA medical covers will be referred to a hospital of their choice.

No new admissions or outpatient services will be offered from today (Monday) for patients using SHA and MAKL medical covers, whereas patients admitted under SHA or MAKL before today will continue to receive care under existing terms.

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“Patients seeking SHA or MAKL services at the point of service shall be informed that services are temporarily unavailable,” reads a section of RUPHA’s guidance notice.

Pay cash

RUPHA chairperson Brian Lishenga said affected patients will be informed that SHA and MAKL services are unavailable until further guidance from SHA or MAKL is provided.

Under the directive, patients will be given the option to pay in cash, seek treatment at another hospital that accepts SHA and MAKL covers, or use an alternative medical insurance scheme, if available.

However, patients admitted before today (February 24) will continue receiving treatment.

“From (Monday), we shall not provide services to SHA holders unless they pay in cash or present an alternative medical cover for treatment,” Dr Lishenga told The Standard.

Lishenga maintained that despite numerous promises, the government lacks a concrete plan to clear the debt.

The official said the suspension was decided due to the government’s failure to commit to clearing the debt.

At least 94 per cent of RUPHA’s services are SHA-contracted.

“We only have promises. We are aware that the Ministry of Health has been lobbying the Treasury but has not committed any funds,” Lishenga said.

He said that although some claims by SHA, which replaced NHIF, have been cleared, patients registered with the new scheme will not receive services.

“NHIF settlement is non-negotiable, and paying SHA is not a favour but payment for services rendered. NHIF liability is non-negotiable,” he asserted.

The lack of funds, he said, had left hospitals struggling to provide services. “How do we offer SHA services when we have no money to operate?” asked Lishenga.

Essential medicines

He said that in 2019, NHIF archived claims worth Sh6.9 billion, some of which have never been cleared.

“If we archive Sh30 billion, hospitals will shut down. They are not going to bribe us by paying SHA claims. Let them clear NHIF. Money was deducted from civil servants’ salaries but never remitted. They have to pay NHIF arrears. It’s non-negotiable,” said Lishenga.

He noted that NHIF employees seconded to SHA, who could authorize claims for payment, are being laid off in three months as their contracts come to an end.

“Who will pay the claims? They have to pay. It has to be first in, first out.”

Failure to clear the debt has resulted in financial struggles, with some hospitals laying off employees.

Hospitals have also defaulted on loans and overdrafts used to sustain operations while awaiting payments. The facilities are also struggling with stock-outs of essential medicines.

“Pharmaceutical suppliers have blacklisted hospitals that cannot clear outstanding bills.”

“As healthcare professionals, our first duty is the welfare of our patients. However, the continued failure to address critical challenges in the SHA transition is now directly endangering the quality and sustainability of care in our hospitals,” Lishenga added in an interview.

When he appeared before the National Assembly’s Health Committee last week, Principal Secretary for Medical Services Harry Kimtai and acting SHA Chief Executive Officer Dr. Robert Ingasira promised to have the debt settled.

Nyeri Catholic Archbishop Anthony Muheria has also appealed to the government to clear the debt to ensure the smooth flow of services.

With the accumulated debt, hospitals have raised concerns over tax burdens on non-existent income. Hospitals are required to declare NHIF claims as income for tax purposes, despite these claims remaining unpaid. This has led to tax liabilities and penalties, further depleting meagre resources.

Lishenga said SHA had “flatly” refused to settle these debts, arguing that NHIF liabilities are not its responsibility.

RUPHA hospitals have also declared they will no longer provide care under the MAKL scheme, which covers police officers and teachers.

According to hospitals, MAKL had failed to pay them for over 11 months, forced them to accept arbitrary and unexplained discounts, and favoured its own clinics.

“Without urgent government intervention, teachers and police officers will be left without quality healthcare services, further straining public hospitals already at breaking point,” said RUPHA in a statement.

SHA replaced NHIF on October 1, 2024.

According to Kenya Health Facility Census of 2023, 71 per cent of all hospitals in Kenya are Level 2, with 48 per cent being government, 47 per cent private while five per cent are faith based.

The report shows that 20 per cent of hospitals are Level 3, while 7 per cent  are level 4, with only less than one per cent being Level 5 and 6.

In the report, private hospitals are responsible for 46 per cent of healthcare in the country.

“This is not a RUPHA issue, but a national issue. It is a national issue affecting all healthcare facilities. If not, why are Kenyans complaining of not getting quality services? Posed Lishenga, adding that at least eight million out of 19 million registered SHA members seek services in private hospitals.

Referral letter

A hospital administrator at a Level 5 hospital in Western, who sought anonymity, told The Standard that from today, the hospital will not provide care.

Services offered at the hospital include maternity, full patient care, imaging, surgical, dialysis, ICU and burns. At least 90 per cent of the services were offered under NHIF, but with SHA, care has dropped.

“We don’t want patients to suffer, but with suspension, it means most patients will have to pay for services,’ said the administrator.

According to him, the SHA model of operation locks patients from care as it requires a referral letter from a lower facility, only for them to lack personnel and drugs.

“The reason why patients flocking to private hospitals, and Level 4 and 5 hospitals is because dispensaries are not functioning,” he observed.

He added: “SHIF came to solve primary healthcare problems without availing solutions. The government should have invested in primary, to deliver the care, but this is missing.”

The suspension, according to the administrator, will affect patients as they will pay SHA but will not get services.

Failed portal

Some mission hospitals across the country are not providing SHA services, but are reluctant to speak out due to fear of victimization.

A Catholic Hospital in Bungoma said it is charging SHA card holders because they need an alternative source of revenue.

According to RUPHA’s transition scorecards, findings from this month highlight deepening dysfunction in the SHA system.

For instance, SHA portal failures were reported by 89 per cent of hospitals, making it impossible to process reimbursements.

As a result of the failed portal, hospitals cannot track claims, leading to massive payment delays.

The report highlights delayed payments, with 54 per cent of hospitals having not received any payments from SHA since December 2024.

Additionally, patient verification failures were noted, with 83 per cent of hospitals reporting difficulties verifying patient eligibility due to SHA system glitches.

At least 74 per cent of hospitals reported being unable to reach SHA for claims and related queries, with calls and e-mails going unanswered.

Efforts by The Standard to get a comment from Health CS Deborah Barasa and top ministry officials on the matter were unsuccessful.