Why most Kenyans cannot access SHA services

Stakeholders in the health sector have identified some of the challenges facing implementation of Social Health Authority (SHA) across the country.

National Assembly's Health Committee Chair James Nyikal, says inadequate funding and resistance to contribution are the two main reasons why Kenyans cannot effectively access SHA services.

According to Dr Nyikal, only four million out of the 20 million registered Kenyans are entitled to all the benefits of SHA since they are the only contributors to the Fund.

"So now, 20 million people are registered. But only 4 million people have paid for SHIF. The 20 million think they are all entitled. They are only entitled to the Primary Care Fund and Emergency Fund. Which, the truth is, we haven't put the money there. Why are we registering you as SHA and you have not paid for SHIF? Because the two funds are from the government and therefore you are entitled to those care, even if you have not paid anything," Nyikal said.

He explains that the now-defunct National Hospital Insurance Fund's (NHIF) beneficiaries were strictly contributors. However, he says SHA has three funds and that all Kenyans are entitled to only two of the services; Primary Health Care and Emergency and Critical Care.

"Social Health Insurance Fund (SHIF) is a fund you contribute to, like NHIF. SHIF is what replaced NHIF. Then there is the Primary Health Care Fund, which is to take care of level 2 and level 3 hospitals. Many are out-patient. However, we know that even in levels 4 and 5, there are outpatients. So, we are now struggling with how that can be covered as well," Nyikal says.

Ministry of Health had proposed  Sh50 billion in funding for Primary Care and an additional Sh30 billion for Emergency and Critical Care. However, Nyikal says that the fund only received Sh3 billion each.

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"That Primary Care Fund is to come from the budget and we will get to that. We propose that should be about Sh50 billion. Then there is the Emergency and Critical Care Fund. That is the fund that should take care of you. If you fall sick and you need care anywhere, you should go to the nearest hospital. However expensive it is. Emergency and Critical Care. You will then be treated and that fund should pay. That also should come from the government," Nyikal says.

He adds: "So we haven't put the money there. I said we wanted 50 billion for primary, and we wanted 30 billion for emergency. What did we put? 3 billion and 3 billion. So, the 16 million people who have not paid for SHIF have no services. And in reality, they are not entitled. Because their payer, which is the government, has not paid,"

Notably, the Health Committee chair says health is devolved and that majority of patients are served in the lower-cadre hospitals.

County governments have also highlighted the concerns and challenges they face when implementing SHA services.

Lennox Mugawari, the chairperson of the Health Committee in Kwale County cites the sluggish implementation of the Facilities Improvement Financing (FIF) Bill, as a hindrance to the adoption of SHA services.

"We have several counties that are still struggling because we understand that the FIF bill states that there must be a 100 per cent transition. But as far as the way it is delineated, we have some bottlenecks that still exist in the system that need to be addressed for the counties to now fully adopt the FIF.

I may not have the exact number of counties that have managed and those who have not managed, but some of the bottlenecks that we've experienced is that, for example, the FIF bill, requires that in every facility you must have a financing officer who is going to be handling the cash," Mugawari said.

The Bill, now the Facilities Improvement Financing Act, 2023, provides the framework for public health facilities to collect, retain, and manage revenue generated from their services, aiming to improve patient care and facility infrastructure. 

It provides for a unified system to guide financial management in public health facilities, improving efficiency and effectiveness, and ultimately quality. 

Mugawari, a county lawmaker, says counties have reached their ceiling and therefore, they are not able to employ more people.

"Then the other issue with the FIF bill is that we've seen a situation where there are some of the governors who are not ready to fully adopt it simply because they used to get the money from the health department and realign it to other priorities instead of channeling the same cash back to health so that it can improve the facilities," he stated.

Mugawari made the observations at a panel discussion during the 5th Legislative Summit by the Council of Assemblies Forum where Members of all County Assemblies were in attendance.

Kisumu was the only county that acknowledged they had successfully implemented the FIF Bill and it was functional. 

For effective service delivery in the counties, private hospitals have urged the state to upgrade health facilities by modernising records and adoption of modern equipment.

SHA was implemented on October 1, 2024, and has faced a myriad of opposition, scrutiny and backlash from Kenyans who have had challenges accessing the service.