Kenyans have questioned the effectiveness and affordability of the newly introduced Social Health Insurance Fund (SHIF), with a section adamant about a transition from the National Health Insurance Fund (NHIF).

Whereas members of the public remain sceptical about the full spectrum of SHIF's benefits, the government has assured Kenyans that the new health cover is an upgrade from NHIF, offering many more health benefits to the general public.

The Social Health Authority (SHA) was established under the Social Health Insurance Act, 2023 (SHI Act) which repealed the NHIF Act No. 9 of 1998. SHA has three Funds namely SHIF, Primary Healthcare Fund (PHCF), and the Emergency, Chronic and Critical Illness Fund (ECCIF).

These Funds are intended to ensure the full spectrum of healthcare is given attention from prevention, promotion, curative, rehabilitative and palliative care. 

For years NHIF has been criticised for offering selective coverage, alienating a section of Kenyans from accessing specific services or partially covering services and leaving the rest to the expense of Kenyans.

For instance, NHIF offered outpatient services where members and their dependents chose their preferred outpatient facility. The focus was also curative care only. The SHI Act has introduced the PHCF to cover outpatient services at dispensaries and health centres. 

NHIF made members choose their facilities, therefore limiting them from accessing services in case they fall sick away from their selected facilities. With SHI, preventive and promotive care in the outpatient services are available.

Members begin utilizing SHIF once they are referred from primary care levels (Levels 2 to 3) to higher-level facilities (Levels 4 to 6). If a member exhausts the necessary level of care at these facilities using the insurance cover under SHIF, the Emergency, Chronic and Critical Care Fund becomes available.

While NHIF limited outpatient services to consultation, drugs, lab tests,KEPI vaccines, and elements of co-charging for chronicdisease medicines - under SHIF, Kenyans will also access specialized lab tests and treatment for critical conditions and illnesses.

On inpatient services, besides medical admissions, bedcharges, nursing charges, lab, radiologyexaminations and drugs covered by NHIF, Kenyans will also access critical care services – ICU, HDU; andspecialized lab tests and medicine.

For maternity services, NHIF only covered ANC, PNC, and deliveries;- attracted co-payment in the event ofcomplications for mother/baby. SHIF has incorporated services mothers accessed through LindaMama Cover and enhanced it from delivery at Ksh4,000to reimbursement at Ksh11,200 (constitutes about a 180 per cent increment) for normal delivery and Ksh32,600 for CS.

The mental and behavioural health package under NHIF attracts copayment. SHIF will cover the full payment of treatment costs from levels 2 to 6.

Kenyans rehabilitating from drug abuse will also have SHIF pay for their occupational therapy sessions, physical therapy sessions, speech-language therapy sessions, detoxification and drug rehabilitation.

For surgical services, SHA will also cover minor, major and specialised surgical proceduresincluding organ transplants, and implants, post-operative visits, pain management, wardphysiotherapy, immunosuppressive therapy organtransplants and an expanded scope of surgical services. 

NHIF does not cover NCD screening, whereas SHIF will cover clinical breast exams, cervical cancer screening (VisualExam – VIA/VILI) and HPV testing, prostate exam (Digital rectal exam and prostate-specificantigen test), and Colorectal cancer screening (faecal occult blood test).

Sickle cell management is not covered under the current cover, however, SHIF will pay for sickle cell disease screening for newborns, drugs for sickle cell and also for red cell exchange.

Currently, under dialysis healthcare services, NHIF covers haemodialysis - limited by sessions, peritoneal dialysis with co-payment, (Two (2) sessions covered per week hencepatients requiring three (3) sessions co-pays). SHIF will additionally cater for the management of chronic or acute kidney failure such ashaemodialysis and peritoneal dialysis. All recommended sessions will also be covered.

NHIF covers up to Ksh500,000 for kidney transplants. The new cover will also cater for pre-transplant evaluation for donor andrecipient including post-transplant management.

Other than the current oncology service already covered by NHIF, SHIF will also pay for the management of pre-cancer cervical lesions, diagnosis and treatment distributed among the 3 Funds (PHCF,SHIF, ECCIF), early cancer treatment such as cryotherapy,thermoablation and LEEP.

SHIF will also cover MRI & CT scans limited to oncology cases, cardiac andtrauma cases, and CT scan for accidents and emergency in addition to the radiology services already covered by NHIF.

NHIF does not cover assistive services. SHIF will provide supervision and training in the use of assistive devices – mobilityaids, prostheses, orthosis, hearing aids, mobility aids,clubfoot brace and gait belts.

In the case of emergency evacuation, NHIF only covers road ambulance services for membersonly whereas SHA incorporates accidents and emergencies paid for all Kenyans, and pre-hospitalization stabilization.

Whereas NHIF does not cover critical care, SHIF will care for admissions in the intensive care unit (ICU),High Dependency Unit (HDU), NICU, PICU, and Burns unit.

Under palliative care, SHIF will cover care for terminal cancer cases, chronic conditions, and pediatric conditions, Inpatient care, home-based care, commodities, assistivedevices, and pain management.

NHIF does not cover mortuary fees. On the other hand, SHIF will cover daily rates up to a maximum of 5 days including bodypreparation.

Emergency care is available to all Kenyans regardless of membership status. According to the Kenyan Constitution (2010), everyKenyan is entitled to the highest standard of medical care. Specifically, Article 43(2) ensures that no Kenyan can be refused emergency medical treatment,thereby securing access to emergency care whenever required.

Under emergency treatment, SHA will ensure the expansion of services not covered under SHIFmembers and their dependents exhaust level of careunder the SHIF, they will have access to this Fund thataims to lessen the burden of sustained treatment forcritical and chronic conditions such as cancer.

LINDA MAMA

 Kenyans have raised concerns over the scrapping of Linda Mama, with a section claiming that the move will make maternity services expensive and might increase infant mortality rates should mothers choose to seek cheap, unsafe midwifery services.

What happens to expectantwomen and mothers nowthat Linda Mama coverhas been terminated?

SHA aims for universal coverage, extendinginsurance to households, where mothers are automaticallyincluded for coverage without needing a separate plan.

Previously, there was a maternity package that also existedunder NHIF. Paid-up NHIF members had access to twoseparate maternity covers: one through NHIF and theother through Linda Mama Cover. NHIF provided coveragefor childbirth and related services at a higher costcompared to Linda Mama.

Now, this coverage has been unified into a standardpackage for all, encompassing delivery services,reproductive health services, and management ofpregnancy, birth and post-natal complications.

Thecoverage amounts have been increased significantly,ranging from an average of Kshs. 10,000 for normaldeliveries to Kshs. 32,000 for Cesarean sections. A plus for mothers who initially did not afford to make NHIF monthlycontributions.

EDU AFYA COVER

How about the Edu AfyaCover? Are wedisadvantaging schoolchildren?

Edu Afya's cover has been redesigned tostreamline and enhance healthcare coverage andaccess. This strategic move allows for theconsolidation of resources and focus on expanding thereach and impact of SHI which now includescomprehensive coverage for households who includethe learners.

By aligning efforts under this unified approach, thegovernment aim to ensure equitable access to essentialhealthcare services for all members of the community.

Health Insurance Subsidies for Orphans, Vulnerable Households, the Elderly, and PWDs

What happens to programslike health insurancesubsidies for orphans,vulnerable children, olderpersons, persons living withsevere disabilities, andindigent families supportedby the government?

The SHI Act,recognizes a household as a social unit consisting ofan eligible contributor—whether contributingindividually or through sponsorship—and theirdependents.

Identification of these segments of the population will beconducted via means testing tools to determine theirfinancial capacity.

Those identified as unable to pay willreceive government-funded support. This approachensures equitable access to healthcare, affirming ourdedication to fostering inclusive healthcare coverage for allindividuals and households in need. 

UNIVERSAL HEALTH COVERAGE (UHC)

Rollout of SHI aims to improve healthcare access andequity for all Kenyans and residents. Under the SHIAct, all persons are to enrol with SHA, expandingaccess to quality healthcare services and addressingcoverage gaps.

The financing model is also progressiveand purposed to be sustainable with an expandedscope of the benefit package which will ultimatelyimprove the health outcomes. 

ACCOUNTABILITY

For years, NHIF has been a crime scene, rocked by scandals of financial mismanagement year after year. This has raised accountability concerns among members of the public as the government plans to roll out SHA.

According to the Ministry of Health, SHA is purposed to commence on a cleanslate by conducting recruitment of its own staffwhile giving staff of NHIF priority (afterrelevant due diligence tests).

SHA services are to be delivered via acentralized digital platform. The platform isaimed at improving efficiency, reducing humancollusion, increasing accountability, and delivering quality services. 

The SHA Board and staff are subject to thelaw, scrutiny and audit by public authoritiesincluding a competent Dispute ResolutionsTribunal where any grievance under the Actmay be channelled to.