Gaps in new health insurance scheme hurting patients

Homa Bay County Referral Hospital nurses attend to a patient with gunshot wound. [File, Standard]

One month after its rollout, the new Social Health Authority (SHA) is exposing critical gaps in the nation’s healthcare system, leaving thousands of vulnerable patients stranded and healthcare providers increasingly frustrated, as the Ministry of Health waxes lyrical about its success.

The transition from the National Health Insurance Fund (NHIF) to SHA has been anything but smooth.

 Critical patient groups, particularly those grappling with cancer and renal issues, are bearing the brunt of a chaotic implementation. Despite having paid their contributions to the defunct NHIF, these patients now face potentially life-threatening delays in accessing essential medical services.

George Gibore, the secretary-general of the Kenya Union of Clinical Officers, sums it up.

 “What we’re witnessing is not just a technical glitch, but a fundamental breakdown in healthcare delivery,” he says, adding, “The SHA system is plagued by technological instabilities and procedural complications that are creating widespread frustration among healthcare providers and patients alike.”

Smooth transition

The ministry, however, reads success in its run.

 Medical Services Principal Secretary Harry Kimtai claims the transition is progressing smoothly.

“As of today, 13.34 million Kenyans have registered under SHA, including former NHIF members and new registrants,” Kimtai announced during a press briefing on October 30, 2024, to mark the first month since the rollout.

He highlighted a daily registration surge of 91,000 Kenyans and maintained that the target of registering the entire population by December 2024, is still on.

Davji Atellah, Secretary General of the Kenya Medical Practitioners and Dentists Union (KMPDU), provides critical insights into what he terms as a system plagued by operational challenges.

“The SHA was rolled out urgently without ensuring the system was fully operational to guarantee access to care,” he explains.

In the initial weeks, hospitals—both public and private—struggled to deliver services. The new system’s infrastructure was inadequate to ensure healthcare providers would be compensated for their services.

Consequently, Davji adds, many facilities resorted to demanding out-of-pocket payments from patients, effectively undermining the universal healthcare vision.

Stark implications

According to the KMPDU chair, the financial implications are stark. “With approximately 30 billion Kenyan shillings owed to hospitals and lingering uncertainties about payment mechanisms, many healthcare facilities remain hesitant to offer services under the new system,” he notes 

Moreover, the benefit packages have been significantly reduced, adds Davji. He notes that services like dialysis, which were previously offered twice a week, have been cut back.

“Capitation rates have decreased, and certain specialised treatments such as oncology brachytherapy, have seen funding slashed by nearly 50 per cent.”

These reductions translate into real human suffering. Phoebe Ongadi, the executive director of the Kenyan Network of Cancer Organisations, is unequivocal.

 “The current situation is untenable and jeopardises the health of cancer patients across the country,” she states.

With cancer being the third leading cause of death in Kenya — claiming approximately 44,700 new cases and 29,300 lives annually — these systemic failures are not mere administrative errors but potential death sentences, she states.

The implementation has also revealed significant regional disparities.

While urban centres, like Mombasa, show progress, marginalised counties such as Isiolo, Marsabit, and Turkana report minimal support, threatening the reform’s fundamental objective of equitable healthcare access.

Technical challenges further compound these issues.

At facilities like Kisii Referral Hospital, persistent system downtimes have disrupted critical processes like claims management and patient pre-authorisation.

“New referral guidelines requiring patients to first seek services at lower-level facilities before accessing advanced care have added layers of bureaucratic complexity,” Says George Gibore.

As of October 28, 2024, while 13,338,143 Kenyans have registered and 7,563 health service providers have been on-boarded, these statistics mask deeper systemic problems.