What new health scheme will offer under scaled down budget

Following a scale-down in budgetary allocation for the public health sector in the recently tabled national budget, the government has released revised medical scheme rates that will see Kenyans dig deeper into their pockets for medical services.

Pregnant women seeking delivery are some of the most affected.

In the 2024/25 budget, free maternity health care was allocated Sh2 billion, a slash from the initial Sh4.1 billion.

Under the Social Health Authority (SHA) tariff, the scheme will remit Sh11,200 for normal deliveries and Sh32,600 for Caesarian Section (C-Section).

Maternity, neonatal and child health services will also be offered under Social Health Insurance Fund (SHIF) at a tariff of Sh11,200 for normal delivery and Sh32,600 for C-Section.

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However, there is another rider under both funds (Primary and SHIF). Hospital stay is restricted to only 48 hours for normal delivery, and 72 hours for C-Section. 

Mothers with complications beyond 48 hours of normal delivery and 72 hours of C-Section, will have to undergo fresh vetting before accessing services under SHIF.

Other packages to be provided under maternity, newborn and child health services (SHIF) include immunisation of newborn and postnatal family planning. 

Health experts and economists have faulted the new tariffs, saying the offer is low in comparison to the 2.75 per cent deductions for the salaried.

In the tariff, Public Healthcare Fund has a capitation of Sh900 per person per year that will offer services at Level 2 and 3 hospitals.

“SHIF tariffs are too low to cover for deliveries. Deliveries cost more than Sh11,000 and Sh32,000 that have been allocated in the new medical schemes. I doubt if this was costed properly,” observes John Nyangi, a health research analyst.

Prof XN Iraki, an Economist at the University of Nairobi, questioned whether current market pricing was considered while coming up with the tariffs.

"Are they based on market prices? Do they consider the earning capacity of citizens?" Posed the economic expert. 

Delivery by C-Section is charged over Kshs 35,000 in most hospitals across the country.

Under the repealed National Health Insurance Fund (NHIF), benefits for deliveries were covered under the Linda Mama programme established in 2016, which benefits more than one million women annually.

Health NGOs’ Network (HENNET), on its part, has raised concerns over the maternal Antenatal Clinic (ANC) profile that has not been included in the new tariff.

The package, according to the organisation, is a crucial diagnostic examination used to monitor overall health of a pregnant woman and her unborn baby.

 “ANC profile should be included in the package and costed,” says HENNET.

The organisation also faults the low delivery package, saying it might either compromise the quality of service or force people to pay extra funds to cover maternity-related costs.

Currently, Kenya records at least 6,000 maternal deaths annually, with 21 neonate deaths out of 100,000 live births.

Apart from deliveries, primary healthcare fund caters for screening and management of pre-cancerous lesions which will be offered at Level 2, 3, 4, 5 and 6 hospitals.

The scope will include screening for common cancers, including  breast, cervix, prostate and colon.

For Human Papillomavirus (HPV), the tariff has been set at Sh3,600 and Sh1,500 for prostrate tests.

In the new package, prostate cancer screening will only be covered to males aged over 55 years, whereas colon cancer screening will only be coved in males over 40 years

In women, screening for cervical cancer will only be covered to those aged between 30 and 50 years.

Age capping is a drawback to early diagnosis of cervical cancer which kills at least nine women every day in the country. The disease manifests in younger women ages, according to health reports.

Additionally, primary healthcare fund will pay Sh935 for consultation and dispensing of eyeglasses, with a limit of Sh1,000 per household, a service which is limited to beneficiaries below 18 years.

Other services covered under primary healthcare fund include end of life services and medical inpatient services.

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

The new medical scheme has three funds, namely Primary Healthcare Fund, Social Health Insurance Fund (SHIF), and the Emergency, Chronic and Critical Illness Fund.

In the appropriation budget read by National Treasury and Planning Cabinet Secretary (CS), Prof. Njuguna Ndung’u last week, Sh4.1 billion was allocated for Primary Healthcare Fund, whereas Emergency Chronic and Emergency Illness Fund got a share of Sh2 billion.

SHIF will be funded by premium contributions pegged at 2.75 per cent for all Kenyans. It will cater for consultation, diagnosis and treatment, prescribed laboratory investigations, basic radiological examinations, including X-rays and ultrasound.

Other services in the fund include management of acute and chronic conditions, together with endemic, non-communicable and neglected tropical diseases.

It will also cover screening for common diseases, minor surgeries and immunization, apart from reproductive, maternal and child health services. For the services, the fund shall remit Kshs 2,000 per person and beneficiaries.

Individuals, however, have a limit of only four visits per year per person.

"For chronic health, the cover is only for SHIF paid-up members. This is a contradiction to what the government had promised—having all Kenyans under SHIF," notes HENNET.

Tariff for medical inpatient services is between Sh3,500 to Sh5,000 at Level 4, 5 and 6 hospitals respectively.

However, services issued under the fund are limited to up to 50 days per household annually.

Services offered under medical inpatient services include pre-admission evaluation, hospital accommodation charges, meals, and nursing care in a general ward bed.

Patients with kidney failure will undergo a maximum of three sessions per week, with payment made from SHIF and Emergency, Critical and chronic illness Funds. 

Care will be provided at Level 4 to level 6 hospitals.

Dialysis has been allocated Kshs10,650 per session, and peritoneal dialysis allocated Sh180,00 per month.

But HENNET says the maximum allocation for dialysis is ambiguous, leaving room for downward review of the number of sessions.

Also, the health organisation proposes to have dialysis “expanded to level 3 hospitals to accommodate stand-alone dialysis units”.

It is however a win for patients battling mental illnesses, since the scheme includes mental health services, a component that was unheard off in NHIF.

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

Inpatient services for mental illnesses will be allocated Shs 1,200 per visit, whereas inpatient services at Level 4, 5, and 6 is Sh3,500, Sh4,000 and Sh5,000 respectively.

The cover has a tariff of Sh125,00 for rehabilitation.

Additionally, the cover is expected to cater for surgical services under SHIF, including minor and major operations.

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

Currently, NHIF pays for up to 16 chemotherapy, and 21 radiotherapy sessions for any patient with a cover.

The cover has a limit of Sh400,000 from SHIF and  Sh250,000 from Emergency, Critical and Chronic Illness Fund.

Meanwhile, all Kenyans will benefit from emergency, Chronic and Critical Illness Fund, services not offered under NHIF.

Accident survivors will also access care at Level 2 to 6 hospitals. The cover includes cardiac pulmonary arrest, major trauma, shock states, and anti-snake venom administration among others.

The tariff for ICU is Sh35,000, only paid for 14 days, whereas High Dependency Unit (HDU) will be allocated Sh10,000 for up to 10 days.

Patients with chronic and life-threatening diseases have a tariff of Sh5,000 payable up to 60 days.

Chronic illness scheme will cater for diseases beyond the SHIF limit, for example diabetes, hypertension, heart diseases, asthma, cardiovascular, sickle cell, dialysis and pre-transplant.

The fund will also cater for cancer patients who deplete their SHIF cover.

Health Cabinet Secretary Susan Nakhumicha has drummed up support for the cover, saying it will guarantee quality healthcare.

In a previous media interview, Nakhumicha maintained that the new scheme has no schemes like NHIF.

But health experts opine that SHA funding is too low to cover essential services for inpatient and outpatients.

“Currently, civil servants enjoy unlimited outpatient of up to Sh100,000, depending on job groups or households. Under SHA, it is Sh900 per person,” said Nyaga. 

HENNET notes that even as the government is sharing tariffs, there is need to improve health infrastructure to meet the level of services indicated; the case of note being the  many levels 3 facilities that do not have theatres hence being unable to offer C-Section services.

"The transition from NHIF to SHIF needs to be communicated to people, for instance, those who are self-employed and would like to make bulk payments are not able due to the uncertainty.