The government has clarified what healthcare coverage the Social Health Authority offers to patients in the Intensive Critical Units (ICU) and High Dependency Units (HDU).

Following public outcry on what the new programme offers, the Ministry of Health has set the record straight on what patients can expect from the service.

“In light of recent concerns regarding the extent of SHA coverage, we wish to clarify the framework governing SHA’s benefits and tariffs. The Ministry of Health confirms that SHA’s coverage is based on gazetted tariffs to the benefits, published in November 2024.

“These tariffs ensure sustainable healthcare coverage and equitable access while maintaining a shared responsibility model. In cases where hospital charges exceed specified limits, beneficiaries may be required to make co-payments. Regarding ICU and HDU services, SHA provides for admissions in critical care units and high dependency units (ICU and HDU).

“The provider payment mechanism (PPM) is a per diem rate, and the rate depends on the type of facility visited as follows: level 4 – Ksh3,360 per day, level 5 – Ksh3,920 per day, and level 6 – Ksh4,480 per day,” a statement from the ministry on Sunday, December 15, 2024, said.

Limit

It added that each household has a limit of 180 days per year for access rules and that members can access service from empanelled and contracted Level 4-6 facilities.

“The members will top up any amount that exceeds the above cover limit (co-pay). The cover limit is the same for public, faith-based, and private facilities,” it added.

The ministry also outlined the challenges SHA has faced and how it hopes to address them.

“SHA is proactively addressing emerging challenges to ensure seamless access to all services like cancer management, renal care, maternity, and outpatient care. We are committed to removing any barriers that may hinder access, ensuring beneficiaries face no hurdles in obtaining the care they need.

“As such, the ministry is fastening the pace of constituting a committee pursuant to Social Health Insurance Regulations to review tariffs and benefits. Based on feedback from stakeholders gathered over time, the committee will be expected to review and provide practical solutions and make informed recommendations,” it added.

The government will depend on the committee’s report to address both short- and long-term interventions to ensure SHA sustainability and responsiveness to the needs of Kenyans.

“As we await the committee’s report’s outcomes, the government encourages all Kenyans to enroll in SHA and informal sector members to undertake means testing and remit their premiums to ensure the continuity of service delivery,” it concluded.