The Ministry of Health has unveiled a new framework to finance overseas medical treatment for Kenyans under the Social Health Insurance (SHI) scheme.

Managed by the Social Health Authority (SHA), the programme will fund up to Ksh500,000 per beneficiary for specialised care unavailable locally.

In a press release, Cabinet Secretary for Health Hon. Aden Duale said the policy, which takes effect immediately, aims to ease access to life-saving procedures abroad while strengthening Kenya’s health system.

“The maximum limit payable for overseas treatment/procedures is capped at Ksh 500,000, subject to review upon completion of contracting and rate negotiations with accredited providers abroad,” read the statement.

The Ksh500,000 ceiling on overseas treatment will also be reviewed after completion of contracting and rate negotiations with accredited providers abroad.

The initiative replaces the previous arrangement under the defunct National Health Insurance Fund and is anchored in the Social Health Insurance Act, 2023, its attendant regulations, and the Public Procurement and Asset Disposal Act.

“The Ministry of Health, through the Social Health Authority (SHA), is proud to announce a new era for specialised medical care for all Kenyans under the Social Health Insurance (SHI) scheme. This milestone is a testament to the government’s commitment to ensuring that no Kenyan is denied access to life-saving, specialised medical and surgical procedures not yet available locally, while simultaneously strengthening our national health system.”

Eligibility and referral process

Under the new rules, SHA will only reimburse healthcare providers empanelled and contracted by the authority.

Beneficiaries must have up-to-date contributions and demonstrate that the required service is unavailable in Kenya. Overseas facilities must also be accredited in their home country and recognised by Kenyan regulatory bodies, with a mandatory link to a local contracted facility for follow-up care upon return.

The press release notes that a beneficiary can only access treatment outside Kenya if the healthcare service is not available locally. The beneficiary’s contributions must also be up-to-date. The treatment must also be provided by an SHA-contracted health facility.

“Overseas facilities must be accredited in their home country and officially recognised by the relevant regulatory body in Kenya. A key requirement is that these overseas providers must be linked to a contracted health facility in Kenya to ensure continuous follow-up care upon the beneficiary’s return.”

Referrals for overseas treatment will undergo peer review by the Claims Management Office to confirm medical necessity. The treatment must fall within the financial limits of the benefits package and cannot be experimental or unconventional.

“Referrals for overseas treatment will be subject to a peer review mechanism by the Claims Management Office to ensure medical necessity. The treatment sought must also fall within the financial limits of the benefits package and must not be an unproven, experimental, or unconventional therapy.”

List of services

The Benefits Package and Tariffs Advisory Panel (BPTAP) has developed an initial list of 36 healthcare services not available in Kenya, which has already been gazetted. The list is subject to expansion as the panel conducts further Health Technology Assessments to identify additional interventions.

“The Benefits Package and Tariffs Advisory Panel (BPTAP) has already developed an initial list of 36 healthcare services not available in Kenya, which has been gazetted. This is a preliminary list, as the process of identifying additional interventions is continuous and will be guided by a comprehensive Health Technology Assessment (HTA).”

The Ministry of Health has directed the SHA Board to proceed with the empanelment and contracting of overseas facilities and to publish the list of approved institutions to guide treatment requests.

The government says the framework is designed to ensure transparent, evidence-based and accountable access to specialised care, delivering quality services to Kenyans who require treatment outside the country.