Lawmakers in uproar as ministry explains SHA
By Mercy Mwai, February 11, 2025Lawmakers yesterday questioned the criterion used to set the Social Health Authority (SHA) medical cover limits even as it emerged that patients seeking services for chronic and critical healthcare services are being forced to pay out of pocket.
The Ministry of Health and SHA managers were on the receiving end from MPs who were of the opinion that Kenyans are not getting value for the money they contribute to the new health scheme.
MPs were shocked to learn that Kenyans are only limited to Sh1,000 for optical treatment each year, Sh500,000 for any overseas treatment, Sh2,000 for dental each year and Sh900 for laboratory tests per visit.
The lawmakers were also told that the SHA rollout has encountered major hurdles, primarily due to system readiness challenges that have forced continued reliance on manual claims processing.
Financial constraints, operational inefficiencies, and non-harmonised bank details within the system have further complicated the transition.
Medical Services Principal Secretary Harry Kimtai was hard-pressed to explain why it had taken so long for the ministry to explain to Kenyans that only emergency cases are being funded, so that they make informed decisions.
On the amount of capped for treatment, Kimtai appeared to throw blame on Kenyans, whom he claimed never participated in public participation exercises.
“We subjected the benefit package to public participation and nobody responded to us and that is why we adopted the draft report we had,” Kimtai told MPs.
The legislators were taken aback when the PS admitted that SHA had only managed to operationalise the Emergency Fund under the Emergency, Chronic and Critical Illnesses Fund (ECCF) instead of all the three aspects.
Only patients admitted under the Emergency Fund are offered healthcare within the first 24 hours while those seeking treatment for chronic and critical illnesses are forced to pay out of their pockets.
The MPs also raised concern on the viability of the Chronic Fund, particularly after it emerged that it registered only Sh21.6 million in claims as at January 2025 due to the failure of the State agencies to remit over Sh25 billion in premiums payable to the SHA.
The PS said only part of the ECCF was operationalised in December with only services such as free resuscitation and stabilisation being offered within the first 24 hours.
Inaccessible services
The available emergency services include patients suffering from cardiac and pulmonary arrest, shocks, trauma, seizures, chest pains, strokes, altered level of consciousness as well as patients who require anti venom.
The PS’ admission comes at a time when many patients have been unable to access the health services due to financial challenges, resulting in numerous individuals being turned away from hospitals due to confusion over implementation and budgetary constraints.
Acting Director for Benefits and Claims management, Tracy John, also admitted that the fund was only implemented in December and thus they only have claims for December and January.
“The implementation did not take effect immediately after the rollout on October 1. The system for these specific services was activated in December, starting with Level Five and Six hospitals. As a result, claims only began coming in at the end of December,” explained Tracy.
Kimtai’s admission came on the day lawmakers demanded to know whether the ministry has undertaken yearly reviews on the various cover limits being offered to meet the market demands.
In particular, the lawmakers took issue with the capping set for renal services, overseas treatment and optical care, demanding to know whether reviews were done before such capping.
Their demands came after Kimtai tabled a document showing that the capping for the optical service per family, per year, is Sh1,000 with only children under 18 years being eligible.
Oral health services are limited at Sh2,000, essential outpatient services, which include laboratory investigations, imaging, prescription medication, vaccinations, management of mental health conditions, health wellness and counselling is Sh900 per beneficiary.
Inpatient packages are limited to Sh2,240 daily, normal delivery and essential new-born care at Sh10,000, caesarean section and essential new-born care at Sh30,000 and renal care therapies in case of haemodialysis at Sh10,650 per session per week.
No bite
Nyeri Town MP Duncan Maina questioned the dental health capacity limits saying the money is not enough to cover the entire family while in the case of optical cover limits, he termed the limits as impractical in this era.
On overseas treatment, he questioned why the ministry has preferred hospitals in India instead of allowing patients to choose the hospitals they want as the same could lead to corruption.
“Mr PS, tell us why patients have to go to hospitals facilitated by SHA because we have been told to go to India. My own mother required endocrine services despite us seeking to go to another hospital, we were denied this request,” Maina said.
Robert Pukose, who questioned how the ministry arrived at Sh1,000 for the optical care, also sought to know the individuals who have been given the mandate to decide the hospitals that Kenyans should visit abroad.
Kitutu Chache South Anthony Kibagendi took on the PS accusing them of denying patients the opportunity to seek health services abroad.
Inherited debt
Mogotio MP Reuben Kiborek raised concerns that the capping of Sh500,000 for patients seeking treatment abroad is too low. Seme MP James Nyikal told the PS to ensure that they will review the capping set every year to reflect the market rate.
Meanwhile Kimtai told the MPs that SHA inherited Sh43 billion from the defunct National Health Insurance Fund (NHIF) in debts owed to healthcare providers and co-insurers.
Kimtai, in the document tabled, revealed that the Ministry of Public Service tops the list of defaulters to SHA with Sh15.54 billion in outstanding premiums as at January 8, 2025.
The Ministry of Interior has Sh1.64 billion in unremitted claims with the Ministry of Health at Sh8.4 billion. The unremitted premiums under the Ministry of Health include Universal Health Care (UHC) for indigents Sh4 billion and Linda Mama Sh2.12 billion.
There is also Health Insurance Subsidy Programmes (HISP) for Orphans and Vulnerable Children (OVCs) Sh1.42 billion, HISP for Older Persons and Persons with Severe Disability (OPPSD) Sh289.5 million and primary health care Sh375 million.