Why MPs want SHA, health services overhauled

Teenage mothers, poor households, prisoners and patients with chronic conditions such as cancer and diabetes have largely been excluded from accessing health services under the Social Health Authority (SHA), a Parliamentary report has revealed.

One year since the setting up of SHA, the existence of operational and policy gaps and lack of a clear national framework for identifying and enrolling vulnerable populations has resulted in their continued exclusion from critical health services, it highlights.

According to a report by the National Assembly’s Health Committee, SHA has been bedeviled by systematic challenges that continue to hamper operations across health facilities. The findings were based on the assessment of 10 health facilities across the country which brought to the fore 19 critical challenges that hamper access to quality healthcare by Kenyans.

 The Committee observed that cancer patients were particularly disadvantaged under SHA as certain essential diagnostic and follow-up tests were not covered, forcing patients to shoulder high out-of-pocket costs.

“Considering the long-term and expensive nature of cancer care, this gap increases the risk of treatment discontinuation, poor outcomes and inequity in access. Laboratory tests are also limited to five tests for outpatients. ICU 12-day package limits are impractical for longer stays,”  Committee chairperson Dr James Nyikal stated.

Contradictions between the actual cost of care and SHA reimbursement rates were also highlighted with the committee detailing that some packages failed to meet the true cost of care such as the Sh30,000 set for caesarean deliveries, 12-day ICU limits and restricted outpatient benefits at Level 5 facilities.

These benefit packages and tariffs, the report noted, undermine quality service delivery and discourage providers from offering specialised care.

The requirement for lump-sum annual premium payments has further excluded many poor households, undermining the principles of equity and Universal Health Coverage (UHC).

“Similarly, prisoners, indigent persons, and individuals living with chronic conditions experience inconsistent coverage across facilities… Teenage mothers without national identification cards face registration barriers that deny them and their infants’ access to essential maternal and child health services,” observes the committee.

“The Committee also noted the absence of a clear national framework for identifying and enrolling vulnerable populations, particularly teenage mothers and their infants, resulting in their continued exclusion from critical health services.”

SHA was also cited over its failure to identify poor or needy persons through Means Testing as it had not implemented a clear and transparent mechanism for identifying the needy and vulnerable persons as stipulated under Section 27(2)(c) of the SHA Act. Consequently, noted the parliamentary team, many deserving citizens were excluded from social health protection, further undermining the goal of Universal Health Coverage (UHC).

For the period under review, it was noted that erroneous payments were made by SHA, which have created significant financial strain on health facilities, as seen in Nyeri County Referral Hospital, which lost over Sh16 million to a neighbouring private hospital due to payment processing errors, with recovery efforts proving unsuccessful. The Committee observed that reimbursements to health facilities under the SHA have been inconsistent, with some months recording no disbursements at all.

A substantial backlog of arrears inherited from the defunct National Health Insurance Fund (NHIF) remains unresolved, while approved but unpaid claims continue to accumulate across facilities, further straining the financial stability of hospitals.

A high rate of claim rejections, even when health facilities submitted proper documentation, has exposed the absence of a clear mechanism for resubmission, with feedback often delayed well beyond the 90-day statutory period.

To improve SHA implementation, service delivery and patient outcomes, the parliamentary team is urging Treasury to invoke Article 223 of the Constitution to settle Sh10 billion in outstanding NHIF debts, ensuring financial stability and restoring confidence in the SHA transition.