Inpatient Benefits Provided by SHA

Introduction

The Social Health Authority (SHA) in Kenya, established under the Social Health Insurance Act of 2023, is a cornerstone of the country’s Universal Health Coverage (UHC) agenda, replacing the National Health Insurance Fund (NHIF). Fully operational since October 1, 2024, SHA manages three funds—the Primary Health Care Fund (PHCF), Social Health Insurance Fund (SHIF), and Emergency, Chronic, and Critical Illness Fund (ECCF)—to provide comprehensive healthcare. The SHIF and ECCF specifically cover inpatient services, addressing hospital-based treatments and high-cost care at Levels 4-6 facilities (county hospitals, referral centers, and specialized units). As of September 2025, over 20 million Kenyans are enrolled, benefiting from expanded inpatient coverage that eliminates NHIF’s restrictive caps and limited scope. This article details SHA’s inpatient benefits, including services, eligibility, access, limitations, and impact, drawing on official regulations and recent data.

Purpose of Inpatient Benefits

SHA’s inpatient benefits aim to provide financial protection for hospital-based treatments, reducing out-of-pocket expenses that previously accounted for 26% of health expenditures and pushed 1.5 million Kenyans into poverty annually. Key objectives include:

• Ensuring equitable access to hospital care for all registered residents, regardless of income.
• Covering a broad range of inpatient services, from routine hospitalizations to critical interventions.
• Supporting seamless care transitions from primary care (PHCF) to secondary/tertiary facilities.
• Addressing NHIF’s shortcomings, such as annual caps (KSh 400,000) and limited chronic illness coverage.

Funding and Contribution Structure

Inpatient benefits are primarily funded through:

• SHIF Contributions: Mandatory 2.75% of gross monthly income for salaried employees (employer-deducted) and means-tested payments for the informal sector (minimum KSh 300/month or KSh 3,600/year). Indigent populations are fully subsidized via government programs like Inua Jamii.
• ECCF Funding: Government appropriations and donations cover high-cost critical and chronic care, with no additional contributions required.
• Disbursement: SHA manages funds, reimbursing approximately 10,000 accredited Level 4-6 facilities via digital claims processed within 30 days, a significant improvement over NHIF’s 90+ day delays.

Eligibility and Access

All SHA-registered residents qualify for inpatient benefits:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and children).
• Registration: Mandatory via national ID, passport, or alternative documents (e.g., birth certificates for minors). Former NHIF members auto-transitioned by October 2024 but require biometric re-verification.
• Access Requirements: Present SHA membership number (via Afya Yangu app, *147#, or SMS) at accredited facilities. No waiting periods apply, unlike NHIF’s 60-day delay for new members.
• Referral System: Patients are referred from Level 1-3 facilities (PHCF) or directly admitted for emergencies. Digital referrals via Afya Yangu ensure continuity.

Inpatient Benefits Covered

SHA’s inpatient benefits, administered through SHIF and ECCF, are comprehensive and uniform for all members, regardless of contribution amount. They cover services at Level 4-6 facilities, including public, private, and faith-based hospitals. The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, defines and updates the package.

SHIF Inpatient Coverage

SHIF covers routine and specialized hospital-based treatments:

• Hospital Admissions: Full coverage for medical and surgical wards, including room and board, nursing care, and medications.
• Surgeries:
• General surgeries (e.g., appendectomies, hernia repairs).
• Specialized procedures (e.g., orthopedic, gynecological, urological surgeries).
• Maternity Care:
• Normal deliveries (up to KSh 20,000, doubled from NHIF’s KSh 10,000).
• Cesarean sections and complications.
• Postnatal care, including neonatal intensive care for premature infants.
• Rehabilitation:
• Inpatient physiotherapy and occupational therapy post-surgery or injury.
• Substance abuse rehabilitation programs.
• Diagnostic Services: Inpatient lab tests (e.g., blood panels), imaging (CT scans, MRIs), and biopsies.
• Chronic Disease Management: Hospital-based treatment for conditions like diabetes, hypertension, and asthma.

ECCF Inpatient Coverage

ECCF activates for high-cost, critical, and chronic conditions beyond SHIF’s scope:

• Emergency Care:
• Intensive Care Unit (ICU) and High Dependency Unit (HDU) stays, covered up to KSh 28,000/day (vs. NHIF’s KSh 4,600).
• Emergency surgeries (e.g., trauma-related craniotomies, fracture repairs).
• Critical Illness Interventions:
• Organ transplants (kidney, liver, bone marrow), including pre- and post-operative care.
• Open-heart surgeries, neurosurgeries, and reconstructive procedures.
• Overseas treatment for unavailable services (e.g., stem cell transplants), up to KSh 500,000, with SHA pre-approval within 72 hours.
• Chronic Illness Management:
• Renal care: Up to 144 dialysis sessions/year (vs. NHIF’s 104) and post-transplant medications.
• Oncology: Inpatient chemotherapy, radiotherapy, and surgical interventions for over 47,000 annual cancer cases.
• Advanced cardiovascular care (e.g., stents, pacemakers).
• Inpatient psychiatric care for severe mental health conditions.
• Palliative Care: Pain management and supportive care for terminal illnesses (e.g., advanced cancer, end-stage organ failure) in hospitals or hospices.

Comparison with NHIF

Limitations and Exclusions

While comprehensive, SHA inpatient benefits have constraints:

• Pre-Approval: Critical procedures (e.g., transplants, overseas treatment) require SHA approval, processed within 72 hours, which may delay urgent care.
• Overseas Cap: Limited to KSh 500,000; some treatments (e.g., complex oncology) may exceed this, requiring private funding. A 2025 review may raise this cap.
• Non-Accredited Facilities: Services at non-empaneled providers are not covered; patients must verify facilities on sha.go.ke.
• Experimental Treatments: Excluded unless medically necessary and approved by SHA’s panel.
• Contribution Dependency: Non-payment of SHIF contributions may delay non-emergency inpatient care unless repayment plans are arranged, though ECCF services remain accessible.

Implementation and Infrastructure

SHA’s inpatient benefits are delivered through:

• Accredited Facilities: Over 10,000 Level 4-6 providers (public, private, faith-based), re-accredited under SHA standards for quality, staffing, and equipment.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches, pre-approvals, and claims tracking. Claims are processed within 30 days, reducing NHIF’s delays.
• Referral System: Community Health Promoters (CHPs) or Level 1-3 facilities refer patients to Level 4-6 hospitals via digital platforms, ensuring coordinated care.
• Oversight: The Benefits and Tariffs Advisory Panel adjusts tariffs and coverage, with SHA enforcing audits to prevent fraud, learning from NHIF scandals.

Impact and Benefits

SHA’s inpatient benefits have transformed healthcare access:

• Financial Protection: Reduced out-of-pocket costs by 30% in 2025, shielding families from medical debt (e.g., cancer treatment costs averaging KSh 1 million).
• Increased Access: Informal sector enrollment rose from 20% under NHIF to 30% in 2025, with subsidies covering 15% of indigent Kenyans.
• Health Outcomes: Enhanced maternity care (20% increase in covered deliveries), dialysis sessions (38% increase), and cancer treatment uptake (25% rise) compared to NHIF.
• Equity: Uniform benefits for all, with 70% of ECCF inpatient users from low-income groups, compared to NHIF’s 5% poor coverage. GeoPoll’s 2025 survey shows 60% of Kenyans view SHA’s inpatient benefits as affordable and accessible.

Challenges and Solutions

Challenges include:

• Provider Reimbursement Delays: Some hospitals report 60-day lags; SHA’s digital claims system targets 30-day payments.
• Rural Access: Limited Level 4-6 facilities in remote areas; SHA is expanding mobile clinics and telehealth via Afya Yangu.
• Awareness Gaps: 30% of rural residents unaware of ECCF’s inpatient scope; SHA’s radio and CHP campaigns aim to educate.
• Funding Limits: ECCF’s KSh 5 billion budget strains high-demand services; SHA seeks KSh 8 billion by 2027.

Future Outlook

SHA plans to enhance inpatient benefits by:

• Increasing ECCF funding to support rising demand for critical care.
• Expanding local transplant programs to reduce overseas treatment reliance.
• Integrating AI diagnostics via Afya Yangu for faster approvals.
• Reviewing overseas treatment caps in 2026 to address high-cost procedures.

Conclusion

SHA’s inpatient benefits, delivered through SHIF and ECCF, mark a significant leap toward UHC, offering comprehensive coverage for hospital admissions, surgeries, maternity, and critical care. By eliminating NHIF’s caps, expanding chronic illness support, and ensuring equity through subsidies, SHA protects Kenyans from financial hardship. Despite challenges like reimbursement delays and rural access, digital tools and governance reforms strengthen implementation. For registered residents, SHA’s inpatient benefits provide a robust safety net, advancing Kenya’s vision of accessible, quality healthcare by 2030.

AURORA’S QUEST WEDNESDAY 17TH SEPTEMBER 2025 FULL EPISODE PART 1 AND PART 2 COMBINED