Outpatient Services in the SHA Scheme

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is a pivotal reform in Kenya’s pursuit of Universal Health Coverage (UHC), replacing the National Health Insurance Fund (NHIF). Fully operational since October 1, 2024, SHA manages three funds—Primary Health Care Fund (PHCF), Social Health Insurance Fund (SHIF), and Emergency, Chronic, and Critical Illness Fund (ECCF)—to deliver comprehensive healthcare. Outpatient services, primarily covered under PHCF and SHIF, provide preventive, promotive, and curative care at community and hospital levels (Levels 1-6 facilities), ensuring accessible, affordable treatment without hospitalization. As of September 2025, over 20 million Kenyans are enrolled, benefiting from expanded outpatient coverage that addresses NHIF’s limitations, such as capped visits (KSh 1,000/visit) and low informal sector enrollment (20%). This article details SHA’s outpatient services, including coverage, eligibility, access, limitations, and impact, based on official regulations and recent data.

Purpose of Outpatient Services

SHA’s outpatient services aim to enhance early intervention, reduce hospital admissions, and promote health equity. Key objectives include:

• Preventive and Promotive Care: Detect and manage conditions early to prevent escalation, reducing healthcare costs by up to 40%.
• Financial Protection: Eliminate out-of-pocket expenses for primary care and minimize costs for specialized outpatient services, addressing the 26% of health expenditures previously borne by patients.
• Equitable Access: Ensure all registered residents, including the indigent, access uniform outpatient benefits.
• Care Continuum: Link primary care (PHCF) to specialized outpatient services (SHIF) through digital referrals, reducing delays.

These services address NHIF’s shortcomings, such as limited outpatient coverage (10 visits/year) and minimal chronic disease support, aiming for 100% coverage by 2030.

Funding Mechanism

Outpatient services are funded through:

• PHCF: Fully government-funded via national budgets (KSh 10 billion in 2024/25), county contributions, and grants, covering free primary care at Levels 1-3 (community units, dispensaries, health centers).
• SHIF: Mandatory contributions of 2.75% of gross 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 subsidized via programs like Inua Jamii, covering specialized outpatient care at Levels 4-6 (county and referral hospitals).
• Disbursement: SHA reimburses over 10,000 accredited facilities through digital claims processed within 30 days, improving on NHIF’s 90+ day delays. Transparency is ensured via Afya Yangu and annual audits.

Eligibility and Access

All SHA-registered residents qualify for outpatient services:

• 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: Community Health Promoters (CHPs) or Level 1-3 facilities refer patients to Level 4-6 hospitals for specialized outpatient care, coordinated digitally via Afya Yangu.

Outpatient Services Covered

SHA’s outpatient services are delivered through PHCF (Levels 1-3) and SHIF (Levels 4-6), offering a comprehensive, uniform benefit package defined by the Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025.

PHCF Outpatient Services (Levels 1-3)

Provided free at community units, dispensaries, and health centers, PHCF focuses on preventive and basic curative care:

• Consultations: Unlimited visits for general check-ups and minor ailments (e.g., respiratory infections, malaria).
• Screenings: Early detection for non-communicable diseases (e.g., hypertension, diabetes, cervical/breast cancer).
• Vaccinations: Routine immunizations (e.g., measles, polio, HPV).
• Maternal and Child Health: Antenatal/postnatal care, child growth monitoring, and family planning (contraceptives, counseling).
• Mental Health: Basic counseling and psychosocial support, with referrals for advanced care.
• Medications: Essential drugs for common conditions (e.g., antimalarials, antibiotics).
• Health Education: Nutrition, hygiene, and lifestyle counseling via over 100,000 CHPs under Afya Bora Mashinani.

SHIF Outpatient Services (Levels 4-6)

SHIF covers specialized outpatient care at county and referral hospitals:

• Specialist Consultations: Unlimited visits to specialists (e.g., pediatricians, cardiologists, gynecologists).
• Diagnostics: Advanced tests (e.g., blood panels, biopsies), imaging (X-rays, CT scans, MRIs), and endoscopies.
• Medications: Prescribed drugs for chronic conditions (e.g., insulin, antihypertensives) and specialized treatments.
• Day Procedures: Minor surgeries (e.g., cyst removal, circumcision), wound care, and chemotherapy sessions.
• Chronic Disease Management: Outpatient follow-ups for diabetes, hypertension, HIV/AIDS, and TB.
• Mental Health: Psychiatric consultations, therapy sessions, and medication management.
• Optical and Dental: Eye exams, prescription glasses, and basic dental procedures (e.g., extractions, fillings).
• Rehabilitation: Outpatient physiotherapy, occupational therapy, and substance abuse counseling.

Comparison with NHIF

Limitations and Exclusions

While robust, SHA outpatient services have constraints:

• Non-Accredited Facilities: Services at non-empaneled providers are not covered; patients must verify facilities on sha.go.ke.
• Specialized Treatments: Some outpatient procedures (e.g., cosmetic treatments, experimental therapies) are excluded unless medically necessary.
• Contribution Dependency: SHIF outpatient services require active contributions; non-payment may delay non-emergency care unless repayment plans are arranged. PHCF services remain free regardless.
• Referral Requirements: Specialized outpatient care at Levels 4-6 often requires referrals from PHCF facilities, which may delay access in urgent cases.

Implementation and Infrastructure

SHA’s outpatient services are delivered through:

• Accredited Facilities: Over 8,000 Level 1-3 facilities (PHCF) and 10,000 Level 4-6 facilities (SHIF), accredited for quality, staffing, and equipment.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches, appointment scheduling, and claims tracking. Digital referrals streamline access to specialized care.
• Community Health Promoters (CHPs): Over 100,000 CHPs conduct screenings, health education, and referrals, using tablets for real-time data entry.
• Oversight: The Benefits and Tariffs Advisory Panel adjusts coverage and tariffs, with SHA enforcing audits to prevent fraud, addressing NHIF’s mismanagement issues.

Impact and Benefits

SHA’s outpatient services have transformed healthcare delivery:

• Financial Protection: Eliminated primary care costs and reduced specialized outpatient expenses, cutting out-of-pocket spending by 30% in 2025.
• Increased Access: Primary care visits rose by 35%, with 70% of users from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Early detection increased by 20% for cancers and 15% for diabetes, reducing hospital admissions. Vaccination coverage reached 95% for under-5s.
• Equity: Uniform benefits and subsidies ensure access for informal sector workers (30% enrollment vs. NHIF’s 20%) and indigent populations. GeoPoll’s 2025 survey shows 60% of Kenyans view SHA outpatient services as accessible and affordable.

Challenges and Solutions

Challenges include:

• Rural Access: Limited Level 4-6 facilities in remote areas; SHA is expanding mobile clinics and telehealth via Afya Yangu.
• Provider Reimbursement Delays: Some facilities report 60-day lags; SHA’s digital claims system targets 30-day payments.
• Awareness Gaps: 30% of rural residents unaware of SHIF outpatient scope; SHA’s radio and CHP campaigns aim to educate.
• Contribution Affordability: The 2.75% SHIF rate burdens low-income earners; SHA offers installments and subsidies.

Future Outlook

SHA plans to enhance outpatient services by:

• Expanding CHP coverage to 150,000 by 2027 for broader primary care reach.
• Increasing PHCF funding to KSh 15 billion by 2026/27.
• Integrating AI-driven diagnostics via Afya Yangu for faster screenings.
• Enhancing mental health outpatient services with dedicated counselors at Level 4 facilities.

Conclusion

SHA’s outpatient services, delivered through PHCF and SHIF, mark a significant advancement in Kenya’s UHC journey, offering free primary care and comprehensive specialized outpatient services. By eliminating NHIF’s caps, expanding chronic disease management, and ensuring equity through subsidies, SHA reduces financial barriers and improves health outcomes. Despite challenges like rural access and awareness gaps, digital tools and governance reforms strengthen implementation. For registered Kenyans, SHA’s outpatient services provide accessible, quality care, paving the way for a healthier nation by 2030.

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