Emergency, Critical, and Chronic Illness Fund Under SHA

Introduction

The Emergency, Critical, and Chronic Illness Fund (ECCF) is a vital component of Kenya’s Social Health Authority (SHA), established under the Social Health Insurance Act of 2023 to advance Universal Health Coverage (UHC). Launched on October 1, 2024, as part of SHA’s tripartite funding structure—alongside the Primary Health Care Fund (PHCF) and Social Health Insurance Fund (SHIF)—the ECCF serves as a financial safety net for high-cost, life-threatening, and chronic conditions. Unlike SHIF, which requires individual contributions, or PHCF, which is government-funded for primary care, ECCF is financed through public appropriations and donations, ensuring no additional cost to members. As of September 2025, with over 20 million Kenyans enrolled in SHA, the ECCF has significantly reduced financial burdens for patients with conditions like cancer and renal failure, addressing gaps left by the National Health Insurance Fund (NHIF). This article details the ECCF’s purpose, funding, coverage, eligibility, implementation, and impact, based on official regulations and recent data.

Purpose and Objectives

The ECCF is designed to protect Kenyans from catastrophic health expenditures associated with emergencies, critical illnesses, and chronic conditions, aligning with Article 43 of the Kenyan Constitution, which guarantees healthcare access without financial hardship. Its key objectives include:

• Financial Protection: Cover high-cost treatments after SHIF limits are exhausted, preventing medical poverty (previously affecting 1.5 million annually).
• Equitable Access: Ensure all registered residents, including the indigent, access advanced care regardless of income.
• Continuity of Care: Support long-term management of chronic diseases and critical interventions like organ transplants.
• Reduced Hospital Burden: Complement PHCF and SHIF by addressing complex cases, allowing primary and secondary care to focus on routine services.

The ECCF addresses NHIF’s limitations, such as capped dialysis sessions (104/year) and minimal oncology coverage, which left patients with out-of-pocket costs averaging 26% of health expenditures.

Funding Mechanism

Unlike SHIF’s contribution-based model, ECCF is funded through:

• Government Appropriations: Annual national budget allocations, with KSh 5 billion earmarked for ECCF in 2024/25.
• Donations and Grants: Contributions from international partners (e.g., Global Fund, WHO) and local philanthropies for specific programs like cancer care.
• Tax Revenues: General taxation supplements funding, with no direct levies on individuals.
• County Contributions: Limited support for critical care infrastructure at referral hospitals.

SHA manages ECCF funds, disbursing payments to accredited Level 4-6 facilities (county and national referral hospitals) for approved treatments. Digital claims processing via the Afya Yangu platform ensures transparency, with audits to prevent fraud, learning from NHIF’s mismanagement scandals.

Eligibility and Access

All SHA-registered residents qualify for ECCF 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 but require biometric re-verification.
• Access Requirements: Present SHA membership number (via Afya Yangu app, *147#, or SMS) at accredited facilities. ECCF activates for treatments beyond SHIF’s scope, requiring pre-approval for specialized procedures.
• No Additional Cost: ECCF services are free at point of care, with no contribution required beyond SHIF payments or subsidies for the indigent.
• No Waiting Period: Immediate access post-registration, unlike NHIF’s 60-day delay for new members.

Coverage Details

ECCF covers high-cost, specialized treatments at Level 4-6 facilities, as outlined in the Fourth Schedule of the Social Health Insurance (General) Regulations, 2024. Coverage kicks in after SHIF benefits are exhausted, ensuring a seamless care continuum. Key services include:

Emergency Care

• Ambulance Services: Emergency transport to accredited facilities, including air evacuation for remote areas.
• Trauma Treatment: Care for accidents, burns, and acute injuries.
• Intensive Care: ICU and HDU stays, with daily coverage increased from NHIF’s KSh 4,600 to KSh 28,000.
• Emergency Surgeries: Procedures like craniotomies or trauma-related orthopedics.

Chronic Illness Management

• Renal Care: Up to 144 dialysis sessions/year (vs. NHIF’s 104), kidney transplant surgeries, and post-transplant medications.
• Oncology: Chemotherapy, radiotherapy, immunotherapy, and cancer drugs for over 47,000 new cases annually (e.g., breast, cervical, prostate cancers).
• Cardiovascular Conditions: Management of heart diseases, including stents and pacemakers.
• HIV/AIDS and TB: Antiretroviral therapy, TB treatment, and monitoring.
• Other Chronic Diseases: Diabetes, hypertension, and asthma management, including insulin and inhalers.

Critical Illness Interventions

• Organ Transplants: Kidney, liver, and bone marrow transplants, with coverage up to KSh 500,000 for overseas procedures (e.g., India for complex cases).
• Specialized Surgeries: Open-heart surgery, neurosurgery, and reconstructive procedures post-trauma.
• Rare Diseases: Treatment for conditions like hemophilia or sickle cell anemia, subject to SHA approval.

Palliative Care

• Pain management and supportive care for terminal illnesses (e.g., advanced cancer, end-stage organ failure).
• Hospice services at designated facilities or via home-based care coordinated by CHPs.

Overseas Treatment

• Covers treatments unavailable in Kenya (e.g., stem cell transplants, advanced oncology) up to KSh 500,000, with SHA’s Benefits and Tariffs Advisory Panel reviewing cases within 72 hours. A 2025 review aims to potentially raise this cap.

Comparison with NHIF

Implementation and Infrastructure

ECCF operates through:

• Accredited Facilities: Approximately 2,000 Level 4-6 facilities, including national referral hospitals (e.g., Kenyatta National Hospital), private hospitals, and specialized units, accredited for advanced care.
• Digital Integration: Afya Yangu platform and *147# USSD facilitate pre-approvals, claims tracking, and facility identification. Claims are processed within 30 days, compared to NHIF’s 90+ days.
• Referral System: Patients transition from PHCF/SHIF to ECCF via digital referrals from CHPs or Level 4 facilities, ensuring coordinated care.
• Oversight: The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, sets tariffs and reviews coverage, ensuring evidence-based adjustments.

Limitations and Exclusions

ECCF has specific constraints:

• Pre-Approval: Overseas treatments and certain critical procedures require SHA approval, which may delay care (72-hour processing).
• Coverage Caps: Overseas treatment limited to KSh 500,000; some rare disease treatments may not be fully covered.
• Non-Accredited Facilities: Services at non-empaneled providers are not reimbursed; patients must verify facilities on sha.go.ke.
• Experimental Treatments: Excluded unless deemed medically necessary by SHA’s panel.

Impact and Benefits

ECCF has delivered significant outcomes:

• Financial Relief: Reduced out-of-pocket costs for chronic illnesses by 40%, protecting families from catastrophic expenses (e.g., cancer treatment costs averaging KSh 1 million).
• Improved Access: Increased dialysis sessions by 38% and cancer treatment uptake by 25% compared to NHIF.
• Equity: Subsidized access for indigent patients, with 70% of ECCF users from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Reduced mortality from emergencies (e.g., trauma care) and better management of chronic diseases, with 2025 data showing a 15% drop in cancer-related deaths.

Challenges and Solutions

Challenges include:

• Funding Constraints: Limited budget (KSh 5 billion) strains high-demand services like oncology; SHA seeks increased 2026/27 allocations.
• Provider Delays: Some hospitals report reimbursement lags; SHA’s digital claims system targets 30-day payments.
• Awareness Gaps: GeoPoll’s 2025 survey notes 35% of rural residents unaware of ECCF’s scope; SHA’s radio and CHP campaigns aim to educate.
• Overseas Approvals: Delays in processing overseas requests; SHA is piloting faster digital pre-approvals.

Future Outlook

ECCF plans to enhance coverage by:

• Raising overseas treatment caps in 2026 based on panel reviews.
• Expanding transplant programs to include local facilities, reducing reliance on foreign care.
• Integrating AI diagnostics via Afya Yangu for faster critical care decisions.
• Increasing funding to KSh 8 billion by 2027 to meet rising demand.

Conclusion

The Emergency, Critical, and Chronic Illness Fund is a transformative element of Kenya’s UHC strategy, providing a lifeline for patients facing life-threatening and high-cost conditions. By covering emergencies, chronic diseases, and critical interventions like transplants, ECCF addresses NHIF’s gaps, offering equitable, government-funded care. Despite challenges like funding limits and awareness gaps, SHA’s digital infrastructure and governance reforms ensure sustainable impact. For registered Kenyans, ECCF guarantees financial protection and access to advanced care, paving the way for a healthier, more inclusive future by 2030.

SHANGA MAISHA MAGIC PLUS SEASON 2 EPISODE 105 TUESDAY SEPTEMBER 16TH 2025 FULL EPISODE