Cancer Treatment Limits Under SHA

Introduction

The Social Health Authority (SHA) in Kenya, established under the Social Health Insurance Act of 2023, is a key pillar of the country’s Universal Health Coverage (UHC) agenda, replacing the National Health Insurance Fund (NHIF) as of 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 equitable access to healthcare services, including oncology care for cancer patients. Cancer remains a major health challenge in Kenya, with over 47,000 new cases annually and approximately 82,000 Kenyans living with the disease as of 2022, according to World Health Organization (WHO) data. Treatments such as chemotherapy, radiotherapy, and surgery are costly, often exceeding KSh 1 million per patient, making financial protection crucial. As of September 2025, SHA’s oncology coverage has evolved amid implementation challenges, with limits set to balance sustainability and access. This article examines these limits, coverage details, eligibility, challenges, and recent reforms, based on official guidelines and stakeholder reports.

Background and Evolution from NHIF

Under NHIF, cancer treatment coverage was fragmented and limited. The scheme covered partial costs for chemotherapy (up to six sessions per line of treatment, with additional lines for advanced cases) and radiotherapy, but with caps that often left patients paying out-of-pocket for drugs and follow-ups. For instance, NHIF reimbursed KSh 9,500 per chemotherapy session, limited to 104 sessions annually for dialysis but similarly restrictive for oncology, leading to incomplete treatments and high financial burdens. Advocacy groups like the Kenya Network of Cancer Organizations (KENCO) criticized these limits for discriminatory practices, contributing to delayed diagnoses and poor outcomes, with over 70% of cases detected at advanced stages.

SHA’s oncology framework, integrated into SHIF and ECCF, aims to address these gaps by providing a more comprehensive package. The transition began in October 2024, with automatic migration of NHIF members. Initial limits sparked controversy, but reforms in April 2025 increased coverage to KSh 550,000 annually per patient, split between SHIF (KSh 400,000) and ECCF (KSh 150,000). This aligns with the Cancer Prevention and Control Act, 2012, and the National Cancer Control Strategy 2017-2022, emphasizing early detection and affordable care. By mid-2025, partnerships like the Ministry of Health’s MoU with Roche reduced breast cancer treatment costs from KSh 120,000 to KSh 40,000 per session, enhancing accessibility.

Coverage Details and Limits

SHA’s cancer treatment is covered under SHIF for standard oncology services at Levels 4-6 facilities (county and referral hospitals) and ECCF for catastrophic cases after SHIF exhaustion. Coverage includes diagnostics, chemotherapy, radiotherapy, surgery, and supportive care, but with defined annual limits to ensure fund sustainability. The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, oversees tariffs and adjustments.

SHIF Oncology Coverage

SHIF, funded by mandatory contributions (2.75% of gross income for salaried workers; minimum KSh 300/month for informal sector via means-testing), covers:

• Diagnostics: Up to KSh 100,000 annually for tests like PET scans, MRIs, biopsies, and lab work.
• Chemotherapy and Radiotherapy: Up to KSh 300,000 per person per year for sessions, drugs, and consumables. This includes targeted therapies like Herceptin for breast cancer, now capped at KSh 40,000 per session under the Roche partnership (effective May 2025, rolled out across SHA-contracted facilities).
• Surgery and Inpatient Care: Full coverage for tumor removals, including pre- and post-operative care, within the overall SHIF inpatient limit (no family cap, unlike NHIF’s per-dependent fees).
• Supportive Services: Medications for side effects, nutritional support, and palliative care.

The SHIF limit for oncology treatment was initially KSh 300,000 (plus KSh 100,000 for diagnostics, totaling KSh 400,000), but enhanced to KSh 400,000 in April 2025 for comprehensive care.

ECCF Oncology Coverage

ECCF, fully government-funded through appropriations (KSh 5 billion in 2024/25) and donations, activates for advanced or high-cost treatments:

• Additional Limit: Up to KSh 150,000 annually after SHIF exhaustion, covering extended chemotherapy cycles, advanced radiotherapy, or immunotherapy for conditions like metastatic cancers.
• Critical Interventions: Bone marrow transplants, stem cell therapies, and overseas treatment (up to KSh 500,000 annually for procedures unavailable locally, such as specialized oncology surgeries).
• Palliative and Chronic Care: Ongoing management for terminal cases, including pain relief and hospice services.

Total annual coverage per patient is thus KSh 550,000 (SHIF KSh 400,000 + ECCF KSh 150,000), a significant increase from NHIF’s partial session-based reimbursements. However, drugs like pertuzumab and letrozole may still require top-ups if exceeding limits, as noted in early 2025 patient complaints.

Preventive and Screening Services

Under PHCF (government-funded, no contributions required), free screenings for cancers (e.g., breast, cervical, prostate) are available at Levels 1-3 facilities, including mammograms and Pap smears, with referrals to SHIF/ECCF for confirmed cases.

Eligibility and Access

Eligibility is universal for SHA-registered residents:

• Who Qualifies: Kenyan citizens, non-citizens residing over 12 months, and dependents (unlimited spouses/children). Cancer patients must be diagnosed by accredited providers.
• Registration: Mandatory and free via *147# USSD, sha.go.ke, or Huduma Centres using national ID or passport. Former NHIF members auto-migrated but require biometric verification. Indigent patients (15% of population) receive full subsidies via means-testing.
• Access Process: Present SHA membership number at empaneled facilities (over 10,000 nationwide, including Kenyatta National Hospital and Aga Khan University Hospital). Referrals from PHCF ensure seamless transition. No waiting periods; immediate access post-registration.
• Claims and Pre-Approval: Digital via Afya Yangu app; oncology treatments require SHA approval for ECCF activation. Overseas care needs a doctor’s referral and panel review (processed within 72 hours).

Contributions fund SHIF, but ECCF ensures no additional costs for eligible catastrophic care.

Comparison with NHIF

SHA’s limits provide more predictability and higher caps, but early implementation issues led to disruptions.

Challenges and Criticisms

Despite reforms, cancer treatment limits under SHA face scrutiny:

• Initial Low Limits: In early 2025, the KSh 300,000 SHIF cap (plus KSh 100,000 diagnostics) was criticized as insufficient, with patients like Rose Wambui exhausting it by February despite higher premiums (KSh 1,050 vs. NHIF’s KSh 950). Advocacy groups (KENCO, NCDAK, CSAK, HENNET) highlighted service disruptions during the NHIF-to-SHA transition, forcing top-ups for drugs like Herceptin (KSh 100,000/dose).
• Drug Availability and Costs: Essential drugs like pertuzumab and letrozole remain unavailable or exceed limits, affecting thousands. The Roche partnership addresses breast cancer but not all types.
• Late Diagnosis and Infrastructure: Over 70% of cases are advanced due to limited diagnostics; rural access to Level 4-6 facilities is uneven.
• Reimbursement Delays: Hospitals report 60-90 day lags, leading to treatment denials. SHA disbursed KSh 1.7 billion for oncology in August 2025, but transparency concerns persist.
• Equity Issues: Informal sector uptake lags at 30%, with subsidies not always reaching indigent patients promptly.

GeoPoll’s March 2025 survey revealed 42% of respondents worried about high costs and 46% cited system issues, though 60% viewed SHA positively overall.

Impact and Benefits

SHA’s limits have improved oncology access:

• Financial Protection: Reduced out-of-pocket costs by 40% for covered treatments, preventing impoverishment for 1.5 million annually from medical expenses.
• Increased Uptake: Cancer consultations rose 25% in 2025; the Roche deal alone benefits thousands with breast cancer, capping sessions at KSh 40,000 (no co-pays).
• Health Outcomes: Early screenings under PHCF increased by 20%, potentially lowering mortality (29,317 cancer deaths in 2022). Partnerships like MoH-Roche ensure equitable rollout across public, faith-based, and private facilities.
• Sustainability: Limits prevent fund depletion, with SHA disbursing KSh 56.4 billion since October 2024—three times NHIF’s annual amount.

Future Outlook

SHA is reviewing benefits to address gaps, including raising ECCF limits and expanding drug formularies. The 2025/26 budget targets KSh 8 billion for ECCF, with plans for 500+ oncology machines and AI diagnostics via Afya Yangu. By 2030, full UHC aims to eliminate limits for essential treatments, focusing on prevention to reduce the 47,000 annual cases.

Conclusion

Cancer treatment limits under SHA represent a balanced approach to UHC, with KSh 550,000 annual coverage (SHIF KSh 400,000 + ECCF KSh 150,000) offering more than NHIF’s session-based caps. While initial limits caused disruptions, April 2025 enhancements and partnerships like Roche’s have improved affordability, particularly for breast cancer (KSh 40,000/session). Challenges like delays and drug shortages persist, but SHA’s digital tools and subsidies promote equity. Cancer patients are urged to register promptly via sha.go.ke or *147# to access these benefits, contributing to Kenya’s fight against this growing epidemic.

KINA MAISHA MAGIC EAST WEDNESDAY 17TH SEPTEMBER 2025 SEASON 5 EPISODE 98