Surgical Procedures Included in SHA

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s flagship initiative to achieve 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 provide equitable access to healthcare. Surgical procedures, a critical component of SHA’s offerings, are primarily covered under SHIF for standard and specialized surgeries and ECCF for high-cost, critical interventions, delivered at Levels 4-6 facilities (county and referral hospitals). As of September 2025, with over 20 million Kenyans enrolled, SHA has significantly expanded surgical coverage, addressing NHIF’s restrictive caps and limited scope, which left many patients facing out-of-pocket costs averaging 26% of health expenditures. This article details SHA’s surgical procedures, including coverage, eligibility, access, limitations, and impact, based on official regulations and recent data.

Background and Evolution from NHIF

Under NHIF, surgical coverage was limited, with caps of KSh 400,000 annually for inpatient care, including surgeries, and per-dependent fees that restricted access for families. Common procedures like appendectomies or cesarean sections were partially covered, but specialized surgeries (e.g., neurosurgery, transplants) were largely excluded, forcing patients to pay out-of-pocket costs exceeding KSh 500,000 for complex cases. Only 26% of Kenyans were enrolled in NHIF by 2023, with informal sector uptake at 20%, leaving many without surgical access.

SHA’s surgical framework, launched in October 2024, integrates services across SHIF and ECCF, aligning with the Kenya Health Policy 2017–2030 and Article 43 of the Constitution, which guarantees healthcare access. By mid-2025, SHA has accredited over 10,000 facilities for surgical services, partnered with providers like Aga Khan University Hospital for advanced procedures, and introduced digital tools like Afya Yangu to streamline access, significantly improving outcomes for conditions requiring surgery.

Funding Mechanism

Surgical procedures are funded through SHA’s tripartite structure:

• SHIF: Contribution-based (2.75% of gross income for salaried employees, deducted by employers; minimum KSh 300/month or KSh 3,600/year for informal sector via means-testing), covering standard and specialized surgeries at Levels 4-6. Indigent populations are fully subsidized via programs like Inua Jamii.
• ECCF: Fully government-funded through appropriations (KSh 5 billion in 2024/25) and donations, covering high-cost, critical surgeries (e.g., transplants, neurosurgery) after SHIF limits are exhausted.
• Disbursement: SHA reimburses over 10,000 accredited facilities via digital claims on the Afya Yangu platform, processed within 30 days, a significant improvement over NHIF’s 90+ day delays. Audits ensure transparency, addressing past mismanagement.

Eligibility and Access

All SHA-registered residents qualify for surgical benefits:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and children).
• Registration: Mandatory and free via *147#, sha.go.ke, or Huduma Centres using 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. Emergency surgeries are accessible without prior registration, with post-treatment enrollment.
• Referral System: Community Health Promoters (CHPs) or Level 1-3 facilities refer patients to Level 4-6 hospitals for surgeries via digital platforms, ensuring coordinated care.

Surgical Procedures Covered

SHA’s surgical coverage, administered through SHIF and ECCF, is comprehensive and uniform, with no family caps, unlike NHIF’s restrictive structure. The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, defines and updates the package.

SHIF Surgical Coverage (Levels 4-6)

Covers standard and specialized surgeries at county and referral hospitals:

• General Surgeries:
• Appendectomy (KSh 50,000–80,000, fully covered).
• Hernia repair.
• Gallbladder surgery (cholecystectomy).
• Cesarean sections (KSh 30,000, including anesthesia and recovery, doubled from NHIF’s KSh 15,000 cap).
• Orthopedic Surgeries:
• Fracture repairs (e.g., plating, pinning).
• Joint replacements (e.g., hip, knee, subject to approval).
• Gynecological Surgeries:
• Hysterectomy for fibroids or endometrial issues.
• Ovarian cyst removal.
• Urological Surgeries:
• Prostate surgery (e.g., TURP for benign prostatic hyperplasia).
• Kidney stone removal (lithotripsy).
• Minor Surgeries:
• Day procedures (e.g., cyst excision, circumcision) performed outpatient.
• Pre- and Post-Operative Care:
• Diagnostics (X-rays, CT scans, biopsies).
• Inpatient stays (no cap on days, unlike NHIF’s KSh 400,000 limit).
• Medications (antibiotics, pain relief).
• Physiotherapy for recovery.

ECCF Surgical Coverage (Levels 4-6)

Covers high-cost, critical surgeries after SHIF exhaustion:

• Organ Transplants:
• Kidney transplants (KSh 700,000, including immunosuppression, up from NHIF’s minimal coverage).
• Liver and bone marrow transplants (subject to availability).
• Neurosurgery:
• Craniotomies for brain tumors or trauma.
• Spinal surgeries for severe deformities or injuries.
• Cardiovascular Surgeries:
• Open-heart surgery (e.g., valve replacement, coronary artery bypass).
• Angioplasty with stent placement.
• Oncology Surgeries:
• Tumor resections for cancers (e.g., breast, colorectal, oral), up to KSh 150,000 annually after SHIF’s KSh 400,000 oncology limit.
• Emergency Surgeries:
• Trauma-related procedures (e.g., for road accidents, burns).
• Maternal emergencies (e.g., ectopic pregnancy, severe hemorrhage).
• Reconstructive Surgeries:
• Post-trauma or cancer reconstruction (e.g., maxillofacial surgery).
• Overseas Treatment:
• Up to KSh 500,000 for procedures unavailable locally (e.g., specialized pediatric surgeries), requiring SHA pre-approval within 72 hours.

Preventive Support via PHCF

While PHCF does not cover surgeries, it supports pre-surgical care through free screenings (e.g., for cancers, heart conditions) at Levels 1-3, facilitating early referrals to surgical facilities.

Comparison with NHIF

Facilities and Infrastructure

SHA accredits over 10,000 facilities for surgical services:

• Level 4-6 Facilities: County hospitals (e.g., Kirinyaga County Hospital), national referral hospitals (Kenyatta National Hospital, Moi Teaching and Referral Hospital), private providers (Aga Khan University Hospital), and faith-based centers (Tenwek Hospital).
• Specialized Units: Dedicated theaters for neurosurgery, cardiac surgery, and transplants at facilities like Kenya University Teaching, Referral and Research Hospital (KUTRRH), which performed Kenya’s first SHA-covered kidney transplants in May 2025.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches, pre-approvals, and claims tracking. Claims are processed within 30 days.
• CHPs: Over 100,000 Community Health Promoters facilitate referrals for surgical needs, using tablets for real-time coordination.
• Oversight: The Benefits and Tariffs Advisory Panel ensures quality and adjusts tariffs, with SHA enforcing audits to prevent fraud.

SHA invested KSh 3 billion in 2025 for surgical theater upgrades, including 25 new units in county hospitals.

Limitations and Exclusions

SHA’s surgical coverage has constraints:

• Pre-Approval: Critical surgeries (e.g., transplants, overseas procedures) require SHA approval, processed within 72 hours, which may delay urgent care.
• Overseas Cap: Limited to KSh 500,000; complex surgeries (e.g., advanced neurosurgery) may require 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.
• Cosmetic Surgeries: Excluded unless medically necessary (e.g., post-cancer reconstruction).
• Contribution Dependency: SHIF surgeries require active contributions; non-payment may delay non-emergency procedures, though ECCF covers critical cases.

Impact and Benefits

SHA’s surgical coverage has delivered significant outcomes:

• Financial Protection: Reduced out-of-pocket costs by 30%, saving families KSh 50,000–500,000 per surgery, preventing medical poverty.
• Increased Access: Surgical procedures rose by 25% in 2025, with 70% of beneficiaries from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Cesarean section access increased by 20%, reducing maternal mortality by 15%. Transplants (e.g., two successful kidney transplants at KUTRRH in May 2025) and cancer surgeries improved survival rates.
• Equity: Subsidies and unlimited dependent coverage boosted informal sector enrollment to 30% (vs. NHIF’s 20%). GeoPoll’s 2025 survey shows 60% of Kenyans view SHA’s surgical services as accessible and affordable.

Challenges and Solutions

Challenges include:

• Reimbursement Delays: Some hospitals report 60-day lags, disrupting services; SHA targets 30-day payments via digital claims.
• Rural Access: Limited Level 4-6 facilities in remote areas; SHA is expanding mobile surgical units and telehealth.
• Provider Shortages: Kenya has only 500 surgeons for 54 million people; SHA is training specialists and partnering with private facilities.
• Awareness Gaps: 35% of rural residents unaware of SHA’s surgical scope; radio and CHP campaigns aim to educate.

Future Outlook

SHA plans to enhance surgical services by:

• Increasing ECCF funding to KSh 8 billion by 2026/27 for critical procedures.
• Expanding local transplant programs to reduce overseas reliance.
• Integrating AI-driven diagnostics via Afya Yangu for pre-surgical assessments.
• Adding 50 surgical theaters in county hospitals by 2027.

Conclusion

SHA’s surgical procedures, covered under SHIF and ECCF, represent a significant advancement over NHIF, offering comprehensive access to general, specialized, and critical surgeries without family caps. From cesarean sections to kidney transplants, SHA reduces financial barriers and improves outcomes, particularly for low-income and rural populations. Despite challenges like reimbursement delays and provider shortages, digital tools and infrastructure investments strengthen implementation. For registered Kenyans, SHA’s surgical benefits provide a vital safety net, advancing Kenya’s vision of equitable healthcare by 2030.

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