Overseas Medical Treatment Under SHA

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s pivotal mechanism for advancing 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 ensure equitable access to healthcare. Overseas medical treatment, a provision for specialized procedures unavailable locally, is covered under the ECCF, with a cap of KSh 500,000 per year per patient. As of September 17, 2025, over 20 million Kenyans are enrolled, but access to overseas care has been tightened following an August 2025 suspension to curb abuse. This reform addresses longstanding issues of cartels and unnecessary referrals, while maintaining coverage for genuine needs like advanced oncology or organ transplants. This article explores the framework, eligibility, process, challenges, and recent updates, based on official guidelines and developments as of mid-September 2025.

Background and Evolution from NHIF

Under NHIF, overseas treatment was available but plagued by inefficiencies and abuse. The scheme covered up to KSh 5 million per case for procedures like organ transplants or rare cancers, but approvals were often influenced by cartels, leading to unnecessary referrals and billions in losses (e.g., KSh 2.5 billion in 2022, per Auditor General reports). Only 26% of Kenyans were enrolled by 2023, with informal sector uptake at 20%, limiting access. Conditions like stem cell therapy or advanced neurosurgery were frequently sought abroad, but delays and corruption eroded trust.

SHA’s overseas treatment benefit, introduced in October 2024, is more stringent, focusing on treatments unavailable in Kenya. The Social Health Insurance (General) Regulations, 2024, outline the package under ECCF, emphasizing local capacity first. Initial implementation allowed referrals for specialized care, but by August 2025, Health Cabinet Secretary Aden Duale announced a 30-day suspension (August 17 to mid-September) to align with new guidelines, halting all approvals to investigate cartels. As of September 11, 2025, the policy resumed with stricter criteria: coverage only for proven unavailability locally, pre-approved foreign hospitals, and a KSh 500,000 cap. This aligns with the Cancer Prevention and Control Act, 2012, and broader UHC goals, reducing abuse while supporting 47,000 annual cancer cases and other complex conditions.

Legal Framework

The Social Health Insurance Act, 2023 (Section 26 and Fourth Schedule), and Social Health Insurance (General) Regulations, 2024, govern overseas treatment. Key provisions:

• Eligibility Criteria: Treatments must be unavailable or inadequate in Kenya, certified by a SHA-empaneled specialist.
• Funding Source: ECCF, government-funded (KSh 5 billion in 2024/25), with no individual contributions required beyond SHIF premiums.
• Cap and Limits: KSh 500,000 per year per patient, covering procedures, transport, and accommodation (excluding luxury expenses).
• Pre-Approval: Mandatory SHA review, including foreign hospital accreditation and cost verification.
• Post-August 2025 Updates: Only for conditions not treatable locally; foreign facilities must be pre-vetted and linked to Kenyan empaneled providers. The 30-day halt allowed policy alignment, resuming with enhanced oversight to curb cartels.

Eligibility and Requirements

Eligibility is limited to SHA-registered residents:

• Who Qualifies: Kenyan citizens, non-citizens residing over 12 months, and dependents (unlimited spouses/children). Conditions include advanced cancers, organ transplants, rare genetic disorders, or specialized surgeries unavailable locally (e.g., stem cell therapy, certain pediatric neurosurgeries).
• Registration: Mandatory via *147#, sha.go.ke, or Huduma Centres. Former NHIF members auto-migrated but need biometric verification.
• Key Requirements:
• Medical diagnosis and recommendation from a SHA-empaneled Kenyan specialist confirming local unavailability.
• Pre-approval from SHA’s Benefits and Tariffs Advisory Panel (within 72 hours).
• Foreign hospital must be accredited (e.g., JCI-certified) and pre-linked to Kenyan providers.
• Patient must return to Kenya for follow-up; no coverage for elective or cosmetic treatments.
• Indigent patients receive full subsidies; all others pay SHIF contributions (2.75% income or KSh 300/month minimum).

Coverage Details

Overseas treatment under ECCF covers:

• Eligible Procedures: Specialized interventions like bone marrow transplants, advanced oncology (e.g., CAR-T therapy), open-heart surgeries for complex congenital defects, or neurosurgeries unavailable locally.
• Financial Coverage: Up to KSh 500,000 annually, including:
• Medical procedures and hospital stays.
• One attendant’s travel and accommodation.
• Economy airfare and basic lodging.
• Exclusions: Luxury travel, non-medical expenses, treatments available in Kenya (e.g., standard chemotherapy), or post-treatment rehabilitation not pre-approved.
• Duration: Typically 30–90 days; extensions require justification.
• Post-Treatment: Follow-up in Kenya mandatory; SHA may cover return transport.

The cap ensures sustainability, with ECCF disbursing KSh 1.2 billion for overseas care in 2024/25 (pre-reform).

Application Process

1. Diagnosis and Referral: Obtain certification from a Kenyan SHA-empaneled specialist that treatment is unavailable locally.
2. SHA Pre-Approval: Submit application via sha.go.ke or Huduma Centres, including medical reports, foreign hospital quote, and proof of accreditation. Processed within 72 hours by the panel.
3. Travel and Treatment: Upon approval, SHA issues a guarantee letter for the foreign hospital. Patient travels with attendant if needed.
4. Claims and Follow-Up: Post-treatment, submit invoices to SHA for reimbursement (up to KSh 500,000). Return to Kenya for monitoring.
5. Contacts: Toll-free 0800 720 601; email customercare@sha.go.ke. Forms available on sha.go.ke.

Challenges and Recent Developments

Overseas treatment under SHA has faced hurdles:

• Abuse and Cartels: Pre-2025, cartels facilitated unnecessary referrals, costing billions. The August 17–September 16, 2025, 30-day halt investigated this, stranding patients abroad (e.g., those mid-treatment for cancer).
• Stranded Patients: The suspension affected 200+ cases, prompting emergency interventions. As of September 11, 2025, approvals resumed only for verified unavailability.
• Local Capacity Gaps: While Kenya has advanced facilities (e.g., KUTRRH for transplants), shortages in specialists (e.g., for rare pediatric surgeries) justify some referrals.
• Cap Insufficiency: KSh 500,000 often falls short for complex treatments (e.g., KSh 1 million+ for stem cell therapy); top-ups are common.
• Administrative Delays: Pre-approval can take up to 7 days in practice, delaying urgent cases.

Solutions include pre-vetting foreign hospitals, linking them to Kenyan providers, and digital tracking via Afya Yangu to prevent abuse.

Impact and Benefits

SHA’s overseas treatment provision has mixed impacts:

• Financial Protection: Covers up to KSh 500,000, reducing out-of-pocket costs by 30–50% for eligible cases, shielding families from medical poverty (1.5 million affected annually).
• Access for Complex Cases: Supported 1,500+ referrals in 2024/25, including transplants (e.g., kidney abroad for ESRD patients) and oncology, improving survival rates for rare conditions.
• Equity: Subsidies ensure indigent access; informal sector enrollment rose to 30% (vs. NHIF’s 20%).
• Local Capacity Building: Reforms prioritize Kenyan facilities, reducing referrals by 40% post-August 2025, saving KSh 2 billion.

GeoPoll’s September 2025 survey shows 50% satisfaction with the tightened policy, citing reduced abuse, though 40% worry about access delays.

Future Outlook

SHA plans to refine overseas treatment by:

• Increasing the cap to KSh 750,000 by 2026 for high-demand cases.
• Expanding pre-approved foreign hospitals to 50 (e.g., in India, South Africa).
• Integrating AI diagnostics via Afya Yangu to verify local unavailability.
• Launching a dedicated oversight committee by December 2025 to monitor cartels.

By 2030, UHC aims to minimize overseas referrals through local advancements.

Conclusion

Overseas medical treatment under SHA, capped at KSh 500,000 via ECCF, provides a vital safety net for specialized care unavailable locally, with stricter post-August 2025 guidelines to curb abuse. From transplants to advanced oncology, the process requires specialist certification and SHA pre-approval, ensuring equity for registered residents. While challenges like delays and stranded patients persist, reforms promote local capacity and transparency. Patients seeking coverage should contact SHA at 0800 720 601 or via sha.go.ke for guidance, supporting Kenya’s UHC journey by 2030.

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