SHA Tariffs and Hospital Reimbursements

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s primary vehicle for advancing Universal Health Coverage (UHC), replacing the National Health Insurance Fund (NHIF) as of 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 pool resources and reimburse healthcare providers for services rendered to enrolled members. Tariffs under SHA are predetermined rates for medical services, designed to standardize costs, ensure affordability, and promote equity across public, private, and faith-based facilities. Hospital reimbursements, processed through digital claims on the Afya Yangu platform, have been a focal point of implementation, with SHA disbursing over KSh 551 billion to facilities by July 2025. However, challenges like delayed payments and lower reimbursement rates compared to NHIF have sparked concerns among providers. As of September 17, 2025, with 26 million Kenyans registered, SHA’s tariff and reimbursement system continues to evolve under the Benefits Package and Tariffs Advisory Panel (BPTAP). This article provides a comprehensive overview of SHA’s tariffs, reimbursement processes, challenges, and recent developments, based on official regulations and data.

Legal Framework for Tariffs and Reimbursements

SHA’s tariffs and reimbursements are governed by the Social Health Insurance Act, 2023, and the Social Health Insurance (General) Regulations, 2024. The Act (Section 32) empowers SHA to set tariffs for benefits under SHIF and ECCF, while the Regulations (Fourth Schedule) outline reimbursable services and rates. Tariffs are evidence-based, determined by the BPTAP—chaired by Prof. Walter Jaoko and inaugurated in May 2025—to ensure cost-effectiveness and alignment with UHC goals.

Key principles include:

• Standardization: Uniform rates across facility levels (1-6) to prevent exploitation and ensure equity.
• Maximum Reimbursable Amounts: SHA reimburses up to the tariff rate; excess costs are borne by patients or facilities.
• Annual Review: BPTAP reviews tariffs every financial year, incorporating health technology assessments (HTA) for updates.
• Claims Processing: Facilities submit electronic claims within seven days of service or discharge, with SHA reviewing and paying within 30 days, a improvement over NHIF’s 90+ days.

The Legal Notice No. 146 of 2024 (Tariffs for Healthcare Services) was repealed on February 28, 2025, by Legal Notice 56 of 2025, reflecting ongoing refinements.

Overview of SHA Tariffs

SHA tariffs are facility-level specific, reflecting the complexity of services and ensuring sustainability. They cover preventive, promotive, curative, rehabilitative, and palliative care across funds. The Benefits Package and Tariffs Advisory Panel (BPTAP) advises on these rates, prioritizing affordability while incentivizing quality.

PHCF Tariffs (Levels 1-3 and Select Level 4)

PHCF, fully government-funded, provides free services at point of care, with capitation payments (quarterly) to facilities based on enrolled population. Tariffs emphasize preventive care:

• Consultation and Basic Services: KSh 935 for consultation, exams, and minor treatments (e.g., wound dressing).
• Maternal and Child Health: Free antenatal/postnatal care, vaccinations, and growth monitoring.
• Screenings: No charge for hypertension, diabetes, or cancer screenings; facilities receive capitation (e.g., KSh 2,400 per patient at Level 3).
• Capitation Model: Facilities like dispensaries receive quarterly payments based on registered members, promoting efficiency. For example, Level 3 facilities get KSh 2,400 per patient annually.

PHCF tariffs ensure no out-of-pocket costs, with reimbursements tied to service volume and quality audits.

SHIF Tariffs (Levels 4-6)

SHIF reimburses fee-for-service for inpatient/outpatient care, with tariffs set to reflect procedure complexity:

• Outpatient Services: Consultation at KSh 1,000–2,000; diagnostics (e.g., lab tests KSh 500–5,000, imaging KSh 2,000–10,000).
• Inpatient Services: Ward stay KSh 2,240/day at Level 3; ICU/HDU up to KSh 28,000/day (increased from NHIF’s KSh 4,600).
• Maternity: Normal delivery KSh 10,000; cesarean section KSh 30,000, including newborn care.
• Chronic Care: Dialysis KSh 10,650/session (up to 8/month); oncology KSh 300,000/year for chemotherapy/radiotherapy, plus KSh 100,000 diagnostics.
• Surgical Procedures: Appendectomy KSh 50,000–80,000; hernia repair KSh 40,000.

Tariffs are lower than market rates (e.g., private cesarean KSh 100,000+), but SHA’s volume-based reimbursements (e.g., KSh 551 billion disbursed by July 2025) sustain facilities.

ECCF Tariffs (Levels 2-6)

ECCF covers catastrophic care with higher tariffs post-SHIF exhaustion:

• Emergency Care: Ambulance KSh 5,000–10,000/trip; ICU/HDU KSh 28,000/day.
• Chronic/Critical: Transplants KSh 700,000 (kidney); additional oncology KSh 150,000/year.
• Overseas Treatment: KSh 500,000/year for unavailable services, with pre-approval.

Tariffs are maximum reimbursable amounts; facilities bill SHA up to these rates.

Hospital Reimbursement Process

Reimbursements follow a digital, claims-based model:

1. Service Delivery: Facilities verify patient SHA membership via Afya Yangu and provide services per tariffs.
2. Claims Submission: Electronic submission within 7 days of service/discharge, including patient records, invoices, and service details.
3. Review and Approval: SHA audits claims (e.g., for accuracy, within 72 hours for rejections), approving up to tariff rates.
4. Payment: Disbursed within 30 days via bank transfer; e.g., KSh 18.2 billion paid in Q4 2024.
5. Audits and Penalties: Fraud (e.g., ghost claims) incurs fines up to KSh 2 million or de-accreditation.

By August 2025, SHA processed KSh 96.2 billion in claims, paying KSh 551 billion total, but private hospitals report Sh43 billion in unpaid dues, including NHIF arrears (Sh33 billion).

Challenges in Tariffs and Reimbursements

SHA’s system faces implementation hurdles:

• Delayed Payments: Facilities report 60–90 day lags, leading to layoffs (66% of nurses affected) and service suspensions (e.g., 14-day go-slow notice in September 2025).
• Lower Tariffs: Rates (e.g., ICU KSh 28,000/day vs. market KSh 50,000+) are below costs, prompting blanket rejections and financial distress for private providers (Sh43 billion owed).
• Fraud and Ghost Claims: Incidents like Sh20 million to non-existent Nyandiwa Dispensary highlight vulnerabilities, leading to audits and suspensions.
• Uneven Disbursements: Public hospitals like KNH received Sh70 million in August 2025, while some private ones got less despite higher claims.
• Awareness and Compliance: Facilities must re-contract with SHA; non-compliance leads to exclusions.

KMPDU and RUPHA urge increased funding (e.g., Parliament boost) and timely payments to sustain operations.

Recent Developments and Reforms

• BPTAP Inauguration (May 2025): Chaired by Prof. Jaoko, the panel reviews benefits and tariffs annually, incorporating HTA for updates (e.g., oncology tariffs revised in April 2025).
• Tariff Revisions: Legal Notice 56 of 2025 (February 2025) repealed prior tariffs, introducing sustainable rates (e.g., hemodiafiltration KSh 11,200/session).
• Payment Disbursements: KSh 551 billion paid by July 2025; monthly remittances (unlike NHIF’s bi-annual) revived facilities like Nairobi clinics.
• Crackdown on Non-Compliance: SHA suspended non-compliant hospitals; government pays contributions for 1.5 million indigent from September 2025.
• Digital Enhancements: Afya Yangu ensures 72-hour rejection notices and 30-day payments.

Impact on Healthcare Providers and Patients

• Providers: Reimbursements have revived facilities (e.g., Nairobi clinics receiving monthly funds), but private hospitals face Sh43 billion arrears, leading to layoffs and service cuts. Public hospitals like KNH received Sh70 million in August 2025.
• Patients: 4.5 million accessed primary care; 2.2 million specialized services by July 2025, reducing out-of-pocket costs by 30%. However, delays caused denials, prompting RUPHA’s go-slow threat.

Future Outlook

BPTAP’s two-year review (by 2027) will refine tariffs, potentially increasing rates for specialized care. SHA aims for 100% enrollment by 2030, with KSh 15 billion for PHCF and KSh 8 billion for ECCF by 2026/27, ensuring timely reimbursements. Enhanced digital systems and anti-fraud measures will sustain the model.

Conclusion

SHA’s tariffs and hospital reimbursements are central to UHC, standardizing costs and ensuring equitable payments across 10,000+ facilities. While PHCF’s capitation promotes preventive care and SHIF/ECCF’s fee-for-service supports specialized treatments, challenges like delays (Sh43 billion owed) and lower rates persist. Reforms via BPTAP and monthly disbursements (KSh 551 billion by July 2025) signal progress. Providers must comply with e-contracting, and patients register via *147# or sha.go.ke to benefit. As SHA evolves, timely reimbursements will be key to sustainable healthcare in Kenya.

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