SHA’s Role in Achieving Universal Health Coverage

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s transformative framework for achieving 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, affordable, and quality healthcare for all Kenyans. UHC, as defined by the World Health Organization (WHO), aims to provide essential health services without financial hardship. With over 20 million Kenyans enrolled by September 17, 2025, SHA addresses NHIF’s shortcomings, such as low informal sector enrollment (20%) and high out-of-pocket costs (26% of health expenditures). This article explores SHA’s structure, services, funding, challenges, and impact on UHC, drawing on official regulations and recent data.

Background and Evolution from NHIF

NHIF, established in 1966, provided limited healthcare coverage, focusing on inpatient services with restrictive caps (e.g., KSh 400,000/year for inpatient care, KSh 1,000/visit for outpatient). By 2023, only 26% of Kenyans were enrolled, with informal sector uptake at 20%, leaving millions vulnerable to out-of-pocket costs that pushed 1.5 million into poverty annually. Specialized care (e.g., dialysis, cancer treatment) was inadequately covered, and reimbursement delays of 90+ days strained providers. NHIF’s inefficiencies, including fraud and cartel-driven overseas referrals, cost billions (e.g., KSh 2.5 billion in 2022).

SHA, launched in October 2024, addresses these gaps through a tripartite funding model and expanded benefits, aligning with Kenya’s Health Policy 2017–2030, the Constitution’s Article 43 (right to health), and WHO’s UHC framework. By September 2025, SHA has disbursed KSh 56.4 billion for healthcare services, three times NHIF’s annual payout, and enrolled 70% of the informal sector, a significant leap toward UHC’s goal of 100% coverage by 2030.

SHA’s Structure and Funds

SHA’s tripartite structure ensures comprehensive coverage across primary, specialized, and critical care:

• Primary Health Care Fund (PHCF): Fully government-funded (KSh 10 billion in 2024/25 via national budgets, county contributions, and grants), PHCF provides free preventive and basic care at Levels 1-3 (community units, dispensaries, health centers). Services include screenings, vaccinations, and maternal health, reducing disease burden by 40% through early intervention.
• Social Health Insurance Fund (SHIF): Contribution-based (2.75% of gross income for salaried employees, minimum KSh 300/month for informal sector via means-testing), SHIF covers outpatient and inpatient services at Levels 4-6 (county/referral hospitals), including dialysis, cancer treatment, and surgeries. Indigent populations are subsidized via Inua Jamii.
• Emergency, Chronic, and Critical Illness Fund (ECCF): Government-funded (KSh 5 billion in 2024/25), ECCF covers high-cost care like organ transplants, emergency ambulance services, and overseas treatment (KSh 500,000 cap), ensuring no patient is excluded due to cost.

SHA disburses funds to over 10,000 accredited facilities via digital claims on the Afya Yangu platform, processed within 30 days, improving on NHIF’s delays. Audits and transparency measures address past fraud.

Eligibility and Enrollment

SHA’s universal eligibility ensures broad access:

• Eligible Groups: All Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses/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.
• No Waiting Periods: Unlike NHIF’s 60-day delay, SHA provides immediate access post-registration, critical for emergencies.

By September 2025, SHA’s enrollment campaigns, supported by over 100,000 Community Health Promoters (CHPs), have achieved 70% coverage, with a focus on informal sector workers.

Comprehensive Services Supporting UHC

SHA’s services are designed to meet UHC’s pillars—access, quality, and financial protection:

• Primary Care (PHCF): Free screenings (e.g., cancer, diabetes), vaccinations (95% coverage for under-5s), maternal/child health, and mental health counseling at Levels 1-3, reducing hospital admissions by 15%.
• Outpatient and Inpatient Care (SHIF): Unlimited specialist visits, diagnostics (e.g., MRIs, up to KSh 100,000), surgeries (e.g., cesarean sections at KSh 30,000), and chronic disease management (e.g., dialysis, KSh 10,650/session) at Levels 4-6.
• Critical Care (ECCF): Organ transplants (e.g., kidney at KSh 700,000), emergency ambulances (1,000+ units), and overseas treatment (KSh 500,000 cap) for life-threatening conditions.
• Specialized Services: Includes dental care (e.g., root canals), prosthetics (e.g., limb prostheses up to KSh 100,000), palliative care for 800,000 patients annually, and mental health support (e.g., therapy for 1.9 million with depression).

SHA’s Strategies for UHC

SHA employs several strategies to achieve UHC:

• Digital Integration: The Afya Yangu platform and *147# USSD facilitate registration, facility searches, and claims, reducing delays to 30 days vs. NHIF’s 90+.
• Community Engagement: Over 100,000 CHPs conduct screenings, health education, and referrals, reaching 70% of rural households.
• Facility Accreditation: Over 10,000 facilities (8,000 Levels 1-3, 2,000 Levels 4-6) ensure quality care, with investments like KSh 3 billion for surgical theaters.
• Partnerships: Collaborations with Kenya Red Cross, KEHPCA, and Aga Khan University Hospital enhance specialized care (e.g., KSh 40,000/session for breast cancer via Roche partnership).
• Subsidies: Inua Jamii supports indigent populations, ensuring 15% of Kenyans access care without contributions.

Impact on UHC

SHA’s impact on UHC is evident:

• Financial Protection: Reduced out-of-pocket costs by 40%, saving families KSh 20,000–500,000 per procedure, preventing medical poverty.
• Access: Enrollment rose to 70% (vs. NHIF’s 26%), with 30% informal sector uptake. Primary care visits increased by 35%, and 515,000 deliveries were supported in 2024/25.
• Health Outcomes: Early screenings reduced cancer mortality by 10% and hospital admissions by 15%. Vaccination coverage hit 95% for under-5s.
• Equity: 70% of beneficiaries are low-income, with subsidies ensuring access for the indigent. GeoPoll’s September 2025 survey shows 60% of Kenyans view SHA as accessible, though 40% cite delays.

Challenges and Solutions

Despite progress, SHA faces hurdles:

• Reimbursement Delays: 60–90 day lags reported; SHA targets 30-day payments via digital claims.
• Rural Access: Limited Level 4-6 facilities; SHA is expanding mobile clinics and telehealth.
• Provider Shortages: Only 500 surgeons and 200 prosthetists for 54 million people; SHA is training specialists.
• Awareness Gaps: 35% of rural residents unaware of benefits; radio and CHP campaigns aim to educate.
• Overseas Treatment: KSh 500,000 cap and August 2025 suspension disrupted access; SHA resumed with stricter criteria.

Future Outlook

SHA plans to advance UHC by:

• Achieving 100% enrollment by 2030 via intensified campaigns.
• Increasing PHCF and ECCF funding to KSh 15 billion and KSh 8 billion by 2026/27.
• Integrating AI diagnostics and telehealth via Afya Yangu.
• Expanding local capacity (e.g., transplant centers) to reduce overseas referrals.

Conclusion

SHA’s tripartite structure, digital integration, and comprehensive services mark a significant leap toward UHC, surpassing NHIF’s limited reach. By providing free primary care, subsidized specialized services, and critical care coverage, SHA reduces financial barriers and promotes equity, particularly for low-income and rural populations. Despite challenges like delays and awareness gaps, SHA’s investments and partnerships signal a robust path to 100% coverage by 2030. Kenyans are urged to register via *147# or sha.go.ke to access these benefits, ensuring a healthier, more inclusive future.

NOMA NTV THURSDAY 18TH SEPTEMBER 2025 FULL EPISODE