Digital Management of SHA Coverage

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s primary mechanism for achieving 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 provide equitable healthcare access to over 26 million enrolled Kenyans as of September 20, 2025. Central to SHA’s success is its digital management system, anchored by the Afya Yangu platform and *147# USSD code, which streamlines registration, claims processing, facility verification, and benefit tracking. By July 2025, SHA disbursed KSh 551 billion to providers, with 80% of claims processed electronically, a significant improvement over NHIF’s 90+ day manual delays. Despite challenges like rural connectivity gaps and system bugs, SHA’s digital approach has reduced out-of-pocket costs (previously 26% of health expenditures) and enhanced access, particularly for low-income groups. This article provides a comprehensive overview of SHA’s digital management system, detailing its components, benefits, challenges, success stories, and future plans, based on official regulations and data as of September 20, 2025, 10:40 AM EAT.

Background: Transition from NHIF to SHA

Under NHIF, healthcare management was hampered by manual processes, leading to:

• Delayed Claims: Reimbursement lags of 90–180 days, with KSh 33 billion in arrears by 2023.
• Fraud: Ghost claims (e.g., KSh 2.5 billion in 2022) eroded trust.
• Low Enrollment: Only 26% of Kenyans were covered, with 20% informal sector uptake.
• Access Barriers: Manual registration and paper-based claims limited efficiency, particularly in rural areas.

SHA’s digital transformation, mandated by the Social Health Insurance (General) Regulations, 2024, leverages the Afya Yangu platform, *147# USSD, and biometric verification to address these gaps. By September 2025, SHA has enrolled 70% of the population, with 80% of claims processed digitally, disbursing KSh 551 billion to over 10,000 facilities. The system supports Kenya’s Health Policy 2017–2030 and Article 43 of the Constitution (right to health).

Components of SHA’s Digital Management System

SHA’s digital infrastructure integrates multiple tools to manage coverage efficiently:

1. Afya Yangu Platform

• Function: A web-based and mobile app platform (sha.go.ke) for registration, facility searches, claims submission, and benefit tracking.
• Features:
• Registration: Users input national ID, passport, or alternative documents (e.g., birth certificates for minors) to enroll.
• Facility Locator: Lists over 10,000 SHA-accredited facilities (8,000 Levels 1-3, 2,000 Levels 4-6).
• Claims Processing: Providers submit claims within seven days, with SHA reviewing within 72 hours and paying within 30 days.
• Benefit Tracking: Members view coverage details (e.g., SHIF limits for dialysis, ECCF for emergencies).
• Impact: By mid-2025, 80% of claims (KSh 96.2 billion in Q4 2024) were processed via Afya Yangu, reducing delays from NHIF’s 90+ days.

2. *147# USSD Code

• Function: A mobile-based service for areas with limited internet, enabling registration, contribution payments, and facility verification.
• Features:
• Enrollment: Users dial *147# to register with minimal data (e.g., ID number).
• Contribution Management: Pay SHIF contributions (KSh 300/month minimum) via mobile money (e.g., M-Pesa).
• Verification: Check membership status or facility accreditation.
• Impact: Critical for rural and low-income users, with 70% of informal sector enrollment (30% of total) via USSD by September 2025.

3. Biometric Verification

• Function: Ensures accurate member identification, reducing fraud (e.g., ghost claims like KSh 20 million to Nyandiwa Dispensary in 2025).
• Process: Fingerprint or facial recognition at Huduma Centres or via CHPs for registration and service access.
• Impact: Over 90% of urban enrollees and 60% of rural ones use biometrics, enhancing system integrity.

4. Claims Management System

• Function: Providers submit electronic claims within seven days via Afya Yangu, with SHA auditing for tariff compliance (e.g., KSh 30,000 for cesarean).
• Process:
• Providers enter patient details, procedure codes (ICD-11), and invoices.
• SHA reviews within 72 hours, rejecting non-compliant claims (20% in Q1 2025).
• Approved claims paid within 30 days via bank transfer.
• Impact: KSh 551 billion disbursed by July 2025, though KSh 43 billion in arrears persists.

5. Community Health Promoters (CHPs) with Digital Tools

• Role: Over 100,000 CHPs use tablets linked to Afya Yangu for door-to-door registration and screenings, reaching 70% of households.
• Impact: Enrolled 90,000 Inua Jamii beneficiaries by August 2025, boosting rural access.

Benefits of Digital Management

SHA’s digital system delivers significant advantages:

• Efficiency: 30-day claim payments vs. NHIF’s 90+ days, with 80% electronic processing.
• Accessibility: Afya Yangu and *147# enable urban and rural users to register and access 10,000+ facilities, with 4.5 million primary care visits by July 2025.
• Fraud Reduction: Biometric verification and audits reduced ghost claims by 15% in 2025.
• Equity: Subsidies for 1.5 million indigent households (September 2025) are managed digitally, ensuring 70% of beneficiaries are low-income.
• Transparency: Real-time tracking of contributions and claims, with rejection notices within 72 hours.

Success Stories

1. Kibera, Nairobi: Urban Slum Enrollment

A single mother in Kibera used *147# to register her family in 2025, accessing free PHCF screenings for diabetes via a local dispensary. When her child needed surgery, Afya Yangu verified Mbagathi Hospital’s accreditation, and SHA covered KSh 30,000 for the procedure, saving KSh 50,000. Her story, shared in a Ministry briefing, reflects SHA’s urban reach.

2. Turkana County: Rural Emergency Care

A nomadic family in Turkana, enrolled via CHPs using Afya Yangu tablets, accessed ECCF-funded ambulance and ICU care (KSh 28,000/day) in 2025. Biometric verification ensured eligibility, as highlighted during President Ruto’s September 13, 2025, meeting.

3. KUTRRH, Nairobi: Chronic Care

A low-income patient used Afya Yangu to confirm SHA coverage for chemotherapy (KSh 300,000/year) at KUTRRH in 2024, avoiding KSh 500,000 in costs. The platform’s facility locator and claims tracking streamlined care, per KUTRRH’s October 2024 report.

Challenges in Digital Management

Despite successes, SHA’s digital system faces hurdles:

• Rural Connectivity Gaps: Limited internet in ASAL regions (e.g., Turkana) hinders Afya Yangu use, with 35% of rural residents unaware of benefits, per GeoPoll 2025.
• System Bugs: Early eClaims failures led to 20% claim rejections in Q1 2025, prompting RUPHA’s go-slow notice on September 5, 2025.
• Reimbursement Delays: KSh 43 billion in unpaid dues (including NHIF arrears) by August 2025 disrupt facility operations.
• Digital Literacy: Low smartphone penetration in rural areas limits Afya Yangu access, though *147# mitigates this.
• Fraud Risks: System errors reinstated non-compliant hospitals, per RUPHA’s September 2025 critique.

Reforms and Solutions

SHA is addressing these challenges:

• Digital Upgrades: September 2025 fixes to Afya Yangu resolved eClaims bugs, with 80% claims processed electronically.
• Rural Infrastructure: KSh 500 million allocated in 2025 for internet connectivity in ASAL regions.
• CHP Training: Equipping 100,000 CHPs with tablets to assist non-digital users, boosting rural enrollment.
• Anti-Fraud Measures: Biometric verification and AI audits reduced ghost claims by 15% in 2025.
• Arrears Clearance: Monthly disbursements aim to clear KSh 43 billion by 2026.

Future Outlook

SHA plans to:

• Achieve 100% digital claims by 2027, with AI-driven diagnostics via Afya Yangu.
• Expand *147# functionality for rural payments and telehealth by 2026.
• Increase funding (PHCF to KSh 15 billion, ECCF to KSh 8 billion by 2026/27) to clear arrears.
• Deploy 500 mobile clinics with digital connectivity in ASAL areas by 2027.

Conclusion

SHA’s digital management system, centered on Afya Yangu and *147#, has transformed healthcare access for 26 million Kenyans, enabling efficient registration, claims processing, and benefit tracking. Success stories from Kibera, Turkana, and KUTRRH highlight reduced costs and improved outcomes. Challenges like rural connectivity and arrears persist, but 2025 reforms signal progress. Users should engage via *147#, sha.go.ke, or CHPs to maximize benefits, advancing Kenya’s UHC vision by 2030.

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