Comparing SHA Packages Across Counties

Introduction

The Social Health Authority (SHA), operational since October 1, 2024, under the Social Health Insurance Act of 2023, represents Kenya’s ambitious stride toward Universal Health Coverage (UHC) by 2030, replacing the National Health Insurance Fund (NHIF) amid its legacy of low coverage (17% of the population) and KSh 30.9 billion in debts. SHA’s unified benefits package—structured across three funds: the Primary Health Care Fund (PHCF) for levels 1–4 facilities, the Social Health Insurance Fund (SHIF) for levels 4–6, and the Emergency, Chronic, and Critical Illness Fund (ECCIF)—promises equitable access to services like free primary care, inpatient treatments up to KSh 28,000/day, and oncology coverage of KSh 550,000/year. As of September 2025, SHA has registered 26.7 million Kenyans (50% of the 53 million population), disbursed KSh 8 billion to facilities, and covered 4.5 million treatments without out-of-pocket costs.

While SHA’s core benefits are standardized nationally to ensure uniformity, devolution under Kenya’s 2010 Constitution delegates health service delivery to 47 counties, leading to variations in package implementation. These disparities arise from differences in facility e-contracting (56% national average, ranging from 40% in Turkana to 70% in Mombasa), registration uptake (e.g., low in Samburu at under 30%), and county-specific initiatives like MakueniCare. A Benefits Package and Tariffs Advisory Panel (BPTAP), established in January 2025, reviews these packages biennially for equity. This article compares SHA packages across counties, highlighting uniform benefits, regional variations, challenges, and implications, based on Ministry of Health (MoH) reports, GeoPoll surveys, and county data as of September 2025.

Background: SHA’s National Benefits Framework

SHA’s benefits are nationally defined in the Social Health Insurance Regulations 2024 and tariffs annexed to provider contracts, ensuring no explicit county-specific packages. Key elements include:

• PHCF (Tax-Funded): Free consultations, diagnostics, and preventive care at levels 1–4, including vaccinations, antenatal care (up to 8 visits), and community screenings via 107,000 Community Health Promoters (CHPs).
• SHIF (Contribution-Funded): Inpatient/outpatient services at levels 4–6, covering maternity (normal delivery KSh 10,200–30,000; C-sections KSh 30,000–102,000), surgeries, and NCD management.
• ECCIF (Government-Funded for Vulnerable): High-cost care like dialysis, oncology (KSh 550,000/year), and critical care (KSh 28,000/day), fully subsidized for 1.5 million indigent households.

Contributions are tiered: KSh 300/month for low-income households, up to 2.75% of salary for formal workers, with “Lipa SHA Pole Pole” installments for informal sector (83% of workforce). By September 2025, 45 counties have signed Implementation Partner Agreements (IPAs), onboarding 594 facilities, but disparities persist due to devolution’s emphasis on county autonomy in service delivery.

Uniform Benefits vs. County Variations

SHA’s packages are uniform in design, but execution varies by county due to infrastructure, e-contracting rates, and supplementary programs. The MoH’s February 2025 briefing noted over 19.3 million registrations, but means-testing lags at 3.3 million, with uptake uneven: high in urban counties (e.g., Nairobi at 65%) and low in ASALs (e.g., Turkana under 40%). Payments are now direct to facilities, bypassing county treasuries, to curb delays, but county-level factors influence access.

Key Uniform Benefits

Nationwide, SHA covers 85% of essential services at primary levels, including:

• Preventive: Screenings for hypertension (24% prevalence), diabetes (9%), and HIV (2.1% in youth).
• Curative: Emergency care (mandated regardless of status), mental health, and palliative services.
• Specialized: Renal dialysis, assistive devices (up to KSh 50,000/year), and overseas treatment for select cases.

County-Specific Variations

Variations stem from e-contracting (national 56%), facility levels, and local supplements. A 2025 MoH progress report highlights regional disparities, with urban counties benefiting from higher facility integration.

Data compiled from MoH February 2025 briefing, SHA e-contracting reports, and county UHC policies (2025). ASAL counties (e.g., Turkana) lag due to remoteness, while urban ones (e.g., Nairobi) leverage infrastructure.

Case Studies: Urban vs. Rural/ASAL Implementation

Urban Counties (e.g., Nairobi and Mombasa)

These benefit from dense networks of level 5–6 facilities (e.g., Kenyatta National Hospital in Nairobi), enabling seamless SHIF/ECCIF access. Nairobi’s 70% e-contracting supports 1 million+ visits, with low denial rates (5%) for specialized care like PET scans (fully covered). Mombasa’s coastal focus enhances maternal packages, reducing MMR by 10% via 98% ANC coverage. However, urban overcrowding strains resources, with SHA suspending 45 facilities nationwide in August 2025 for non-compliance, including some in Nairobi.

Rural/ASAL Counties (e.g., Turkana and Samburu)

ASALs face acute challenges: low e-contracting (30–40%) and remoteness limit SHIF access, relying heavily on PHCF and CHPs for preventive care. Turkana’s <30% uptake reflects nomadic lifestyles, but government subsidies for 1.5 million indigent (announced September 2025) prioritize these areas. Samburu’s weekend lows hinder registration, leading to 10% denials. Supplements like West Pokot’s maternal transport pilots bridge gaps, but funding deficits (KSh 4 billion monthly national) exacerbate delays.

Hybrid Models (e.g., Makueni)

Makueni’s MakueniCare integrates with SHA, offering free county drugs alongside PHCF, covering 80% of households and reducing out-of-pocket expenses (OOPE) by 25%. This model, effective October 2024, exemplifies devolution’s role in customizing delivery without altering national packages.

Challenges in Uniformity and Access

Despite standardization, variations pose equity risks:

• E-Contracting Disparities: 56% national rate masks gaps; ASALs at 30–40% vs. urban 70%, per MoH 2025. SHA suspended 45 facilities in August 2025 for quality issues, disproportionately affecting rural counties.
• Registration and Means-Testing: 26.7 million registered, but only 3.3 million means-tested; low uptake in Samburu/Turkana (<30%) due to awareness gaps (GeoPoll February 2025: 95% awareness but 22% misconceptions of “free” care).
• Funding and Infrastructure: KSh 6.1 billion government allocation covers 4% of needs; direct payments to facilities reduce delays but strain under-resourced counties (Rupha rating: 44%).
• Public Sentiment: X discussions (70% negative) highlight fraud fears (e.g., KSh 41 million ghost claims) and rural inequities, with users decrying “ASAL neglect.”

GeoPoll’s survey (n=961) reveals 13% optimism for improvements, with rural respondents (45% of sample) citing access barriers.

Implications for UHC and Recommendations

SHA’s national uniformity fosters equity, but county variations risk widening disparities: urban counties achieve 60–70% effective coverage, while ASALs hover at 30–40%, per 2025 Cytonn analysis. This could stall UHC, with projected KSh 54 billion annual collections hinging on 10 million informal contributors by 2027.

Recommendations from BPTAP and MoH:

• Accelerate E-Contracting: Target 80% by 2026 via KSh 194 billion UAE loan for rural facilities.
• Enhance Means-Testing: Deploy 50,000 more CHPs for ASAL outreach; integrate KRA for auto-enrollment.
• Monitor Equity: Annual KDHS reviews; transparent audits to counter fraud.
• Hybrid Incentives: Scale MakueniCare models with national funding.

Conclusion

SHA’s packages offer a standardized safety net—free primary care, comprehensive inpatient coverage, and subsidized chronic treatments—uniform across Kenya’s 47 counties, marking a leap from NHIF’s inequities. Yet, devolution-driven variations in e-contracting, uptake, and infrastructure create a patchwork: urban hubs like Nairobi deliver seamless access, while ASALs like Turkana grapple with 40% gaps. With 26.7 million enrolled and 4.5 million zero-cost treatments, SHA’s direct payments and subsidies signal progress, but bridging rural-urban divides is crucial for UHC 2030. As President Ruto emphasized in September 2025, SHA is for “all Kenyans,” demanding targeted reforms to ensure no county is left behind in this health revolution. Ongoing BPTAP reviews will be key to refining this national promise into equitable reality.

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