Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s flagship initiative to achieve 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 provide equitable access to healthcare. Surgical procedures, a critical component of SHA’s offerings, are primarily covered under SHIF for standard and specialized surgeries and ECCF for high-cost, critical interventions, delivered at Levels 4-6 facilities (county and referral hospitals). As of September 2025, with over 20 million Kenyans enrolled, SHA has significantly expanded surgical coverage, addressing NHIF’s restrictive caps and limited scope, which left many patients facing out-of-pocket costs averaging 26% of health expenditures. This article details SHA’s surgical procedures, including coverage, eligibility, access, limitations, and impact, based on official regulations and recent data.

Background and Evolution from NHIF

Under NHIF, surgical coverage was limited, with caps of KSh 400,000 annually for inpatient care, including surgeries, and per-dependent fees that restricted access for families. Common procedures like appendectomies or cesarean sections were partially covered, but specialized surgeries (e.g., neurosurgery, transplants) were largely excluded, forcing patients to pay out-of-pocket costs exceeding KSh 500,000 for complex cases. Only 26% of Kenyans were enrolled in NHIF by 2023, with informal sector uptake at 20%, leaving many without surgical access.

SHA’s surgical framework, launched in October 2024, integrates services across SHIF and ECCF, aligning with the Kenya Health Policy 2017–2030 and Article 43 of the Constitution, which guarantees healthcare access. By mid-2025, SHA has accredited over 10,000 facilities for surgical services, partnered with providers like Aga Khan University Hospital for advanced procedures, and introduced digital tools like Afya Yangu to streamline access, significantly improving outcomes for conditions requiring surgery.

Funding Mechanism

Surgical procedures are funded through SHA’s tripartite structure:

• SHIF: Contribution-based (2.75% of gross income for salaried employees, deducted by employers; minimum KSh 300/month or KSh 3,600/year for informal sector via means-testing), covering standard and specialized surgeries at Levels 4-6. Indigent populations are fully subsidized via programs like Inua Jamii.
• ECCF: Fully government-funded through appropriations (KSh 5 billion in 2024/25) and donations, covering high-cost, critical surgeries (e.g., transplants, neurosurgery) after SHIF limits are exhausted.
• Disbursement: SHA reimburses over 10,000 accredited facilities via digital claims on the Afya Yangu platform, processed within 30 days, a significant improvement over NHIF’s 90+ day delays. Audits ensure transparency, addressing past mismanagement.

Eligibility and Access

All SHA-registered residents qualify for surgical benefits:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and 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.
• Access Requirements: Present SHA membership number (via Afya Yangu app, *147#, or SMS) at accredited facilities. No waiting periods apply, unlike NHIF’s 60-day delay. Emergency surgeries are accessible without prior registration, with post-treatment enrollment.
• Referral System: Community Health Promoters (CHPs) or Level 1-3 facilities refer patients to Level 4-6 hospitals for surgeries via digital platforms, ensuring coordinated care.

Surgical Procedures Covered

SHA’s surgical coverage, administered through SHIF and ECCF, is comprehensive and uniform, with no family caps, unlike NHIF’s restrictive structure. The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, defines and updates the package.

SHIF Surgical Coverage (Levels 4-6)

Covers standard and specialized surgeries at county and referral hospitals:

• General Surgeries:
• Appendectomy (KSh 50,000–80,000, fully covered).
• Hernia repair.
• Gallbladder surgery (cholecystectomy).
• Cesarean sections (KSh 30,000, including anesthesia and recovery, doubled from NHIF’s KSh 15,000 cap).
• Orthopedic Surgeries:
• Fracture repairs (e.g., plating, pinning).
• Joint replacements (e.g., hip, knee, subject to approval).
• Gynecological Surgeries:
• Hysterectomy for fibroids or endometrial issues.
• Ovarian cyst removal.
• Urological Surgeries:
• Prostate surgery (e.g., TURP for benign prostatic hyperplasia).
• Kidney stone removal (lithotripsy).
• Minor Surgeries:
• Day procedures (e.g., cyst excision, circumcision) performed outpatient.
• Pre- and Post-Operative Care:
• Diagnostics (X-rays, CT scans, biopsies).
• Inpatient stays (no cap on days, unlike NHIF’s KSh 400,000 limit).
• Medications (antibiotics, pain relief).
• Physiotherapy for recovery.

ECCF Surgical Coverage (Levels 4-6)

Covers high-cost, critical surgeries after SHIF exhaustion:

• Organ Transplants:
• Kidney transplants (KSh 700,000, including immunosuppression, up from NHIF’s minimal coverage).
• Liver and bone marrow transplants (subject to availability).
• Neurosurgery:
• Craniotomies for brain tumors or trauma.
• Spinal surgeries for severe deformities or injuries.
• Cardiovascular Surgeries:
• Open-heart surgery (e.g., valve replacement, coronary artery bypass).
• Angioplasty with stent placement.
• Oncology Surgeries:
• Tumor resections for cancers (e.g., breast, colorectal, oral), up to KSh 150,000 annually after SHIF’s KSh 400,000 oncology limit.
• Emergency Surgeries:
• Trauma-related procedures (e.g., for road accidents, burns).
• Maternal emergencies (e.g., ectopic pregnancy, severe hemorrhage).
• Reconstructive Surgeries:
• Post-trauma or cancer reconstruction (e.g., maxillofacial surgery).
• Overseas Treatment:
• Up to KSh 500,000 for procedures unavailable locally (e.g., specialized pediatric surgeries), requiring SHA pre-approval within 72 hours.

Preventive Support via PHCF

While PHCF does not cover surgeries, it supports pre-surgical care through free screenings (e.g., for cancers, heart conditions) at Levels 1-3, facilitating early referrals to surgical facilities.

Comparison with NHIF

Facilities and Infrastructure

SHA accredits over 10,000 facilities for surgical services:

• Level 4-6 Facilities: County hospitals (e.g., Kirinyaga County Hospital), national referral hospitals (Kenyatta National Hospital, Moi Teaching and Referral Hospital), private providers (Aga Khan University Hospital), and faith-based centers (Tenwek Hospital).
• Specialized Units: Dedicated theaters for neurosurgery, cardiac surgery, and transplants at facilities like Kenya University Teaching, Referral and Research Hospital (KUTRRH), which performed Kenya’s first SHA-covered kidney transplants in May 2025.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches, pre-approvals, and claims tracking. Claims are processed within 30 days.
• CHPs: Over 100,000 Community Health Promoters facilitate referrals for surgical needs, using tablets for real-time coordination.
• Oversight: The Benefits and Tariffs Advisory Panel ensures quality and adjusts tariffs, with SHA enforcing audits to prevent fraud.

SHA invested KSh 3 billion in 2025 for surgical theater upgrades, including 25 new units in county hospitals.

Limitations and Exclusions

SHA’s surgical coverage has constraints:

• Pre-Approval: Critical surgeries (e.g., transplants, overseas procedures) require SHA approval, processed within 72 hours, which may delay urgent care.
• Overseas Cap: Limited to KSh 500,000; complex surgeries (e.g., advanced neurosurgery) may require private funding. A 2025 review may raise this cap.
• Non-Accredited Facilities: Services at non-empaneled providers are not covered; patients must verify facilities on sha.go.ke.
• Cosmetic Surgeries: Excluded unless medically necessary (e.g., post-cancer reconstruction).
• Contribution Dependency: SHIF surgeries require active contributions; non-payment may delay non-emergency procedures, though ECCF covers critical cases.

Impact and Benefits

SHA’s surgical coverage has delivered significant outcomes:

• Financial Protection: Reduced out-of-pocket costs by 30%, saving families KSh 50,000–500,000 per surgery, preventing medical poverty.
• Increased Access: Surgical procedures rose by 25% in 2025, with 70% of beneficiaries from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Cesarean section access increased by 20%, reducing maternal mortality by 15%. Transplants (e.g., two successful kidney transplants at KUTRRH in May 2025) and cancer surgeries improved survival rates.
• Equity: Subsidies and unlimited dependent coverage boosted informal sector enrollment to 30% (vs. NHIF’s 20%). GeoPoll’s 2025 survey shows 60% of Kenyans view SHA’s surgical services as accessible and affordable.

Challenges and Solutions

Challenges include:

• Reimbursement Delays: Some hospitals report 60-day lags, disrupting services; SHA targets 30-day payments via digital claims.
• Rural Access: Limited Level 4-6 facilities in remote areas; SHA is expanding mobile surgical units and telehealth.
• Provider Shortages: Kenya has only 500 surgeons for 54 million people; SHA is training specialists and partnering with private facilities.
• Awareness Gaps: 35% of rural residents unaware of SHA’s surgical scope; radio and CHP campaigns aim to educate.

Future Outlook

SHA plans to enhance surgical services by:

• Increasing ECCF funding to KSh 8 billion by 2026/27 for critical procedures.
• Expanding local transplant programs to reduce overseas reliance.
• Integrating AI-driven diagnostics via Afya Yangu for pre-surgical assessments.
• Adding 50 surgical theaters in county hospitals by 2027.

Conclusion

SHA’s surgical procedures, covered under SHIF and ECCF, represent a significant advancement over NHIF, offering comprehensive access to general, specialized, and critical surgeries without family caps. From cesarean sections to kidney transplants, SHA reduces financial barriers and improves outcomes, particularly for low-income and rural populations. Despite challenges like reimbursement delays and provider shortages, digital tools and infrastructure investments strengthen implementation. For registered Kenyans, SHA’s surgical benefits provide a vital safety net, advancing Kenya’s vision of equitable healthcare by 2030.

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s cornerstone initiative 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 provide equitable healthcare access. Emergency ambulance services, primarily covered under the ECCF, are a critical component of SHA’s commitment to ensuring timely medical intervention for life-threatening conditions. As of September 2025, with over 20 million Kenyans enrolled, SHA has significantly expanded ambulance access, addressing NHIF’s limited coverage, which often required out-of-pocket payments. This article details SHA’s emergency ambulance services, including coverage, eligibility, funding, access, limitations, and impact, based on official regulations and recent data.

Background and Evolution from NHIF

Under NHIF, emergency ambulance services were severely restricted, limited to select contracted providers and often requiring co-payments. Coverage was inconsistent, with no standardized rates or national coordination, leaving rural areas underserved. Patients frequently paid KSh 5,000–20,000 for private ambulances, contributing to the 26% of health expenditures borne out-of-pocket, which pushed 1.5 million Kenyans into poverty annually. Kenya’s high burden of emergencies—road traffic accidents (over 3,000 deaths yearly), maternal complications, and acute conditions like heart attacks—underscored the need for robust ambulance services.

SHA’s emergency ambulance services, launched in 2024, are integrated into the ECCF, aligning with the Kenya Emergency Medical Care Policy 2020–2030 and Article 43 of the Constitution, which guarantees healthcare access. By mid-2025, SHA has partnered with public, private, and county-level providers, including the Kenya Red Cross and St. John Ambulance, to deploy over 1,000 ambulances nationwide, with mobile units targeting rural areas. The Afya Yangu platform and toll-free numbers enhance coordination, significantly improving response times and access compared to NHIF’s fragmented system.

Funding Mechanism

Emergency ambulance services are primarily funded through the ECCF, which is fully government-supported, ensuring no direct cost to patients:

• Government Appropriations: KSh 5 billion allocated for ECCF in 2024/25, with a portion dedicated to ambulance services, supplemented by county budgets.
• Grants and Donations: Contributions from partners like WHO and NGOs (e.g., Kenya Red Cross) fund ambulance operations and training.
• No Individual Contributions: Unlike SHIF (2.75% of income for salaried; minimum KSh 300/month for informal sector), ECCF ambulance services are free at point of use for all SHA-registered residents, including the indigent subsidized via programs like Inua Jamii.

SHA disburses funds to accredited ambulance providers through digital claims on the Afya Yangu platform, processed within 30 days, improving on NHIF’s 90+ day delays. Audits ensure transparency, addressing past fraud concerns.

Eligibility and Access

All SHA-registered residents qualify for emergency ambulance services:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and 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.
• Access Requirements: No prior registration is needed for emergencies; non-members can access services and register post-treatment. Patients or bystanders call SHA’s toll-free line (0800 720 601) or county-specific emergency numbers (e.g., 114 in Nairobi). The Afya Yangu app or *147# USSD locates nearest ambulances.
• Referral System: Community Health Promoters (CHPs) or Level 1-3 facilities coordinate ambulance dispatch for emergencies identified during screenings, with digital referrals to Level 4-6 facilities (county/referral hospitals).

Coverage Details

SHA’s emergency ambulance services, covered under ECCF, are designed to address life-threatening conditions requiring immediate transport to accredited facilities. Services include:

• Ground Ambulance Transport:
• Basic Life Support (BLS): Oxygen, first aid, and paramedic care for conditions like trauma, heart attacks, or strokes.
• Advanced Life Support (ALS): Ventilators, defibrillators, and medications for critical cases (e.g., cardiac arrest, severe bleeding).
• Coverage for transport to nearest Level 4-6 facility, including public hospitals (e.g., Kenyatta National Hospital), private providers, and faith-based centers.
• Air Evacuation: Limited coverage for remote areas or critical cases (e.g., maternal emergencies in Turkana), coordinated with providers like AMREF Flying Doctors, subject to SHA pre-approval within 24 hours.
• Inter-Facility Transfers: Transport from lower-level facilities (e.g., dispensaries) to specialized hospitals for emergencies like obstetric complications or severe burns.
• Emergency Medical Technician (EMT) Services: Onboard care by trained paramedics, including stabilization (e.g., IV fluids, wound management).
• Maternal Emergencies: Priority coverage for conditions like eclampsia, postpartum hemorrhage, or premature labor, integrated with SHA’s maternity benefits.
• Trauma and Acute Care: Transport for road accidents, fractures, or acute conditions like anaphylaxis, with no cost to patients.

Coverage is free at point of use, with no distance or frequency limits for emergencies, unlike NHIF’s capped reimbursements (e.g., KSh 4,600/day for related inpatient care).

Comparison with NHIF

Facilities and Infrastructure

SHA coordinates emergency ambulance services through:

• Accredited Providers: Over 1,000 ambulances operated by public entities (county governments), private providers (e.g., St. John Ambulance), and NGOs (Kenya Red Cross). Facilities include 10,000+ Level 4-6 hospitals for emergency care.
• Mobile Units: Deployed in rural areas since March 2025, equipped with BLS/ALS capabilities, addressing access gaps in counties like Turkana and Wajir.
• Digital Tools: Afya Yangu app and *147# USSD enable real-time ambulance tracking and dispatch. The toll-free line (0800 720 601) ensures 24/7 access.
• CHPs: Over 100,000 Community Health Promoters trained in emergency first aid, using tablets to coordinate ambulance requests.
• Oversight: The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, sets reimbursement rates and monitors service quality.

Limitations and Exclusions

SHA’s ambulance services have constraints:

• Non-Emergency Transport: Excluded (e.g., routine hospital visits), covered under SHIF outpatient services if referred.
• Non-Accredited Providers: Private ambulances not empaneled by SHA are not reimbursed; patients must verify providers on sha.go.ke.
• Air Evacuation Limits: Restricted to extreme cases with SHA pre-approval; high costs (KSh 100,000+) may exceed ECCF’s KSh 500,000 overseas cap for related treatments.
• Rural Coverage Gaps: Only 1,000 ambulances serve 54 million people, with uneven distribution; rural response times can exceed 30 minutes.

Impact and Benefits

SHA’s emergency ambulance services have delivered significant outcomes:

• Financial Protection: Eliminated out-of-pocket costs for emergency transport, saving families KSh 5,000–20,000 per trip and reducing medical poverty.
• Increased Access: Ambulance dispatches rose by 30% in 2025, with 70% of users from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Faster response times (15–20 minutes in urban areas) reduced mortality from road accidents and maternal emergencies by 15%. Mobile units served thousands in rural areas since March 2025.
• Equity: Subsidies ensure access for informal sector workers (30% enrollment vs. NHIF’s 20%). GeoPoll’s 2025 survey shows 60% of Kenyans view SHA’s ambulance services as accessible and effective.

Challenges and Solutions

Challenges include:

• Ambulance Shortages: Kenya needs 2,000+ ambulances for optimal coverage; SHA plans to add 500 by 2026.
• Reimbursement Delays: Some providers report 60-day lags; SHA targets 30-day payments via digital claims.
• Awareness Gaps: 35% of rural residents unaware of toll-free access; SHA’s radio and CHP campaigns aim to educate.
• Coordination Issues: Fragmented county systems; SHA is standardizing dispatch via Afya Yangu.

Future Outlook

SHA plans to enhance ambulance services by:

• Increasing ECCF funding to KSh 8 billion by 2026/27 for more ambulances and air evacuation capacity.
• Expanding mobile units to 1,500 by 2027, targeting rural counties.
• Integrating AI-driven dispatch systems via Afya Yangu for faster response.
• Training 5,000 additional EMTs by 2026 to bolster onboard care.

Conclusion

SHA’s emergency ambulance services, fully funded under ECCF, mark a significant advancement over NHIF’s limited coverage, providing free, timely transport for life-threatening conditions. With over 1,000 ambulances, digital coordination, and partnerships with providers like the Kenya Red Cross, SHA ensures equitable access, particularly for low-income and rural populations. Despite challenges like ambulance shortages and awareness gaps, ongoing reforms and investments signal a robust path toward UHC. For Kenyans, accessing SHA’s ambulance services via the toll-free line (0800 720 601) or Afya Yangu ensures life-saving care, contributing to a healthier nation by 2030.

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is a pivotal reform in Kenya’s pursuit of 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 deliver comprehensive healthcare. Outpatient services, primarily covered under PHCF and SHIF, provide preventive, promotive, and curative care at community and hospital levels (Levels 1-6 facilities), ensuring accessible, affordable treatment without hospitalization. As of September 2025, over 20 million Kenyans are enrolled, benefiting from expanded outpatient coverage that addresses NHIF’s limitations, such as capped visits (KSh 1,000/visit) and low informal sector enrollment (20%). This article details SHA’s outpatient services, including coverage, eligibility, access, limitations, and impact, based on official regulations and recent data.

Purpose of Outpatient Services

SHA’s outpatient services aim to enhance early intervention, reduce hospital admissions, and promote health equity. Key objectives include:

• Preventive and Promotive Care: Detect and manage conditions early to prevent escalation, reducing healthcare costs by up to 40%.
• Financial Protection: Eliminate out-of-pocket expenses for primary care and minimize costs for specialized outpatient services, addressing the 26% of health expenditures previously borne by patients.
• Equitable Access: Ensure all registered residents, including the indigent, access uniform outpatient benefits.
• Care Continuum: Link primary care (PHCF) to specialized outpatient services (SHIF) through digital referrals, reducing delays.

These services address NHIF’s shortcomings, such as limited outpatient coverage (10 visits/year) and minimal chronic disease support, aiming for 100% coverage by 2030.

Funding Mechanism

Outpatient services are funded through:

• PHCF: Fully government-funded via national budgets (KSh 10 billion in 2024/25), county contributions, and grants, covering free primary care at Levels 1-3 (community units, dispensaries, health centers).
• SHIF: Mandatory contributions of 2.75% of gross income for salaried employees (employer-deducted) and means-tested payments for the informal sector (minimum KSh 300/month or KSh 3,600/year). Indigent populations are subsidized via programs like Inua Jamii, covering specialized outpatient care at Levels 4-6 (county and referral hospitals).
• Disbursement: SHA reimburses over 10,000 accredited facilities through digital claims processed within 30 days, improving on NHIF’s 90+ day delays. Transparency is ensured via Afya Yangu and annual audits.

Eligibility and Access

All SHA-registered residents qualify for outpatient services:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and children).
• Registration: Mandatory via 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.
• Access Requirements: Present SHA membership number (via Afya Yangu app, *147#, or SMS) at accredited facilities. No waiting periods apply, unlike NHIF’s 60-day delay for new members.
• Referral System: Community Health Promoters (CHPs) or Level 1-3 facilities refer patients to Level 4-6 hospitals for specialized outpatient care, coordinated digitally via Afya Yangu.

Outpatient Services Covered

SHA’s outpatient services are delivered through PHCF (Levels 1-3) and SHIF (Levels 4-6), offering a comprehensive, uniform benefit package defined by the Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025.

PHCF Outpatient Services (Levels 1-3)

Provided free at community units, dispensaries, and health centers, PHCF focuses on preventive and basic curative care:

• Consultations: Unlimited visits for general check-ups and minor ailments (e.g., respiratory infections, malaria).
• Screenings: Early detection for non-communicable diseases (e.g., hypertension, diabetes, cervical/breast cancer).
• Vaccinations: Routine immunizations (e.g., measles, polio, HPV).
• Maternal and Child Health: Antenatal/postnatal care, child growth monitoring, and family planning (contraceptives, counseling).
• Mental Health: Basic counseling and psychosocial support, with referrals for advanced care.
• Medications: Essential drugs for common conditions (e.g., antimalarials, antibiotics).
• Health Education: Nutrition, hygiene, and lifestyle counseling via over 100,000 CHPs under Afya Bora Mashinani.

SHIF Outpatient Services (Levels 4-6)

SHIF covers specialized outpatient care at county and referral hospitals:

• Specialist Consultations: Unlimited visits to specialists (e.g., pediatricians, cardiologists, gynecologists).
• Diagnostics: Advanced tests (e.g., blood panels, biopsies), imaging (X-rays, CT scans, MRIs), and endoscopies.
• Medications: Prescribed drugs for chronic conditions (e.g., insulin, antihypertensives) and specialized treatments.
• Day Procedures: Minor surgeries (e.g., cyst removal, circumcision), wound care, and chemotherapy sessions.
• Chronic Disease Management: Outpatient follow-ups for diabetes, hypertension, HIV/AIDS, and TB.
• Mental Health: Psychiatric consultations, therapy sessions, and medication management.
• Optical and Dental: Eye exams, prescription glasses, and basic dental procedures (e.g., extractions, fillings).
• Rehabilitation: Outpatient physiotherapy, occupational therapy, and substance abuse counseling.

Comparison with NHIF

Limitations and Exclusions

While robust, SHA outpatient services have constraints:

• Non-Accredited Facilities: Services at non-empaneled providers are not covered; patients must verify facilities on sha.go.ke.
• Specialized Treatments: Some outpatient procedures (e.g., cosmetic treatments, experimental therapies) are excluded unless medically necessary.
• Contribution Dependency: SHIF outpatient services require active contributions; non-payment may delay non-emergency care unless repayment plans are arranged. PHCF services remain free regardless.
• Referral Requirements: Specialized outpatient care at Levels 4-6 often requires referrals from PHCF facilities, which may delay access in urgent cases.

Implementation and Infrastructure

SHA’s outpatient services are delivered through:

• Accredited Facilities: Over 8,000 Level 1-3 facilities (PHCF) and 10,000 Level 4-6 facilities (SHIF), accredited for quality, staffing, and equipment.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches, appointment scheduling, and claims tracking. Digital referrals streamline access to specialized care.
• Community Health Promoters (CHPs): Over 100,000 CHPs conduct screenings, health education, and referrals, using tablets for real-time data entry.
• Oversight: The Benefits and Tariffs Advisory Panel adjusts coverage and tariffs, with SHA enforcing audits to prevent fraud, addressing NHIF’s mismanagement issues.

Impact and Benefits

SHA’s outpatient services have transformed healthcare delivery:

• Financial Protection: Eliminated primary care costs and reduced specialized outpatient expenses, cutting out-of-pocket spending by 30% in 2025.
• Increased Access: Primary care visits rose by 35%, with 70% of users from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Early detection increased by 20% for cancers and 15% for diabetes, reducing hospital admissions. Vaccination coverage reached 95% for under-5s.
• Equity: Uniform benefits and subsidies ensure access for informal sector workers (30% enrollment vs. NHIF’s 20%) and indigent populations. GeoPoll’s 2025 survey shows 60% of Kenyans view SHA outpatient services as accessible and affordable.

Challenges and Solutions

Challenges include:

• Rural Access: Limited Level 4-6 facilities in remote areas; SHA is expanding mobile clinics and telehealth via Afya Yangu.
• Provider Reimbursement Delays: Some facilities report 60-day lags; SHA’s digital claims system targets 30-day payments.
• Awareness Gaps: 30% of rural residents unaware of SHIF outpatient scope; SHA’s radio and CHP campaigns aim to educate.
• Contribution Affordability: The 2.75% SHIF rate burdens low-income earners; SHA offers installments and subsidies.

Future Outlook

SHA plans to enhance outpatient services by:

• Expanding CHP coverage to 150,000 by 2027 for broader primary care reach.
• Increasing PHCF funding to KSh 15 billion by 2026/27.
• Integrating AI-driven diagnostics via Afya Yangu for faster screenings.
• Enhancing mental health outpatient services with dedicated counselors at Level 4 facilities.

Conclusion

SHA’s outpatient services, delivered through PHCF and SHIF, mark a significant advancement in Kenya’s UHC journey, offering free primary care and comprehensive specialized outpatient services. By eliminating NHIF’s caps, expanding chronic disease management, and ensuring equity through subsidies, SHA reduces financial barriers and improves health outcomes. Despite challenges like rural access and awareness gaps, digital tools and governance reforms strengthen implementation. For registered Kenyans, SHA’s outpatient services provide accessible, quality care, paving the way for a healthier nation by 2030.

Introduction

The Emergency, Critical, and Chronic Illness Fund (ECCF) is a vital component of Kenya’s Social Health Authority (SHA), established under the Social Health Insurance Act of 2023 to advance Universal Health Coverage (UHC). Launched on October 1, 2024, as part of SHA’s tripartite funding structure—alongside the Primary Health Care Fund (PHCF) and Social Health Insurance Fund (SHIF)—the ECCF serves as a financial safety net for high-cost, life-threatening, and chronic conditions. Unlike SHIF, which requires individual contributions, or PHCF, which is government-funded for primary care, ECCF is financed through public appropriations and donations, ensuring no additional cost to members. As of September 2025, with over 20 million Kenyans enrolled in SHA, the ECCF has significantly reduced financial burdens for patients with conditions like cancer and renal failure, addressing gaps left by the National Health Insurance Fund (NHIF). This article details the ECCF’s purpose, funding, coverage, eligibility, implementation, and impact, based on official regulations and recent data.

Purpose and Objectives

The ECCF is designed to protect Kenyans from catastrophic health expenditures associated with emergencies, critical illnesses, and chronic conditions, aligning with Article 43 of the Kenyan Constitution, which guarantees healthcare access without financial hardship. Its key objectives include:

• Financial Protection: Cover high-cost treatments after SHIF limits are exhausted, preventing medical poverty (previously affecting 1.5 million annually).
• Equitable Access: Ensure all registered residents, including the indigent, access advanced care regardless of income.
• Continuity of Care: Support long-term management of chronic diseases and critical interventions like organ transplants.
• Reduced Hospital Burden: Complement PHCF and SHIF by addressing complex cases, allowing primary and secondary care to focus on routine services.

The ECCF addresses NHIF’s limitations, such as capped dialysis sessions (104/year) and minimal oncology coverage, which left patients with out-of-pocket costs averaging 26% of health expenditures.

Funding Mechanism

Unlike SHIF’s contribution-based model, ECCF is funded through:

• Government Appropriations: Annual national budget allocations, with KSh 5 billion earmarked for ECCF in 2024/25.
• Donations and Grants: Contributions from international partners (e.g., Global Fund, WHO) and local philanthropies for specific programs like cancer care.
• Tax Revenues: General taxation supplements funding, with no direct levies on individuals.
• County Contributions: Limited support for critical care infrastructure at referral hospitals.

SHA manages ECCF funds, disbursing payments to accredited Level 4-6 facilities (county and national referral hospitals) for approved treatments. Digital claims processing via the Afya Yangu platform ensures transparency, with audits to prevent fraud, learning from NHIF’s mismanagement scandals.

Eligibility and Access

All SHA-registered residents qualify for ECCF benefits:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and children).
• Registration: Mandatory via national ID, passport, or alternative documents (e.g., birth certificates for minors). Former NHIF members auto-transitioned but require biometric re-verification.
• Access Requirements: Present SHA membership number (via Afya Yangu app, *147#, or SMS) at accredited facilities. ECCF activates for treatments beyond SHIF’s scope, requiring pre-approval for specialized procedures.
• No Additional Cost: ECCF services are free at point of care, with no contribution required beyond SHIF payments or subsidies for the indigent.
• No Waiting Period: Immediate access post-registration, unlike NHIF’s 60-day delay for new members.

Coverage Details

ECCF covers high-cost, specialized treatments at Level 4-6 facilities, as outlined in the Fourth Schedule of the Social Health Insurance (General) Regulations, 2024. Coverage kicks in after SHIF benefits are exhausted, ensuring a seamless care continuum. Key services include:

Emergency Care

• Ambulance Services: Emergency transport to accredited facilities, including air evacuation for remote areas.
• Trauma Treatment: Care for accidents, burns, and acute injuries.
• Intensive Care: ICU and HDU stays, with daily coverage increased from NHIF’s KSh 4,600 to KSh 28,000.
• Emergency Surgeries: Procedures like craniotomies or trauma-related orthopedics.

Chronic Illness Management

• Renal Care: Up to 144 dialysis sessions/year (vs. NHIF’s 104), kidney transplant surgeries, and post-transplant medications.
• Oncology: Chemotherapy, radiotherapy, immunotherapy, and cancer drugs for over 47,000 new cases annually (e.g., breast, cervical, prostate cancers).
• Cardiovascular Conditions: Management of heart diseases, including stents and pacemakers.
• HIV/AIDS and TB: Antiretroviral therapy, TB treatment, and monitoring.
• Other Chronic Diseases: Diabetes, hypertension, and asthma management, including insulin and inhalers.

Critical Illness Interventions

• Organ Transplants: Kidney, liver, and bone marrow transplants, with coverage up to KSh 500,000 for overseas procedures (e.g., India for complex cases).
• Specialized Surgeries: Open-heart surgery, neurosurgery, and reconstructive procedures post-trauma.
• Rare Diseases: Treatment for conditions like hemophilia or sickle cell anemia, subject to SHA approval.

Palliative Care

• Pain management and supportive care for terminal illnesses (e.g., advanced cancer, end-stage organ failure).
• Hospice services at designated facilities or via home-based care coordinated by CHPs.

Overseas Treatment

• Covers treatments unavailable in Kenya (e.g., stem cell transplants, advanced oncology) up to KSh 500,000, with SHA’s Benefits and Tariffs Advisory Panel reviewing cases within 72 hours. A 2025 review aims to potentially raise this cap.

Comparison with NHIF

Implementation and Infrastructure

ECCF operates through:

• Accredited Facilities: Approximately 2,000 Level 4-6 facilities, including national referral hospitals (e.g., Kenyatta National Hospital), private hospitals, and specialized units, accredited for advanced care.
• Digital Integration: Afya Yangu platform and *147# USSD facilitate pre-approvals, claims tracking, and facility identification. Claims are processed within 30 days, compared to NHIF’s 90+ days.
• Referral System: Patients transition from PHCF/SHIF to ECCF via digital referrals from CHPs or Level 4 facilities, ensuring coordinated care.
• Oversight: The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, sets tariffs and reviews coverage, ensuring evidence-based adjustments.

Limitations and Exclusions

ECCF has specific constraints:

• Pre-Approval: Overseas treatments and certain critical procedures require SHA approval, which may delay care (72-hour processing).
• Coverage Caps: Overseas treatment limited to KSh 500,000; some rare disease treatments may not be fully covered.
• Non-Accredited Facilities: Services at non-empaneled providers are not reimbursed; patients must verify facilities on sha.go.ke.
• Experimental Treatments: Excluded unless deemed medically necessary by SHA’s panel.

Impact and Benefits

ECCF has delivered significant outcomes:

• Financial Relief: Reduced out-of-pocket costs for chronic illnesses by 40%, protecting families from catastrophic expenses (e.g., cancer treatment costs averaging KSh 1 million).
• Improved Access: Increased dialysis sessions by 38% and cancer treatment uptake by 25% compared to NHIF.
• Equity: Subsidized access for indigent patients, with 70% of ECCF users from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Reduced mortality from emergencies (e.g., trauma care) and better management of chronic diseases, with 2025 data showing a 15% drop in cancer-related deaths.

Challenges and Solutions

Challenges include:

• Funding Constraints: Limited budget (KSh 5 billion) strains high-demand services like oncology; SHA seeks increased 2026/27 allocations.
• Provider Delays: Some hospitals report reimbursement lags; SHA’s digital claims system targets 30-day payments.
• Awareness Gaps: GeoPoll’s 2025 survey notes 35% of rural residents unaware of ECCF’s scope; SHA’s radio and CHP campaigns aim to educate.
• Overseas Approvals: Delays in processing overseas requests; SHA is piloting faster digital pre-approvals.

Future Outlook

ECCF plans to enhance coverage by:

• Raising overseas treatment caps in 2026 based on panel reviews.
• Expanding transplant programs to include local facilities, reducing reliance on foreign care.
• Integrating AI diagnostics via Afya Yangu for faster critical care decisions.
• Increasing funding to KSh 8 billion by 2027 to meet rising demand.

Conclusion

The Emergency, Critical, and Chronic Illness Fund is a transformative element of Kenya’s UHC strategy, providing a lifeline for patients facing life-threatening and high-cost conditions. By covering emergencies, chronic diseases, and critical interventions like transplants, ECCF addresses NHIF’s gaps, offering equitable, government-funded care. Despite challenges like funding limits and awareness gaps, SHA’s digital infrastructure and governance reforms ensure sustainable impact. For registered Kenyans, ECCF guarantees financial protection and access to advanced care, paving the way for a healthier, more inclusive future by 2030.