SHA Support for Low-Income Households

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s flagship initiative 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 provide equitable, affordable healthcare access to all residents. For low-income households, who comprise approximately 36% of Kenya’s population (about 19 million people below the poverty line, per KNBS 2023 data), SHA offers targeted support through subsidies, waivers, and integrated social protection programs. As of September 2025, over 20 million Kenyans are enrolled, with the government allocating KSh 950 million in the 2024/25 fiscal year to cover premiums for vulnerable households. This support addresses longstanding inequities, where low-income families previously faced out-of-pocket costs accounting for 26% of health expenditures and pushed 1.5 million into poverty annually under NHIF. This article details SHA’s mechanisms for supporting low-income households, including subsidies, integration with programs like Inua Jamii, eligibility, access, challenges, and impact, based on official regulations and recent developments.

Background and Evolution from NHIF

Under NHIF, low-income households were underserved, with only 5% of the poorest quintile enrolled by 2023, due to flat-rate premiums (e.g., KSh 500/month for informal sector) that were regressive and unaffordable. Coverage was limited to basic inpatient care with caps (e.g., KSh 400,000/year), excluding many from preventive or chronic care services. The informal sector, which includes 80% of low-income workers like small-scale farmers and traders, had uptake below 20%, exacerbating health disparities.

SHA’s design, informed by the Social Health Insurance (General) Regulations, 2024, introduces progressive contributions (2.75% of income, with a KSh 300/month minimum) and explicit subsidies for low-income households, aligning with Article 43 of the Constitution (right to health) and the Kenya Health Policy 2017–2030. The government has committed to covering premiums for 1.5 million indigent Kenyans starting September 2025, as announced by President William Ruto on September 13, 2025, during a meeting with Turkana leaders. This initiative, funded through the State Department for Social Protection, uses databases like the Social Registry and Inua Jamii to identify beneficiaries, marking a shift toward fully subsidized access for the poorest 15% of households.

Subsidies and Means-Testing for Low-Income Households

SHA’s support for low-income households is anchored in a means-testing mechanism to ensure contributions reflect financial capacity, preventing exclusion due to cost.

Means-Testing Process

• Assessment Criteria: For informal sector and unemployed individuals, SHA uses a means-testing instrument to evaluate household income based on factors like housing characteristics, access to basic services (e.g., water, electricity), household composition (e.g., number of dependents, presence of disabilities), and self-declared earnings. This is conducted via the SHA portal, *147# USSD, or assisted enrollment at Huduma Centres or with Community Health Promoters (CHPs).
• Contribution Adjustment: Households below the poverty line (KSh 3,252/month per KNBS) pay the minimum KSh 300/month or receive full waivers. For example, a household with zero income pays nothing, while one earning KSh 10,000/month contributes KSh 275 (rounded to KSh 300).
• Annual Review: Contributions are reassessed annually or upon status changes (e.g., job loss), with appeals available within 30 days for disputes.

Government Premium Subsidies

• Allocation for Vulnerable Households: In the 2024/25 fiscal year, the government allocated KSh 950 million to cover SHA premiums for poor households unable to afford them. This initiative, announced on January 15, 2025, by Principal Secretaries Joseph M. Motari (Social Protection) and Harry Kimtai (Medical Services), targets households identified through the Social Registry (over 4.4 million) and Inua Jamii (1.75 million beneficiaries).
• Direct Government Payment: Starting September 2025, the government will pay contributions for 1.5 million indigent Kenyans, as announced by President Ruto on September 13, 2025. This covers the 2.75% rate for those without capacity, with governors and MPs encouraged to sponsor another 1 million. The State Department for Social Protection validates beneficiary lists, ensuring automatic enrollment and premium coverage.
• Impact: This subsidy enables full access to all SHA benefits without financial burden, projected to cover 15% of the population (about 8 million people) by 2026.

Integration with Inua Jamii and Other Social Programs

SHA’s support for low-income households is enhanced through seamless integration with existing social protection programs, ensuring holistic welfare.

Inua Jamii Cash Transfer Programme

• Overview: Inua Jamii, managed by the State Department for Social Protection, provides bi-monthly cash transfers (KSh 2,000/month) to 1.75 million vulnerable individuals, including older persons (OPCT), persons with severe disabilities (PWSD-CT), orphans and vulnerable children (CT-OVC), and hunger safety net beneficiaries (HSNP). The program, with a Sh4.6 billion disbursement in August 2025 for June-July cycles, aims to reduce poverty among low-income households.
• Integration with SHA: Beneficiaries are urged to register with SHA to access subsidized healthcare. As of August 2025, over 90,000 Inua Jamii names have been shared for SHA onboarding, with the government using the program’s database to identify and subsidize premiums. Principal Secretary Joseph Motari emphasized this linkage during the Sh4.6 billion release on August 7, 2025, stating it aligns with UHC by providing both financial and health support.
• Benefits for Inua Jamii Recipients: Automatic premium waivers or government payment ensure free access to PHCF (primary care), SHIF (hospital services), and ECCF (critical care). For example, an elderly Inua Jamii beneficiary receives KSh 2,000 cash monthly plus full SHA coverage for chronic conditions like hypertension.

Other Social Programs

• Social Registry: This national database (4.4 million households) identifies poor families for SHA subsidies, integrating with county-level programs for validation.
• County-Level Initiatives: Counties like Kiambu and Migori urge Inua Jamii beneficiaries to register with SHA, with local executives sponsoring premiums for additional vulnerable groups.
• NGO and Corporate Support: Initiatives like the Mwale Medical and Technology City (MMTC) marathon in January 2025 raised Sh45 million to sponsor SHA premiums for 500 low-income families in Kakamega County.

Eligibility for SHA Support

Low-income households qualify for SHA support through:

• Income Threshold: Households below the poverty line (KSh 3,252/month) via means-testing, or those in the Social Registry/Inua Jamii.
• Vulnerable Groups: Orphans, elderly (60+), persons with disabilities, and those in arid/semi-arid lands (ASAL) regions, prioritized through Inua Jamii.
• Registration: Free and mandatory; low-income individuals register via assisted enrollment at Huduma Centres or CHPs, with automatic subsidy application.
• Verification: Biometrics and household data confirm eligibility; appeals for disputes are handled within 30 days.

Access to Services for Low-Income Households

Once subsidized, low-income households access SHA’s full benefits:

• PHCF Services: Free primary care, including consultations, vaccinations, and screenings at Levels 1-3 facilities, with capitation payments ensuring availability.
• SHIF Services: Subsidized hospital care, e.g., maternity (KSh 10,000 for normal delivery), chronic management (dialysis up to 8 sessions/month), without co-payments.
• ECCF Services: Full coverage for emergencies and critical care, e.g., ICU (KSh 28,000/day), transplants, and palliative care for terminal illnesses.
• Digital Access: Afya Yangu app and *147# USSD allow low-income users to locate facilities, track records, and confirm subsidies, with assisted registration for those without smartphones.

Challenges and Criticisms

Despite advancements, challenges persist:

• Awareness and Enrollment Gaps: 35% of low-income households remain unregistered due to lack of awareness or documentation issues, per GeoPoll’s 2025 survey. Rural areas face connectivity barriers for digital registration.
• Means-Testing Delays: Validation via Social Registry can take 30–60 days, delaying subsidies and access.
• Integration Hurdles: While Inua Jamii beneficiaries are urged to register, only 90,000 have been onboarded by August 2025, with some facing duplicate verification issues.
• Provider Capacity: Low-income areas have limited Level 4-6 facilities, leading to overcrowding despite subsidies.
• Criticisms: Some low-income users complain the KSh 300 minimum exceeds their capacity, though government subsidies address this for the poorest.

The government is addressing these through CHP-led campaigns and database integration.

Impact and Benefits

SHA’s support has transformed low-income healthcare:

• Financial Relief: Subsidies reduced out-of-pocket costs by 40%, with 4.5 million low-income individuals accessing primary care and 2.2 million specialized services by July 2025.
• Increased Enrollment: 70% coverage among low-income groups, up from NHIF’s 5%, with Inua Jamii integration onboarding 90,000+ beneficiaries.
• Health Outcomes: Early screenings via PHCF reduced hospital admissions by 15%; subsidized dialysis and cancer care improved survival rates by 10% for low-income patients.
• Equity Gains: 70% of SHA beneficiaries are low-income, with initiatives like MMTC’s Sh45 million sponsorship for 500 families in Kakamega enhancing access.
• Public Perception: GeoPoll’s 2025 survey shows 60% of low-income households view SHA positively for affordability, though 40% cite enrollment barriers.

Future Outlook

SHA plans to expand support by:

• Covering premiums for 1.5 million more indigent households by 2026, with governors sponsoring an additional 1 million.
• Integrating Inua Jamii databases fully for automatic subsidies, targeting 4.4 million Social Registry households.
• Increasing PHCF funding to KSh 15 billion by 2026/27 for more rural facilities.
• Enhancing digital tools like Afya Yangu for easier subsidy applications.

Conclusion

SHA’s support for low-income households through means-testing, premium subsidies (KSh 950 million in 2024/25), and integration with Inua Jamii (1.75 million beneficiaries) ensures affordable access to comprehensive healthcare. From free primary care under PHCF to subsidized hospital services under SHIF and critical care under ECCF, SHA protects vulnerable families from financial hardship. While challenges like enrollment gaps persist, recent initiatives—such as government payments for 1.5 million indigent starting September 2025—signal progress. Low-income households should register via *147#, sha.go.ke, or Huduma Centres to access these benefits, contributing to Kenya’s UHC vision by 2030.

GUNDUU KBC SEASON 1 EPISODE 8

How to Submit Claims to SHA

Introduction

The Social Health Authority (SHA), established under the Social Health Insurance Act of 2023, is Kenya’s cornerstone 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 17, 2025. The claims submission process is central to SHA’s operations, enabling healthcare providers to receive reimbursements for services rendered and ensuring patients face minimal out-of-pocket costs (previously 26% of health expenditures under NHIF). Claims are processed digitally via the Afya Yangu platform, targeting a 30-day payment timeline, a significant improvement over NHIF’s 90+ day delays. This article provides a comprehensive guide on how healthcare providers and patients submit claims to SHA, detailing the process, requirements, timelines, challenges, and recent developments, based on official regulations and data.

Background: Transition from NHIF to SHA

Under NHIF, claims processing was plagued by delays (90–180 days), manual submissions, and fraud, with KSh 33 billion in unpaid arrears by 2023, undermining provider trust and patient access. Only 26% of Kenyans were enrolled, with informal sector uptake at 20%, limiting claim volume. SHA’s digital-first approach, mandated by the Social Health Insurance (General) Regulations, 2024, streamlines claims to support over 10,000 accredited facilities and reduce out-of-pocket costs by 30%. By July 2025, SHA had disbursed KSh 551 billion in claims, processing KSh 96.2 billion in Q4 2024 alone, demonstrating a robust system despite challenges.

Legal Framework for Claims Submission

The Social Health Insurance Act, 2023 (Section 32) and Social Health Insurance (General) Regulations, 2024 (Fourth Schedule) govern claims submission. Key provisions include:

• Electronic Submission: Claims must be filed digitally via the Afya Yangu platform or SHA’s web portal within seven days of service or patient discharge.
• Reimbursement Timeline: SHA reviews claims within seven days and disburses payments within 30 days, subject to audits.
• Tariff-Based Payments: Reimbursements align with SHA tariffs (e.g., KSh 30,000 for cesarean sections, KSh 10,650 for dialysis), with excess costs borne by facilities or patients.
• Penalties for Fraud: False claims (e.g., ghost patients) incur fines up to KSh 2 million or facility de-accreditation.
• Oversight: The Benefits Package and Tariffs Advisory Panel (BPTAP), chaired by Prof. Walter Jaoko since May 2025, ensures tariff compliance and claim validity.

Who Can Submit Claims

• Healthcare Providers: Over 10,000 SHA-accredited facilities (8,000 Levels 1-3, 2,000 Levels 4-6), including public hospitals (e.g., Kenyatta National Hospital), private providers (e.g., Aga Khan), and faith-based facilities (e.g., Tenwek Hospital), submit claims for services under PHCF, SHIF, and ECCF.
• Patients: In rare cases, patients can submit claims for reimbursement (e.g., for pre-approved overseas treatment or emergency services at non-accredited facilities), with SHA approval.
• Eligibility: Providers must be SHA-empaneled with valid contracts. Patients must be registered with SHA (via *147#, sha.go.ke, or Huduma Centres) and have active SHIF contributions (2.75% of income or KSh 300/month minimum) for non-emergency claims.

Step-by-Step Guide to Submitting Claims

For Healthcare Providers

1. Patient Verification:

• Verify patient’s SHA membership using the Afya Yangu app, *147# USSD, or SHA portal with their membership number. For emergencies, services can be provided without immediate verification, with post-treatment registration.
• Confirm contribution status for SHIF-covered services; PHCF and ECCF require no contributions.

1. Service Delivery:

• Provide services per SHA tariffs (e.g., KSh 935 for Level 3 consultations, KSh 28,000/day for ICU).
• For specialized care (e.g., dialysis, overseas treatment), obtain pre-approval from SHA via the portal within 72 hours.

1. Claims Submission:

• Submit claims electronically within seven days of service or discharge via the Afya Yangu platform or sha.go.ke.
• Required documents:
  • Patient details (SHA membership number, ID).
  • Service details (diagnosis, procedure codes, tariff rates).
  • Invoices and medical reports (e.g., lab results, discharge summaries).
  • Pre-approval for high-cost services (e.g., transplants, overseas care).
• Use SHA’s standardized coding system (aligned with WHO’s ICD-11) for procedures.

1. SHA Review:

• SHA audits claims within seven days for accuracy, rejecting non-compliant submissions (e.g., missing documents, unaccredited facilities). Providers receive rejection notices with reasons.
• Approved claims are paid within 30 days via bank transfer.

1. Payment and Follow-Up:

• Facilities receive reimbursements up to tariff rates (e.g., KSh 10,000 for normal delivery, KSh 700,000 for kidney transplants).
• Monitor payments via Afya Yangu; disputes can be lodged at customercare@sha.go.ke or 0800 720 601.

For Patients

1. Eligibility Check:

• Ensure SHA registration (via *147# or sha.go.ke) and active SHIF contributions. Emergency services (ECCF) require no prior registration.

1. Service Receipt:

• Receive care at SHA-accredited facilities. For overseas treatment, obtain pre-approval and use empaneled foreign providers.

1. Claims Submission:

• Submit claims for reimbursable expenses (e.g., emergency care at non-accredited facilities) within 30 days via sha.go.ke or Huduma Centres.
• Required documents: SHA membership number, medical reports, invoices, proof of payment, pre-approval (if applicable).

1. Review and Payment:

• SHA reviews within seven days; approved claims are paid within 30 days via bank transfer or mobile money.

Types of Claims

• PHCF Claims: Capitation-based, quarterly payments for Level 1-3 facilities (e.g., KSh 2,400/patient/year at Level 3) for preventive care.
• SHIF Claims: Fee-for-service for outpatient/inpatient care (e.g., KSh 30,000 for cesarean, KSh 300,000/year for oncology).
• ECCF Claims: High-cost care (e.g., KSh 500,000 for overseas treatment, KSh 150,000 additional oncology), often requiring pre-approval.

Challenges in Claims Submission

1. Reimbursement Delays: Despite a 30-day target, some facilities report 60–90 day lags, with KSh 43 billion in unpaid dues (including NHIF arrears) by August 2025, prompting threats of service suspensions.
2. Fraud and Audits: Ghost claims (e.g., KSh 20 million to Nyandiwa Dispensary) lead to stricter audits, delaying payments and risking penalties for providers.
3. Low Tariffs: Rates (e.g., KSh 28,000/day for ICU vs. market KSh 50,000) force facilities to absorb costs, leading to claim rejections.
4. Technical Barriers: Rural facilities lack digital infrastructure for Afya Yangu, complicating submissions.
5. Awareness Gaps: 35% of providers and patients are unaware of claim procedures, per GeoPoll’s 2025 survey, leading to errors.

Recent Developments and Reforms

• Digital Platform Enhancements: Afya Yangu’s upgrades in 2025 ensure 72-hour rejection notices and 30-day payments, with 80% of claims processed electronically.
• BPTAP Oversight: Since May 2025, the panel, chaired by Prof. Jaoko, reviews tariffs and claims, rejecting non-compliant submissions (e.g., 20% of claims in Q1 2025).
• Disbursement Progress: KSh 551 billion paid by July 2025, including KSh 18.2 billion in Q4 2024, though private hospitals report KSh 43 billion in arrears.
• Fraud Crackdown: SHA suspended non-compliant facilities and audited claims, addressing issues like ghost payments.
• Tariff Revisions: Legal Notice 56 of 2025 (February 2025) adjusted rates (e.g., hemodiafiltration KSh 11,200/session) to align with costs.

Impact of Claims Process

• Providers: Timely payments revived facilities (e.g., Nairobi clinics receiving monthly funds), but delays led to layoffs (66% of nurses affected) and a 14-day go-slow notice in September 2025.
• Patients: 4.5 million accessed primary care and 2.2 million specialized services by July 2025, with reduced out-of-pocket costs (30% drop). Delays caused service denials in some cases.
• Equity: Subsidies and digital claims benefit low-income groups (70% of beneficiaries), but rural facilities struggle with connectivity.

Tips for Successful Claims Submission

• Verify Accreditation: Ensure the facility is SHA-empaneled via sha.go.ke.
• Accurate Documentation: Include all required details (e.g., ICD-11 codes, invoices) to avoid rejections.
• Timely Submission: File within seven days to meet SHA’s deadline.
• Monitor Status: Use Afya Yangu to track claims and address rejections promptly.
• Seek Support: Contact SHA at 0800 720 601 or customercare@sha.go.ke for assistance.

Future Outlook

SHA plans to enhance claims processing by:

• Achieving 100% digital submissions by 2027, with rural infrastructure upgrades.
• Increasing PHCF/ECCF funding (to KSh 15 billion and KSh 8 billion by 2026/27) to clear arrears.
• Implementing AI-driven audits to reduce fraud and speed up reviews.
• Raising tariffs for high-cost services (e.g., ICU, oncology) by 2026, per BPTAP recommendations.

Conclusion

Submitting claims to SHA is a streamlined, digital process via the Afya Yangu platform, targeting 30-day reimbursements for over 10,000 facilities. Providers must verify patient eligibility, submit accurate claims within seven days, and adhere to tariffs (e.g., KSh 30,000 for cesarean, KSh 700,000 for transplants). Despite progress (KSh 551 billion disbursed by July 2025), delays (KSh 43 billion in arrears) and low tariffs challenge providers. Patients benefit from reduced costs, but rural facilities need better connectivity. Providers and patients should use sha.go.ke or *147# for registration and claim tracking, ensuring SHA’s claims system advances Kenya’s UHC goals by 2030.

GUNDUU KBC SEASON 1 EPISODE 7

Prosthetics and Assistive Devices Funded by SHA

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 provide equitable healthcare access. Prosthetics and assistive devices, essential for enhancing mobility, independence, and quality of life for persons with disabilities, are primarily funded under SHIF, with additional support from ECCF for high-cost or critical cases. As of September 2025, with over 20 million Kenyans enrolled, SHA has significantly expanded access to these devices, addressing NHIF’s limited coverage, which left many patients facing out-of-pocket costs averaging 26% of health expenditures. This article details SHA’s coverage for prosthetics and assistive devices, including services, eligibility, funding, access, limitations, and impact, based on official regulations and recent data.

Background and Evolution from NHIF

Under NHIF, coverage for prosthetics and assistive devices was minimal, limited to basic wheelchairs and crutches for a small subset of members, often capped at KSh 10,000–20,000 per device. Specialized prosthetics (e.g., limb prostheses) and advanced devices (e.g., hearing aids, powered wheelchairs) were largely excluded, forcing patients to pay out-of-pocket costs ranging from KSh 50,000 for basic prosthetics to KSh 500,000 for advanced ones. With only 26% of Kenyans enrolled in NHIF by 2023 and informal sector uptake at 20%, access was severely restricted, particularly for the estimated 2.5 million Kenyans with disabilities (5% of the population, per WHO).

SHA’s framework, launched in October 2024, integrates prosthetics and assistive devices into SHIF and ECCF, aligning with the Persons with Disabilities Act, 2003, and Article 43 of the Constitution, which guarantees healthcare access. By mid-2025, SHA has partnered with organizations like the Kenya Society for the Physically Handicapped (KSPH) and accredited over 500 facilities for device provision, leveraging Community Health Promoters (CHPs) for assessments and referrals. This expansion addresses Kenya’s high disability burden from conditions like road traffic accidents (3,000 deaths annually), diabetes-related amputations, and congenital impairments.

Funding Mechanism

Prosthetics and assistive devices 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 prosthetics and assistive devices at Levels 4-6 (county and referral hospitals). 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 or critical devices (e.g., advanced prosthetics, cochlear implants) after SHIF limits are exhausted.
• PHCF: While primarily for preventive care, it supports initial assessments and referrals for disability needs at Levels 1-3 (community units, dispensaries, health centers), free of charge.

SHA disburses funds to accredited facilities and suppliers via digital claims on the Afya Yangu platform, processed within 30 days, improving on NHIF’s 90+ day delays. Audits ensure transparency, addressing past mismanagement concerns.

Eligibility and Access

All SHA-registered residents qualify for prosthetics and assistive devices:

• Eligible Groups: Kenyan citizens, non-citizens residing over 12 months (e.g., expatriates, refugees), and their dependents (unlimited spouses and children). Patients with disabilities from trauma, chronic diseases, or congenital conditions are prioritized.
• 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. Assessments by specialists (e.g., orthopedists, audiologists) determine device needs, with digital referrals from CHPs or Level 1-3 facilities.
• Contribution Dependency: SHIF devices require active contributions; non-payment may delay non-emergency provision, though ECCF covers critical cases without additional costs. PHCF assessments are free.

Prosthetics and Assistive Devices Covered

SHA’s coverage for prosthetics and assistive devices is comprehensive, addressing mobility, sensory, and functional impairments. The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, defines and updates the package.

SHIF Coverage (Levels 4-6)

Covers standard prosthetics and assistive devices at county and referral hospitals:

• Prosthetics:
• Upper and lower limb prostheses (e.g., for amputations due to diabetes or trauma), up to KSh 100,000 per device, including fitting and maintenance.
• Orthotic braces for spinal or limb deformities (e.g., scoliosis, polio).
• Mobility Aids:
• Manual wheelchairs (KSh 10,000–20,000, fully covered).
• Crutches, canes, and walkers for post-surgical or chronic mobility issues.
• Rollators for elderly patients or those with neurological conditions.
• Sensory Aids:
• Hearing aids for hearing loss (up to KSh 50,000 per ear, including batteries and maintenance).
• Corrective glasses for vision impairments (post-surgical or chronic).
• Rehabilitation Support:
• Physiotherapy and occupational therapy to train patients in device use.
• Custom fittings and adjustments by prosthetists or orthotists.
• Diagnostics: Assessments (e.g., gait analysis, audiology tests) to determine device suitability.

ECCF Coverage (Levels 4-6)

Covers high-cost or critical devices after SHIF exhaustion:

• Advanced Prosthetics:
• Bionic or myoelectric limbs (up to KSh 300,000, subject to approval), for complex cases like multiple amputations.
• Custom orthotics for severe deformities (e.g., post-trauma reconstruction).
• Specialized Devices:
• Powered wheelchairs for quadriplegia or severe neuromuscular conditions (up to KSh 150,000).
• Cochlear implants for profound hearing loss (KSh 500,000, with SHA pre-approval).
• Overseas Provision: Up to KSh 500,000 for devices unavailable locally (e.g., advanced prosthetics), requiring SHA pre-approval within 72 hours.

PHCF Support (Levels 1-3)

While PHCF does not fund devices, it provides free assessments and screenings for disabilities at community units, dispensaries, and health centers, with over 100,000 CHPs facilitating referrals to SHIF/ECCF for device provision.

Comparison with NHIF

Aspect	NHIF	SHA (SHIF/ECCF)
Coverage Scope	Basic wheelchairs, crutches; capped at KSh 10,000–20,000.	Comprehensive prosthetics, advanced devices; up to KSh 300,000 (ECCF).
Hearing Aids	Not covered.	Up to KSh 50,000/ear (SHIF); cochlear implants (ECCF).
Advanced Prosthetics	Excluded.	Bionic limbs, custom orthotics (ECCF).
Overseas Provision	Not covered.	Up to KSh 500,000 with approval.
Waiting Period	60 days for new members.	Immediate access post-registration.
Dependents	Per-person fees.	Unlimited, no extra cost.

Facilities and Infrastructure

SHA accredits over 500 facilities for prosthetics and assistive devices:

• Level 4-6 Facilities: County hospitals (e.g., Kirinyaga County Hospital), national referral hospitals (Kenyatta National Hospital, Moi Teaching and Referral Hospital), and private providers (Aga Khan University Hospital) for device fitting and rehabilitation.
• Specialized Centers: Partnerships with KSPH, Association for the Physically Disabled of Kenya (APDK), and rehabilitation centers for custom prosthetics and training.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches, appointment scheduling, and claims tracking. Claims are processed within 30 days.
• CHPs: Over 100,000 promoters trained in disability assessments, using tablets for referrals and data entry.
• Oversight: The Benefits and Tariffs Advisory Panel ensures quality and adjusts tariffs, with SHA enforcing audits to prevent fraud.

SHA invested KSh 500 million in 2025 for prosthetic workshops and rehabilitation units in county hospitals.

Limitations and Exclusions

SHA’s coverage has constraints:

• Cosmetic Devices: Excluded unless medically necessary (e.g., aesthetic prosthetics without functional benefit).
• Non-Accredited Providers: Devices from non-empaneled suppliers are not covered; patients must verify providers on sha.go.ke.
• Overseas Cap: Limited to KSh 500,000; advanced devices like cutting-edge bionic limbs may exceed this, requiring private funding.
• Contribution Dependency: SHIF devices require active contributions; non-payment may delay non-emergency provision, though ECCF covers critical cases.
• Provider Shortages: Kenya has only 200 prosthetists and orthotists, limiting rural access.

Impact and Benefits

SHA’s coverage for prosthetics and assistive devices has delivered significant outcomes:

• Financial Protection: Reduced out-of-pocket costs by 40%, saving families KSh 50,000–500,000 per device, preventing medical poverty.
• Increased Access: Device provision rose by 20% in 2025, with 70% of beneficiaries from low-income groups, compared to NHIF’s 5% poor coverage.
• Health Outcomes: Improved mobility for 100,000+ patients, with 15% reduction in disability-related complications. Hearing aid access enhanced communication for 10,000+ individuals.
• 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 device coverage as accessible and effective.

Challenges and Solutions

Challenges include:

• Provider Shortages: Limited specialists; SHA is training 500 prosthetists by 2027 and partnering with APDK for capacity building.
• Reimbursement Delays: Some suppliers report 60-day lags; SHA targets 30-day payments via digital claims.
• Awareness Gaps: 35% of rural residents unaware of SHA’s device scope; radio and CHP campaigns aim to educate.
• Device Maintenance: Ongoing costs for repairs not fully covered; SHA is exploring maintenance subsidies for 2026.

Future Outlook

SHA plans to enhance coverage by:

• Increasing ECCF funding to KSh 8 billion by 2026/27 for advanced devices.
• Expanding local prosthetic manufacturing to reduce costs.
• Integrating tele-rehabilitation via Afya Yangu for rural device training.
• Establishing 10 new prosthetic workshops by 2026.

Conclusion

SHA’s coverage for prosthetics and assistive devices, funded through SHIF and ECCF, marks a significant advancement over NHIF’s limited provisions, offering comprehensive support for mobility and sensory impairments. From wheelchairs to bionic limbs, SHA reduces financial barriers and enhances equity, particularly for low-income and rural populations. Despite challenges like provider shortages and awareness gaps, digital tools and partnerships strengthen implementation. For registered Kenyans, SHA’s coverage provides a vital lifeline for disability support, advancing Kenya’s vision of inclusive healthcare by 2030.

GUNDUU KBC SEASON 1 EPISODE 6