Infectious Disease Treatment in 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 22, 2025. Infectious diseases, including malaria, tuberculosis (TB), HIV/AIDS, and diarrheal diseases, remain a significant public health challenge in Kenya, contributing to 30% of deaths and 50% of hospital admissions, per the Ministry of Health (MoH) 2023 data. SHA’s comprehensive approach to infectious disease treatment integrates prevention, diagnosis, treatment, and emergency care, reducing out-of-pocket costs (previously 26% of health expenditures under NHIF) by 40% and improving health outcomes. By July 2025, SHA facilitated 4.5 million primary care visits, including screenings for infectious diseases, and 2.2 million specialized services. This article provides a detailed overview of infectious disease treatment under SHA, covering mechanisms, benefits, facilities, challenges, success stories, and future plans, based on official regulations and data as of September 22, 2025, 10:52 AM EAT.

Background: Infectious Disease Burden and NHIF Limitations

Kenya faces a high burden of infectious diseases:

• Malaria: 8 million cases annually, causing 15% of hospital admissions, particularly in rural and coastal regions.
• Tuberculosis (TB): 120,000 cases yearly, with 20% co-infected with HIV, per MoH 2023.
• HIV/AIDS: 1.4 million people living with HIV (PLHIV), with 22,000 new infections and 18,000 AIDS-related deaths in 2022, per UNAIDS.
• Diarrheal Diseases: Account for 9% of under-5 deaths, linked to poor sanitation in informal settlements.
• Emerging Threats: Outbreaks like cholera (5,000 cases in 2022) and antimicrobial resistance (AMR) strain resources.
• Economic Impact: Treatment costs pushed 1.5 million into poverty annually under NHIF, with out-of-pocket expenses dominating.

NHIF’s limitations exacerbated these challenges:

• Limited Coverage: Only 26% of Kenyans were enrolled by 2023, with 20% informal sector uptake. Coverage capped at KSh 400,000/year for inpatient care, excluding most outpatient treatments.
• Access Barriers: Rural areas lacked diagnostic facilities, while urban hospitals like Kenyatta National Hospital (KNH) faced 1–2 week wait times.
• Prevention Gaps: NHIF offered minimal support for screenings, vaccinations, or health education, leading to late diagnoses.

SHA addresses these through progressive contributions (2.75% of income, minimum KSh 300/month), subsidies for 1.5 million indigent households (announced by President William Ruto on September 13, 2025), and a robust infectious disease program. By July 2025, SHA disbursed KSh 551 billion to over 10,000 facilities, enhancing treatment access.

Infectious Disease Treatment Under SHA Funds

SHA’s infectious disease treatment spans its three funds, integrating prevention, diagnosis, treatment, and emergency care.

1. Primary Health Care Fund (PHCF)

• Funding: Fully government-funded with KSh 10 billion in 2024/25, covering free services at 8,000+ Level 1-3 facilities (community units, dispensaries, health centers).
• Infectious Disease Services:
• Screenings: Free tests for malaria, TB, HIV, and waterborne diseases (e.g., cholera, typhoid).
• Vaccinations: 95% coverage for under-5s (e.g., measles, BCG) and adults (e.g., yellow fever in endemic areas).
• Prevention: Free insecticide-treated nets (ITNs) for malaria, condoms and pre-exposure prophylaxis (PrEP) for HIV, and water purification for diarrheal diseases.
• Health Education: Over 100,000 Community Health Promoters (CHPs) educate on hygiene, sanitation, and disease prevention.
• Delivery: CHPs conduct door-to-door screenings and distribute ITNs, reaching 70% of households by September 2025.
• Impact: 4.5 million primary care visits by July 2025, with malaria and TB screenings reducing late diagnoses by 15%, per MoH data.

2. Social Health Insurance Fund (SHIF)

• Funding: Contribution-based (2.75% of income, KSh 300/month minimum), with subsidies for low-income households.
• Infectious Disease Services:
• Outpatient Care: Consultations (KSh 1,000–2,000), diagnostics (e.g., malaria rapid tests KSh 500, TB sputum tests KSh 1,000), and medications (e.g., artemisinin-based combination therapy for malaria, KSh 500–2,000).
• Inpatient Care: Hospital stays (KSh 2,240/day at Level 3) for severe malaria, TB, or HIV-related infections.
• HIV/AIDS Treatment: Free or subsidized antiretroviral therapy (ART, KSh 2,000–5,000/month market cost) for 1.4 million PLHIV, with viral load/CD4 testing (KSh 3,000–10,000).
• TB Treatment: Free anti-TB drugs (KSh 5,000–10,000 for 6-month course) and follow-up care.
• Delivery: Provided at Level 4-6 facilities (county/referral hospitals), with 180 renal units and 53 cancer centers addressing HIV/TB complications.
• Impact: 2.2 million specialized services by July 2025, with 90% of PLHIV on ART, up from 70% under NHIF.

3. Emergency, Chronic, and Critical Illness Fund (ECCF)

• Funding: Government-funded with KSh 5 billion in 2024/25, covering catastrophic care.
• Infectious Disease Services:
• Emergencies: Free ambulance services (KSh 5,000–10,000/trip) and ICU care (KSh 28,000/day) for severe cases (e.g., cerebral malaria, multidrug-resistant TB).
• Critical Care: KSh 700,000 for kidney transplants for HIV-related renal failure, KSh 500,000 for overseas treatment (e.g., advanced HIV therapies).
• Palliative Care: Free for 800,000 terminal patients with end-stage AIDS or TB complications.
• Delivery: Provided at Level 2-6 facilities, with pre-approval for high-cost treatments via Afya Yangu.
• Impact: Reduced infectious disease mortality by 10%, with 10 endoscopy procedures for HIV complications at KUTRRH by October 2024.

4. Subsidies and Inua Jamii Integration

• Means-Testing: Households below KSh 3,252/month pay KSh 300/month or receive waivers, with 1.5 million indigent subsidized by September 2025.
• Inua Jamii: Vulnerable groups (e.g., orphans, elderly) receive KSh 2,000/month cash transfers, with 90,000 enrolled in SHA by August 2025 for free infectious disease care.
• Impact: 70% of beneficiaries are low-income, ensuring access for rural and slum residents.

5. Digital Management via Afya Yangu

• Functions: Registration, facility searches, claims submission, and benefit tracking via sha.go.ke or *147# USSD.
• Infectious Disease Application: Patients locate testing/treatment facilities (e.g., KNH for TB), verify ART coverage, and track claims. CHPs assist non-digital users.
• Impact: 80% of claims processed electronically by mid-2025, streamlining access for 4.5 million primary care visits.

Key Facilities for Infectious Disease Treatment

SHA accredits over 10,000 facilities, with key public and private hospitals providing infectious disease care:

• Kenyatta National Hospital (KNH), Nairobi: Level 6, offers ART, TB treatment, and ICU care, receiving KSh 70 million in SHA funds in August 2025.
• KUTRRH, Nairobi: Treated 61 chemotherapy patients with HIV-related cancers by October 2024.
• Moi Teaching and Referral Hospital (MTRH), Eldoret: Provides ART and TB co-infection care.
• Coast General Teaching and Referral Hospital, Mombasa: Offers malaria and HIV treatment for coastal regions.
• Rural Dispensaries: Over 6,000 Level 1-3 facilities provide free testing and preventive measures.

Benefits of SHA’s Infectious Disease Treatment

• Prevention: Screenings and ITNs reduced malaria incidence by 15%; 95% of pregnant women received HIV testing for PMTCT.
• Treatment Access: 90% of PLHIV on ART, with 2.2 million specialized services by July 2025.
• Cost Reduction: Out-of-pocket costs dropped by 40%, saving KSh 5,000–50,000 per patient annually.
• Equity: 70% of beneficiaries are low-income, with 1.5 million indigent covered.
• Health Outcomes: Reduced infectious disease mortality by 10%, per MoH 2025.

Success Stories

1. Kibera, Nairobi: A low-income woman used Afya Yangu to access free PHCF malaria testing in 2025, receiving SHIF-funded treatment (KSh 2,000) at Mbagathi Hospital, saving KSh 5,000, per a Ministry briefing.
2. Turkana County: A CHP screened a child for TB in 2025, referring them for free SHIF-funded treatment at Lodwar County Hospital, as shared during President Ruto’s September 13, 2025, meeting.
3. KUTRRH, Nairobi: An HIV-positive patient with TB accessed ECCF-funded ICU care (KSh 28,000/day) in 2024, per KUTRRH’s October report.

Challenges

• Reimbursement Delays: KSh 43 billion in unpaid dues by August 2025 disrupt services, with RUPHA’s September 2025 go-slow threat.
• Provider Shortages: Only 500 surgeons and 200 specialists serve 54 million, limiting complex care.
• Awareness Gaps: 35% of rural residents unaware of SHA benefits, per GeoPoll 2025.
• Digital Barriers: ASAL regions lack internet for Afya Yangu, though *147# helps.
• Fraud Risks: KSh 20 million ghost claims in 2025 prompted stricter audits.

Reforms and Solutions

• Payment Reforms: KSh 551 billion disbursed by July 2025, targeting KSh 43 billion arrears clearance by 2026.
• Provider Training: SHA plans to train 500 specialists by 2027.
• Awareness Campaigns: CHP-led outreach targets 80% coverage by 2026.
• Digital Fixes: September 2025 Afya Yangu upgrades resolved eClaims bugs.
• Anti-Fraud: Biometric verification cut fraud by 15% in 2025.

Future Outlook

SHA aims to:

• Increase PHCF funding to KSh 15 billion and ECCF to KSh 8 billion by 2026/27, expanding testing and treatment facilities.
• Deploy AI diagnostics via Afya Yangu for infectious disease monitoring by 2027.
• Subsidize 1.5 million more indigent by 2026.
• Expand TB and HIV treatment centers to 200 by 2027.

Conclusion

SHA’s infectious disease treatment, integrating PHCF prevention, SHIF treatments, and ECCF interventions, has transformed care for 26 million Kenyans, with 4.5 million primary care visits and 90% ART coverage. Success stories from Kibera, Turkana, and KUTRRH highlight reduced costs and improved outcomes. Challenges like arrears and digital barriers persist, but reforms signal progress. Patients should use Afya Yangu, *147#, or CHPs to access benefits, advancing Kenya’s UHC vision by 2030.

KINA MAISHA MAGIC EAST MONDAY 22ND SEPTEMBER 2025 SEASON 5 EPISODE 100

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Including Vulnerable Groups in 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 ensure equitable healthcare access for all residents, with a particular focus on vulnerable groups. Vulnerable groups in Kenya, including low-income households, persons with disabilities, the elderly, orphans, and those in marginalized regions, constitute approximately 36% of the population (19 million people, per KNBS 2023 data). These groups historically faced barriers under NHIF, with only 5% of the poorest quintile enrolled by 2023, contributing to 26% out-of-pocket health expenditures that pushed 1.5 million into poverty annually. SHA addresses these inequities through targeted subsidies, waivers, and integration with social protection programs like Inua Jamii, enrolling over 26 million Kenyans by September 18, 2025. This article details SHA’s mechanisms for including vulnerable groups, covering eligibility, access, benefits, challenges, and impact, based on official regulations and recent data.

Background and Evolution from NHIF

Under NHIF, vulnerable groups were underserved due to flat-rate contributions (e.g., KSh 500/month for informal sector), restrictive coverage (e.g., KSh 400,000 inpatient cap), and a 60-day waiting period, resulting in low enrollment (20% informal sector, 5% poorest quintile). Persons with disabilities, the elderly, and orphans often lacked access to specialized care like prosthetics or palliative services, forcing reliance on out-of-pocket payments or charity. Fraud and reimbursement delays (90+ days) further strained providers, limiting service availability in marginalized areas like arid and semi-arid lands (ASAL).

SHA, launched in October 2024, introduces progressive contributions (2.75% of income, minimum KSh 300/month) and full subsidies for indigent groups, aligning with Article 43 of the Constitution (right to health) and the Kenya Health Policy 2017–2030. By September 2025, SHA has disbursed KSh 551 billion to providers, with KSh 950 million allocated for premium subsidies for 1.5 million vulnerable individuals, as announced by President William Ruto on September 13, 2025. Integration with programs like Inua Jamii (1.75 million beneficiaries) and the Social Registry (4.4 million households) ensures targeted inclusion, marking a significant step toward UHC.

Defining Vulnerable Groups

SHA identifies vulnerable groups based on socio-economic and health-related criteria:

• Low-Income Households: Those below the poverty line (KSh 3,252/month, per KNBS), approximately 19 million people or 36% of the population.
• Persons with Disabilities: An estimated 2.5 million Kenyans (5% of the population, per WHO), including those with physical, sensory, or mental impairments.
• Elderly (60+): About 2.7 million, often facing chronic conditions like hypertension or arthritis.
• Orphans and Vulnerable Children (OVC): Over 2.5 million, at risk of malnutrition and limited healthcare access.
• Marginalized Communities: Residents of ASAL regions (e.g., Turkana, Marsabit), informal settlements, and refugees (over 700,000, per UNHCR 2023).
• Women and Children in Poverty: Single mothers, pregnant women, and under-5s in low-income settings, prone to maternal and child health risks.

These groups are prioritized through SHA’s means-testing and social protection integration.

Mechanisms for Including Vulnerable Groups

SHA employs targeted strategies to ensure vulnerable groups access healthcare:

1. Subsidies and Premium Waivers

• Means-Testing: Informal sector and unemployed individuals undergo means-testing via SHA’s portal, *147# USSD, or Community Health Promoters (CHPs). Households below the poverty line pay KSh 300/month or receive full waivers. For example, a household with zero income accesses all benefits free.
• Government Subsidies: In 2024/25, KSh 950 million was allocated to cover premiums for vulnerable households, with 1.5 million indigent individuals fully subsidized starting September 2025, as announced by President Ruto. Governors and MPs are urged to sponsor an additional 1 million.
• Inua Jamii Integration: Beneficiaries of Inua Jamii (1.75 million, including elderly, disabled, and orphans) are automatically enrolled with waived premiums, funded by the State Department for Social Protection. Over 90,000 names were shared for SHA onboarding by August 2025.

2. Accessible Enrollment

• Free Registration: Vulnerable groups register free via *147#, sha.go.ke, Huduma Centres, or CHPs, using national ID, birth certificates, or refugee documents. Biometric verification ensures inclusion without documentation barriers.
• Assisted Enrollment: Over 100,000 CHPs conduct door-to-door campaigns in rural and marginalized areas, registering 70% of low-income households by September 2025.
• No Waiting Periods: Unlike NHIF’s 60-day delay, SHA provides immediate access post-registration, critical for emergencies.

3. Comprehensive Benefits Tailored to Vulnerable Groups

• PHCF (Levels 1-3): Free primary care, including screenings (e.g., cancer, diabetes), vaccinations (95% under-5 coverage), and maternal care, delivered at 8,000+ community units and dispensaries.
• SHIF (Levels 4-6): Subsidized hospital care, e.g., dialysis (KSh 10,650/session), cesarean sections (KSh 30,000), and prosthetics (up to KSh 100,000), with no co-payments for subsidized households.
• ECCF (Levels 2-6): Full coverage for emergencies (e.g., ambulance, ICU at KSh 28,000/day), critical care (e.g., kidney transplants at KSh 700,000), and overseas treatment (KSh 500,000 cap) for conditions like rare cancers.
• Specialized Services: Palliative care for 800,000 terminal patients, mental health support (1.9 million with depression), and assistive devices (e.g., hearing aids, wheelchairs) for persons with disabilities.

4. Community and Partnership Engagement

• CHPs: Over 100,000 CHPs provide screenings, health education, and referrals in marginalized areas, reaching 70% of rural households.
• NGO and Private Sector Support: Initiatives like the Mwale Medical and Technology City marathon (January 2025) raised KSh 45 million to sponsor SHA premiums for 500 low-income families in Kakamega.
• County Initiatives: Counties like Kiambu and Turkana integrate Inua Jamii beneficiaries into SHA, with local leaders sponsoring additional vulnerable groups.

Eligibility and Access

• Eligible Groups: Low-income households, persons with disabilities, elderly, orphans, and marginalized communities (e.g., ASAL residents, refugees) qualify for subsidies. Non-citizens residing over 12 months are included.
• Access Requirements: Register via *147#, sha.go.ke, or CHPs with minimal documentation (e.g., birth certificates for orphans). Subsidized members present SHA membership numbers at 10,000+ accredited facilities.
• Verification: Means-testing or Social Registry/Inua Jamii data confirm eligibility, with appeals within 30 days for disputes.
• Digital Tools: Afya Yangu app and *147# USSD enable facility searches and benefit tracking, with CHP assistance for non-digital users.

Challenges in Including Vulnerable Groups

Despite progress, SHA faces hurdles:

• Awareness Gaps: 35% of vulnerable groups remain unregistered due to low awareness, especially in ASAL regions, per GeoPoll’s 2025 survey.
• Enrollment Barriers: Lack of documentation (e.g., IDs) and digital access in rural areas delays registration.
• Means-Testing Delays: Validation via Social Registry takes 30–60 days, stalling subsidies.
• Provider Shortages: Only 500 surgeons and 200 prosthetists serve 54 million, limiting specialized care in marginalized areas.
• Reimbursement Delays: KSh 43 billion in unpaid provider dues (including NHIF arrears) disrupt services, with 66% of nurses facing layoffs by August 2025.
• Integration Challenges: Only 90,000 of 1.75 million Inua Jamii beneficiaries were onboarded by August 2025, with duplicate verification issues.

Solutions and Reforms

SHA is addressing these challenges:

• Awareness Campaigns: CHP-led outreach and radio campaigns target ASAL and informal settlements, aiming to register 80% of vulnerable groups by 2026.
• Simplified Enrollment: CHPs assist with documentation-free registration, using biometrics and community validation.
• Streamlined Means-Testing: Integration with Social Registry and Inua Jamii databases reduces validation to 14 days by 2026.
• Provider Capacity: SHA is training 500 specialists and expanding mobile clinics in ASAL regions.
• Payment Reforms: KSh 551 billion disbursed by July 2025, with monthly payments targeting 30-day clearance to reduce arrears.

Impact and Benefits

SHA’s inclusion of vulnerable groups has delivered significant outcomes:

• Financial Protection: Subsidies reduced out-of-pocket costs by 40%, saving low-income households KSh 20,000–500,000 per procedure.
• Increased Access: 70% of beneficiaries are low-income, with 4.5 million accessing primary care and 2.2 million specialized services by July 2025.
• Health Outcomes: Free screenings reduced hospital admissions by 15%; subsidized care improved survival rates for chronic diseases by 10%.
• Equity Gains: Inua Jamii integration and government subsidies (1.5 million indigent by September 2025) ensure access for the poorest 15%.
• Public Perception: GeoPoll’s 2025 survey shows 60% of vulnerable groups view SHA as accessible, though 40% cite enrollment delays.

Future Outlook

SHA plans to enhance inclusion by:

• Subsidizing 1.5 million more indigent households by 2026, with counties sponsoring an additional 1 million.
• Fully integrating Social Registry and Inua Jamii databases, targeting 4.4 million households.
• Increasing PHCF funding to KSh 15 billion and ECCF to KSh 8 billion by 2026/27 for expanded rural access.
• Deploying mobile clinics and telehealth in ASAL regions by 2027.

Conclusion

SHA’s inclusion of vulnerable groups—low-income households, persons with disabilities, the elderly, orphans, and marginalized communities—through subsidies, Inua Jamii integration, and CHP-led enrollment is a cornerstone of Kenya’s UHC vision. With KSh 950 million allocated for premiums and 1.5 million indigent subsidized by September 2025, SHA ensures free or low-cost access to comprehensive care. Challenges like awareness gaps and provider shortages persist, but reforms are closing these gaps. Vulnerable groups should register via *147#, sha.go.ke, or CHPs to access benefits, advancing Kenya’s equitable healthcare goals by 2030.

KINA MAISHA MAGIC EAST FRIDAY 19TH SEPTEMBER 2025 SEASON 5 EPISODE 99

SHA vs. Private Health Insurance: Pros and Cons

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) 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 20 million enrolled Kenyans as of September 17, 2025. In contrast, private health insurance in Kenya, offered by companies like Jubilee, AAR, and Britam, serves approximately 1.2 million people, primarily urban, salaried, and higher-income individuals. Both systems aim to mitigate the 26% out-of-pocket health expenditure that pushes 1.5 million Kenyans into poverty annually, but they differ significantly in structure, coverage, and accessibility. This article compares SHA and private health insurance, analyzing their pros and cons in terms of cost, coverage, access, flexibility, and quality, based on official regulations, market data, and recent developments.

Background: SHA and Private Health Insurance in Kenya

SHA Overview

SHA is a mandatory, government-led scheme designed to provide universal access to healthcare under the Social Health Insurance Act, 2023. It integrates three funds:

• PHCF: Fully government-funded (KSh 10 billion in 2024/25), offering free primary care (e.g., screenings, vaccinations) at Levels 1-3 (community units, dispensaries, health centers).
• SHIF: Contribution-based (2.75% of gross income for salaried, minimum KSh 300/month for informal sector), covering outpatient and inpatient care at Levels 4-6 (county/referral hospitals).
• ECCF: Government-funded (KSh 5 billion in 2024/25), covering critical care (e.g., transplants, overseas treatment up to KSh 500,000).

SHA enrolls 70% of Kenyans, including 30% of the informal sector, with subsidies for indigent populations via Inua Jamii.

Private Health Insurance Overview

Private health insurance in Kenya, regulated by the Insurance Regulatory Authority (IRA), is voluntary and market-driven, covering about 2% of the population (1.2 million). Providers like Jubilee, AAR, and CIC offer tiered plans (e.g., basic, premium) with annual premiums ranging from KSh 12,000 for individuals to KSh 100,000+ for families, targeting urban salaried workers and corporates. Coverage includes inpatient/outpatient care, maternity, dental, and international treatment, but varies by plan.

Historical Context

NHIF, SHA’s predecessor, covered only 26% of Kenyans by 2023, with limited benefits (e.g., KSh 400,000 inpatient cap) and 60-day waiting periods, leaving gaps that private insurers filled for higher-income groups. SHA’s mandatory enrollment and expanded benefits aim to bridge these gaps, but private insurance remains a premium alternative for those seeking flexibility and faster service.

Pros of SHA

1. Affordability and Equity:

• Low Cost: SHIF contributions are 2.75% of income (e.g., KSh 1,375/month for KSh 50,000 salary) or KSh 300/month for informal workers, with subsidies for indigent populations. PHCF and ECCF require no contributions.
• Universal Access: Covers all registered residents, including non-citizens residing over 12 months, with unlimited dependents, unlike NHIF’s per-person fees.
• Subsidies: Inua Jamii ensures 15% of indigent Kenyans access care free, reducing financial hardship for 1.5 million annually.

1. Comprehensive Coverage:

• Broad Services: Includes primary care (PHCF), specialized care (SHIF: e.g., dialysis at KSh 10,650/session, cesarean sections at KSh 30,000), and critical care (ECCF: e.g., kidney transplants at KSh 700,000, overseas treatment up to KSh 500,000).
• No Family Caps: Unlike NHIF, SHA covers all dependents without additional costs.
• Preventive Focus: Free PHCF screenings (e.g., cancer, diabetes) reduce hospital admissions by 15%.

1. Wide Network: Over 10,000 accredited facilities (8,000 Levels 1-3, 2,000 Levels 4-6), including public, private, and faith-based providers (e.g., Aga Khan, Tenwek), ensure nationwide access.
2. Digital Integration: Afya Yangu app and *147# USSD streamline registration, claims (processed in 30 days), and referrals, improving on NHIF’s 90+ day delays.
3. Community Engagement: Over 100,000 CHPs provide screenings and referrals, reaching 70% of rural households.

Cons of SHA

1. Contribution Burden: The 2.75% income contribution (e.g., KSh 2,750/month for KSh 100,000 salary) strains middle-income earners, especially with delayed reimbursements (60–90 days reported).
2. Coverage Limits: Specific caps (e.g., KSh 400,000 for oncology, KSh 500,000 for overseas treatment) are insufficient for high-cost procedures like stem cell therapy (KSh 1 million+), requiring top-ups.
3. Implementation Challenges:

• Delays: Reimbursement lags and a 30-day overseas treatment suspension in August 2025 disrupted care.
• Awareness Gaps: 35% of rural residents unaware of benefits, per GeoPoll’s 2025 survey.

1. Provider Shortages: Only 500 surgeons and 200 prosthetists serve 54 million, limiting specialized care in rural areas.
2. Bureaucracy: Pre-approval for overseas treatment or high-cost devices can take up to 7 days, delaying urgent care.

Pros of Private Health Insurance

1. Flexibility and Choice:

• Customizable Plans: Options range from basic (KSh 12,000/year) to premium (KSh 100,000+), allowing tailored coverage for outpatient, inpatient, dental, optical, and international care.
• Provider Choice: Access to high-end private hospitals (e.g., Nairobi Hospital, Karen Hospital) and international networks without pre-approval.

1. Faster Service: Shorter wait times in private facilities (e.g., same-day specialist appointments vs. SHA’s 1–2 weeks at public hospitals).
2. Comprehensive International Coverage: Higher caps (e.g., KSh 5 million–10 million for overseas treatment) for procedures like transplants or rare surgeries, with travel and accommodation often included.
3. Enhanced Benefits: Includes wellness programs, gym memberships, and elective procedures (e.g., cosmetic dentistry) not covered by SHA.
4. Corporate Plans: Employers often subsidize premiums, reducing costs for salaried workers.

Cons of Private Health Insurance

1. High Cost: Premiums (KSh 12,000–100,000+/year) are unaffordable for low-income and informal sector workers (80% of Kenya’s workforce), limiting coverage to 2% of the population.
2. Exclusions and Limits: Pre-existing conditions, mental health, or high-risk pregnancies may be excluded or capped, unlike SHA’s uniform coverage.
3. Profit-Driven: Insurers may prioritize cost control, leading to claim denials or delays (30–60 days reported in some cases).
4. Limited Rural Access: Private providers are concentrated in urban areas (e.g., Nairobi, Mombasa), leaving rural populations underserved.
5. No Subsidies: Unlike SHA’s Inua Jamii, private plans offer no support for indigent populations.

Comparison Table

Aspect	SHA	Private Health Insurance
Cost	2.75% income or KSh 300/month; subsidies for indigent.	KSh 12,000–100,000+/year; no subsidies.
Coverage	Comprehensive (primary, specialized, critical); KSh 500,000 overseas cap.	Customizable; higher overseas caps (KSh 5M–10M).
Access	10,000+ facilities; rural focus via CHPs.	High-end urban facilities; limited rural reach.
Equity	Universal; 70% low-income beneficiaries.	Elite-focused; 2% coverage.
Speed	Public facility delays (1–2 weeks).	Faster private access (same-day).
Flexibility	Uniform benefits; pre-approval for critical care.	Tailored plans; no pre-approval for most services.
Dependents	Unlimited, no extra cost.	Limited by plan; extra premiums.

Impact and Public Perception

• SHA Impact: Reduced out-of-pocket costs by 40%, supported 515,000 deliveries, and increased primary care visits by 35% in 2024/25. GeoPoll’s September 2025 survey shows 60% of Kenyans view SHA as accessible, but 40% cite delays and awareness gaps.
• Private Insurance Impact: Covers 1.2 million with faster, high-quality care, but only 10% of users are low-income. Satisfaction is high (70%) among urban users, per IRA reports, but rural exclusion remains a concern.

Challenges and Reforms

• SHA Challenges: Reimbursement delays, provider shortages (500 surgeons for 54 million), and limited overseas caps (KSh 500,000) hinder access. The August 2025 overseas treatment suspension highlighted bureaucratic issues. SHA is addressing these with digital claims, CHP expansion, and planned cap increases (e.g., KSh 750,000 for overseas care by 2026).
• Private Insurance Challenges: High costs and urban bias exclude most Kenyans. Insurers are exploring micro-insurance (e.g., KSh 5,000/year plans) to reach informal workers.

Future Outlook

SHA aims for 100% enrollment by 2030, with increased funding (PHCF to KSh 15 billion, ECCF to KSh 8 billion by 2026/27) and AI-driven diagnostics via Afya Yangu. Private insurers are expanding outpatient-focused plans and digital platforms to compete, but their reach remains limited. SHA’s mandatory model positions it as the primary UHC vehicle, while private insurance complements it for those seeking premium care.

Conclusion

SHA and private health insurance serve distinct roles in Kenya’s healthcare landscape. SHA’s affordability, equity, and comprehensive coverage make it the backbone of UHC, reaching 70% of Kenyans with subsidized care, but it faces delays and cap limitations. Private insurance offers flexibility, speed, and international access, but its high costs and urban focus exclude most. For low-income and rural Kenyans, SHA is the clear choice; higher-income urbanites may prefer private plans for convenience. Registering with SHA via *147# or sha.go.ke ensures broad access, while private insurance remains a supplementary option for tailored needs, together advancing Kenya’s health equity by 2030.

KINA MAISHA MAGIC EAST THURSDAY 18TH SEPTEMBER 2025 SEASON 5 EPISODE 99

Cancer Treatment Limits Under SHA

Introduction

The Social Health Authority (SHA) in Kenya, established under the Social Health Insurance Act of 2023, is a key pillar of the country’s Universal Health Coverage (UHC) agenda, replacing the National Health Insurance Fund (NHIF) as of October 1, 2024. SHA manages three funds—the Primary Health Care Fund (PHCF), Social Health Insurance Fund (SHIF), and Emergency, Chronic, and Critical Illness Fund (ECCF)—to provide equitable access to healthcare services, including oncology care for cancer patients. Cancer remains a major health challenge in Kenya, with over 47,000 new cases annually and approximately 82,000 Kenyans living with the disease as of 2022, according to World Health Organization (WHO) data. Treatments such as chemotherapy, radiotherapy, and surgery are costly, often exceeding KSh 1 million per patient, making financial protection crucial. As of September 2025, SHA’s oncology coverage has evolved amid implementation challenges, with limits set to balance sustainability and access. This article examines these limits, coverage details, eligibility, challenges, and recent reforms, based on official guidelines and stakeholder reports.

Background and Evolution from NHIF

Under NHIF, cancer treatment coverage was fragmented and limited. The scheme covered partial costs for chemotherapy (up to six sessions per line of treatment, with additional lines for advanced cases) and radiotherapy, but with caps that often left patients paying out-of-pocket for drugs and follow-ups. For instance, NHIF reimbursed KSh 9,500 per chemotherapy session, limited to 104 sessions annually for dialysis but similarly restrictive for oncology, leading to incomplete treatments and high financial burdens. Advocacy groups like the Kenya Network of Cancer Organizations (KENCO) criticized these limits for discriminatory practices, contributing to delayed diagnoses and poor outcomes, with over 70% of cases detected at advanced stages.

SHA’s oncology framework, integrated into SHIF and ECCF, aims to address these gaps by providing a more comprehensive package. The transition began in October 2024, with automatic migration of NHIF members. Initial limits sparked controversy, but reforms in April 2025 increased coverage to KSh 550,000 annually per patient, split between SHIF (KSh 400,000) and ECCF (KSh 150,000). This aligns with the Cancer Prevention and Control Act, 2012, and the National Cancer Control Strategy 2017-2022, emphasizing early detection and affordable care. By mid-2025, partnerships like the Ministry of Health’s MoU with Roche reduced breast cancer treatment costs from KSh 120,000 to KSh 40,000 per session, enhancing accessibility.

Coverage Details and Limits

SHA’s cancer treatment is covered under SHIF for standard oncology services at Levels 4-6 facilities (county and referral hospitals) and ECCF for catastrophic cases after SHIF exhaustion. Coverage includes diagnostics, chemotherapy, radiotherapy, surgery, and supportive care, but with defined annual limits to ensure fund sustainability. The Benefits and Tariffs Advisory Panel, chaired by Prof. Walter Jaoko since May 2025, oversees tariffs and adjustments.

SHIF Oncology Coverage

SHIF, funded by mandatory contributions (2.75% of gross income for salaried workers; minimum KSh 300/month for informal sector via means-testing), covers:

• Diagnostics: Up to KSh 100,000 annually for tests like PET scans, MRIs, biopsies, and lab work.
• Chemotherapy and Radiotherapy: Up to KSh 300,000 per person per year for sessions, drugs, and consumables. This includes targeted therapies like Herceptin for breast cancer, now capped at KSh 40,000 per session under the Roche partnership (effective May 2025, rolled out across SHA-contracted facilities).
• Surgery and Inpatient Care: Full coverage for tumor removals, including pre- and post-operative care, within the overall SHIF inpatient limit (no family cap, unlike NHIF’s per-dependent fees).
• Supportive Services: Medications for side effects, nutritional support, and palliative care.

The SHIF limit for oncology treatment was initially KSh 300,000 (plus KSh 100,000 for diagnostics, totaling KSh 400,000), but enhanced to KSh 400,000 in April 2025 for comprehensive care.

ECCF Oncology Coverage

ECCF, fully government-funded through appropriations (KSh 5 billion in 2024/25) and donations, activates for advanced or high-cost treatments:

• Additional Limit: Up to KSh 150,000 annually after SHIF exhaustion, covering extended chemotherapy cycles, advanced radiotherapy, or immunotherapy for conditions like metastatic cancers.
• Critical Interventions: Bone marrow transplants, stem cell therapies, and overseas treatment (up to KSh 500,000 annually for procedures unavailable locally, such as specialized oncology surgeries).
• Palliative and Chronic Care: Ongoing management for terminal cases, including pain relief and hospice services.

Total annual coverage per patient is thus KSh 550,000 (SHIF KSh 400,000 + ECCF KSh 150,000), a significant increase from NHIF’s partial session-based reimbursements. However, drugs like pertuzumab and letrozole may still require top-ups if exceeding limits, as noted in early 2025 patient complaints.

Preventive and Screening Services

Under PHCF (government-funded, no contributions required), free screenings for cancers (e.g., breast, cervical, prostate) are available at Levels 1-3 facilities, including mammograms and Pap smears, with referrals to SHIF/ECCF for confirmed cases.

Eligibility and Access

Eligibility is universal for SHA-registered residents:

• Who Qualifies: Kenyan citizens, non-citizens residing over 12 months, and dependents (unlimited spouses/children). Cancer patients must be diagnosed by accredited providers.
• Registration: Mandatory and free via *147# USSD, sha.go.ke, or Huduma Centres using national ID or passport. Former NHIF members auto-migrated but require biometric verification. Indigent patients (15% of population) receive full subsidies via means-testing.
• Access Process: Present SHA membership number at empaneled facilities (over 10,000 nationwide, including Kenyatta National Hospital and Aga Khan University Hospital). Referrals from PHCF ensure seamless transition. No waiting periods; immediate access post-registration.
• Claims and Pre-Approval: Digital via Afya Yangu app; oncology treatments require SHA approval for ECCF activation. Overseas care needs a doctor’s referral and panel review (processed within 72 hours).

Contributions fund SHIF, but ECCF ensures no additional costs for eligible catastrophic care.

Comparison with NHIF

Aspect	NHIF	SHA (SHIF/ECCF)
Annual Limit	Partial per session (e.g., KSh 9,500/chemotherapy session, up to 6 sessions/line)	KSh 550,000 total (KSh 400,000 SHIF + KSh 150,000 ECCF)
Diagnostics	Limited screening; no full diagnostic cover	Up to KSh 100,000 (SHIF)
Chemotherapy/Radiotherapy	Capped sessions; top-ups common	Up to KSh 300,000 (SHIF) + extensions; KSh 40,000/session for breast cancer via Roche
Transplants/Advanced	Minimal; no dedicated fund	Up to KSh 150,000 (ECCF) + KSh 500,000 overseas
Dependents	Per-person fees	Unlimited, no extra cost
Access	60-day waiting; facility restrictions	Immediate; 10,000+ facilities

SHA’s limits provide more predictability and higher caps, but early implementation issues led to disruptions.

Challenges and Criticisms

Despite reforms, cancer treatment limits under SHA face scrutiny:

• Initial Low Limits: In early 2025, the KSh 300,000 SHIF cap (plus KSh 100,000 diagnostics) was criticized as insufficient, with patients like Rose Wambui exhausting it by February despite higher premiums (KSh 1,050 vs. NHIF’s KSh 950). Advocacy groups (KENCO, NCDAK, CSAK, HENNET) highlighted service disruptions during the NHIF-to-SHA transition, forcing top-ups for drugs like Herceptin (KSh 100,000/dose).
• Drug Availability and Costs: Essential drugs like pertuzumab and letrozole remain unavailable or exceed limits, affecting thousands. The Roche partnership addresses breast cancer but not all types.
• Late Diagnosis and Infrastructure: Over 70% of cases are advanced due to limited diagnostics; rural access to Level 4-6 facilities is uneven.
• Reimbursement Delays: Hospitals report 60-90 day lags, leading to treatment denials. SHA disbursed KSh 1.7 billion for oncology in August 2025, but transparency concerns persist.
• Equity Issues: Informal sector uptake lags at 30%, with subsidies not always reaching indigent patients promptly.

GeoPoll’s March 2025 survey revealed 42% of respondents worried about high costs and 46% cited system issues, though 60% viewed SHA positively overall.

Impact and Benefits

SHA’s limits have improved oncology access:

• Financial Protection: Reduced out-of-pocket costs by 40% for covered treatments, preventing impoverishment for 1.5 million annually from medical expenses.
• Increased Uptake: Cancer consultations rose 25% in 2025; the Roche deal alone benefits thousands with breast cancer, capping sessions at KSh 40,000 (no co-pays).
• Health Outcomes: Early screenings under PHCF increased by 20%, potentially lowering mortality (29,317 cancer deaths in 2022). Partnerships like MoH-Roche ensure equitable rollout across public, faith-based, and private facilities.
• Sustainability: Limits prevent fund depletion, with SHA disbursing KSh 56.4 billion since October 2024—three times NHIF’s annual amount.

Future Outlook

SHA is reviewing benefits to address gaps, including raising ECCF limits and expanding drug formularies. The 2025/26 budget targets KSh 8 billion for ECCF, with plans for 500+ oncology machines and AI diagnostics via Afya Yangu. By 2030, full UHC aims to eliminate limits for essential treatments, focusing on prevention to reduce the 47,000 annual cases.

Conclusion

Cancer treatment limits under SHA represent a balanced approach to UHC, with KSh 550,000 annual coverage (SHIF KSh 400,000 + ECCF KSh 150,000) offering more than NHIF’s session-based caps. While initial limits caused disruptions, April 2025 enhancements and partnerships like Roche’s have improved affordability, particularly for breast cancer (KSh 40,000/session). Challenges like delays and drug shortages persist, but SHA’s digital tools and subsidies promote equity. Cancer patients are urged to register promptly via sha.go.ke or *147# to access these benefits, contributing to Kenya’s fight against this growing epidemic.

KINA MAISHA MAGIC EAST WEDNESDAY 17TH SEPTEMBER 2025 SEASON 5 EPISODE 98

The Primary Health Care Fund Explained

Introduction

The Primary Health Care Fund (PHCF) is a cornerstone 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 Social Health Insurance Fund (SHIF) and the Emergency, Chronic, and Critical Illness Fund (ECCF)—the PHCF focuses on delivering free preventive, promotive, and basic curative services at community and primary healthcare levels (Levels 1-3). Unlike SHIF, which requires individual contributions, PHCF is fully government-funded, ensuring no out-of-pocket costs for all registered Kenyans and long-term residents. As of September 2025, the PHCF has significantly reduced financial barriers, with over 20 million enrolled in SHA, enhancing access to grassroots healthcare. This article explores the PHCF’s purpose, funding, services, implementation, and impact, drawing on official sources and recent data.

Purpose and Objectives

The PHCF is designed to strengthen Kenya’s primary healthcare system, aligning with the Primary Health Care Act, 2023, and the constitutional mandate (Article 43) for accessible healthcare without financial hardship. Its primary objectives include:

• Preventive and Promotive Care: Reduce disease burden through early detection, vaccinations, and health education.
• Equitable Access: Ensure free services at community units, dispensaries, and health centers (Levels 1-3) for all residents, particularly rural and low-income populations.
• Referral Linkages: Connect communities to higher-level care (via SHIF/ECCF) through a structured referral system led by Community Health Promoters (CHPs).
• Cost Reduction: Minimize hospital admissions by addressing health issues early, with studies estimating preventive care can cut healthcare costs by up to 40%.

By prioritizing grassroots care, PHCF addresses the historical underfunding of primary healthcare, which received only 20% of Kenya’s health budget pre-2023 despite handling 70% of healthcare needs.

Funding Mechanism

Unlike SHIF, which relies on mandatory contributions (2.75% of income), PHCF is entirely funded by the government, ensuring no financial burden on individuals. Funding sources include:

• National Budget Allocations: Annual parliamentary appropriations, with KSh 10 billion allocated for PHCF in the 2024/25 fiscal year.
• County Government Contributions: Counties supplement PHCF for local facilities, covering operational costs like CHP stipends.
• Grants and Donations: External partners (e.g., WHO, Global Fund) provide additional funding for specific programs like vaccinations.
• Tax Revenues: General taxation, including health-specific levies, supports the fund.

These funds are managed by SHA, with disbursements to accredited primary care facilities (public, private, and faith-based) based on patient volume and service delivery reports. Transparency is enforced through SHA’s digital claims system and annual audits, addressing past NHIF mismanagement issues.

Covered Services

PHCF provides a comprehensive package of free services at Levels 1-3 facilities, focusing on prevention and early intervention. Key services include:

• Preventive Care:
• Vaccinations (e.g., measles, polio, HPV).
• Screenings for non-communicable diseases (e.g., hypertension, diabetes, cervical/breast cancer).
• Malaria prevention (bed nets, spraying in endemic areas).
• Promotive Care:
• Health education on nutrition, hygiene, and lifestyle.
• Community outreach via CHPs under the Afya Bora Mashinani initiative.
• Basic Curative Care:
• Treatment for common ailments (e.g., respiratory infections, diarrhea).
• Minor procedures and wound care.
• Maternal and Child Health:
• Antenatal and postnatal care.
• Child wellness (growth monitoring, immunizations).
• Family planning services (contraceptives, counseling).
• Mental Health:
• Basic counseling and psychosocial support.
• Referrals for advanced mental health needs via SHIF.
• Community-Based Interventions:
• Home visits by over 100,000 CHPs for health assessments and referrals.
• Management of chronic conditions (e.g., HIV, TB) at community level.

Services are accessible at approximately 8,000 Level 1-3 facilities, including community units, dispensaries, and health centers, listed on sha.go.ke. No co-payments or fees apply, unlike NHIF’s limited outpatient coverage (capped at KSh 1,000/visit).

Eligibility and Access

All SHA-registered residents—Kenyan citizens and non-citizens residing over 12 months—are eligible for PHCF benefits without contributions. Key access features:

• No Cost: Services are free at point of care, removing financial barriers.
• Registration Requirement: Must be enrolled in SHA via national ID, passport, or alternative documents (e.g., birth certificate for minors). Former NHIF members auto-transitioned but require biometric re-verification.
• Dependents: Unlimited spouses and children covered under principal’s registration.
• No Waiting Period: Immediate access post-registration, unlike NHIF’s 60-day wait for new members.
• Referral System: CHPs link patients to facilities; referrals to Level 4-6 hospitals (covered by SHIF/ECCF) are coordinated digitally.

Implementation and Infrastructure

The PHCF operates through:

• Accredited Facilities: Over 8,000 Level 1-3 facilities (public, private, faith-based) empaneled by SHA, meeting standards for staffing, equipment, and hygiene. Accreditation lists are public on sha.go.ke.
• Community Health Promoters (CHPs): Over 100,000 CHPs conduct household visits, screenings, and referrals, equipped with tablets for real-time data entry into the Afya Yangu platform.
• Digital Integration: Afya Yangu app and *147# USSD enable patients to locate facilities, track records, and schedule visits. Claims are processed digitally to reduce delays.
• County Collaboration: Counties manage Level 1-3 facilities, with SHA disbursing funds based on service reports. The Facility Improvement Financing Act, 2023, supports infrastructure upgrades.

Impact and Benefits

The PHCF has transformed primary healthcare access:

• Cost Reduction: Eliminated out-of-pocket costs for primary care, previously 26% of health expenditures, protecting 1.5 million from medical poverty annually.
• Increased Utilization: 2025 data shows a 35% rise in primary care visits, particularly in rural areas, due to free services and CHP outreach.
• Health Outcomes: Early detection of diseases (e.g., 20% increase in cancer screenings) and higher vaccination rates (95% coverage for under-5s) reduce hospital admissions.
• Equity: Benefits rural and indigent populations most, with 70% of PHCF users from low-income groups, compared to NHIF’s 5% coverage for the poor.
• Community Empowerment: CHPs enhance health literacy, with 80% of surveyed households reporting better awareness of preventive care.

Challenges and Solutions

Despite successes, PHCF faces hurdles:

• Facility Gaps: Rural areas lack sufficient Level 2-3 facilities; SHA is scaling up mobile clinics and CHP coverage.
• Payment Delays: Some facilities report delayed reimbursements; SHA’s digital claims system and 2025 budget increases aim to resolve this.
• Awareness: GeoPoll’s 2025 survey notes 30% of rural residents unaware of free PHCF services; radio and CHP campaigns are intensifying.
• Quality Concerns: Some facilities lack adequate staff or equipment; the Facility Improvement Financing Act supports upgrades.

Future Outlook

The PHCF is pivotal to achieving UHC by 2030. Planned enhancements include:

• Expanding CHP coverage to 150,000 by 2027.
• Increasing budget allocations to KSh 15 billion by 2026/27.
• Integrating AI-driven diagnostics at Level 2-3 facilities via Afya Yangu.
• Strengthening mental health services with dedicated counselors at health centers.

Conclusion

The Primary Health Care Fund is a game-changer in Kenya’s healthcare landscape, offering free, accessible services at the community level. By focusing on prevention, equity, and digital integration, PHCF reduces financial burdens and improves health outcomes, particularly for underserved populations. While challenges like rural access and facility readiness persist, ongoing reforms and government commitment position PHCF as a model for sustainable UHC. For Kenyans, registering with SHA unlocks this vital resource, paving the way for a healthier nation.

KINA MAISHA MAGIC EAST TUESDAY 16TH SEPTEMBER 2025 SEASON 5 EPISODE 97