Healthcare reforms suffer setback as SHA performance declines

Kenya's transition to the Social Health Authority (SHA) from the National Health Insurance Fund (NHIF) has suffered another setback, with implementation scores declining from 46 per cent in December 2024 to 44 per cent in February. This translates to a poor grade of D.

According to a new survey by the Rural and Urban Private Hospitals Association of Kenya (Rupha), the decline highlights growing challenges in Kenya's ambitious healthcare reforms.
While there have been some notable improvements in e-contracting and patient verification, these advances have been overshadowed by increasing difficulties in claims management, reimbursement models and the financial stability of healthcare providers. 

“The overall SHA transition score has fallen from 46 per cent in December 2024 to 44 per cent, signaling a regression in the implementation of SHA reforms. This decline reflects deterioration in key service delivery areas, particularly financial health, system functionality and outpatient reimbursement. Although there have been improvements in e-contracting and patient verification, these gains have been overshadowed by worsening challenges in claims management, reimbursement models and provider financial stability," said Dr Brian Lishenga, the chairperson of Rupha.

The report also reveals that the financial health of healthcare providers remains a major concern, with 46 per cent of facilities reporting irregular payments, down slightly from 48 per cent in December. 

Smaller facilities, particularly level two and three hospitals, are most affected, with 64 per cent reporting that they have not received payments. This delayed and unclear payment structure is putting an immense strain on healthcare providers, especially those in the private and faith-based sectors.

Patients’ out-of-pocket costs are also rising, with four in 10 patients facing high costs - a situation that is exacerbated in faith-based and private facilities. 

"These out-of-pocket costs place significant financial pressure on patients and undermine access to care, particularly in facilities already struggling with payment irregularities,” read the report.

As system updates continue to impact service delivery, the report indicates that the demand for training remains high. 

About 43 per cent of providers seek training during system updates, with requests for in-person training increasing from 32 per cent to 37 per cent and requests for online training increasing to 19 per cent. 

Despite these efforts, challenges in navigating the SHA portal persist, indicating the need for ongoing and more effective training and support.

One of the most significant issues affecting SHA implementation is inadequate funding. 

While about 19.4 million Kenyans are registered under the scheme, only 3.3 million are actively contributing, leaving a significant funding gap. The situation is further complicated by an inherited debt of Sh30.9 billion from the NHIF, which further strains the SHA's already limited resources.

Kenya also faces a critical shortage of health workers. As of January 2025, an estimated 70,000 additional health workers were needed to meet demand, with projections suggesting that this shortfall could exceed 114,000 by 2030.

Operational inefficiencies have emerged as a major obstacle to SHA expansion. Surveys show that patients in public hospitals experience long waiting times, frequent service delays and technical system failures.

In contrast, private health facilities report limited SHA coverage, often limited to specific groups such as civil servants. As a result, many Kenyans are forced to pay out-of-pocket for services previously covered by the NHIF.

According to the latest Kenya National Bureau of Statistics Consumer Price Indices and Inflation Rates 2025 Report, the cost of healthcare in Kenya has risen by 3.3 per cent in the past year, making it more expensive than ever. With limited SHA coverage and delayed reimbursements to providers, the risk of reduced access to care is increasing, further complicating the country's Universal Health Coverage goals.

lowoko@ke.nationmedia.com