Private hospitals award 'D' grade to Kenya's new health plan
The transition from NHIF to the new health insurance fund has placed a financial strain on healthcare facilities.
What you need to know:
- The report highlights substantial gains in the e-contracting process and the submission of claims.
- E-contracting completion has increased from 50 percent to 71.4 percent, showing improved adaptation by healthcare providers.
The government has received a disappointing Grade D (47 percent) in the latest scorecard evaluating the transition to the Social Health Authority (SHA) as evaluated by private healthcare providers.
The Rural and Urban Private Hospitals Association of Kenya (RUPHA) conducted the fifth scorecard survey between November 9 and 12, involving 462 member healthcare facilities nationwide.
The assessment comes amidst mounting frustrations following the launch of the SHA on October 1, which was intended to replace the National Hospital Insurance Fund (NHIF) and advance Kenya's goal of achieving Universal Health Coverage (UHC).
SHA is designed to provide accessible, affordable and quality healthcare services to all Kenyans.
However, the reality has been starkly different for millions of low-income Kenyans who rely on public facilities and have yet to experience the promised benefits.
Although the government has allocated Sh6.1 billion to facilitate a smooth transition, health experts estimate that a full implementation would require Sh168 billion to ensure the system’s effectiveness.
The scorecard indicates that while there are signs of gradual improvement, many obstacles remain.
It points to progress in key areas such as claim submission, e-contracting and portal access.
Yet, significant challenges in patient verification, portal functionality and financial strain on healthcare facilities are undermining SHA’s goal of delivering high-quality healthcare to all Kenyans without financial barriers.
The report highlights substantial gains in the e-contracting process and the submission of claims.
E-contracting completion has increased from 50 percent to 71.4 percent, showing improved adaptation by healthcare providers.
In addition, claim submission success has risen from 61 percent to 80 percent, particularly for inpatient and maternity claims which achieved 44 percent and 31 percent success rates, respectively.
“Improved submission success from 61 percent to 80 percent shows increased provider adaptation to claims processes. Outpatient claims challenges and tracking issues remain, but the upward trend is promising,” the report noted.
In terms of SHA Portal Credentials and System Access, 94.3 percent of healthcare providers reported functional credentials, a marked improvement.
The proportion of providers without credentials dropped from 20 percent to six percent, while access issues among credentialed providers increased from 13 percent to 17 percent.
“Credential coverage has improved significantly, with only six percent of providers lacking access. However, a slight increase in access issues among credentialed providers highlights ongoing technical support needs,” stated the report, signed by Dr Brian Lishenga, the RUPHA Chairman.
Despite some gains, persistent challenges continue to hamper the system’s full potential. Patient verification remains a major obstacle, with 100 percent of providers reporting difficulties. This issue is compounded by ongoing problems with the SHA portal's functionality, where 89 percent of providers cited problems such as system downtimes (44 percent) and delays (28 percent).
“Training on SHA portal navigation is crucial, and further training is needed while reaching the SHA contact centre remains a major challenge,” said the report.
While there has been progress in preauthorisation approval times—now stable at 65 percent—the reliability of the system still requires enhancement.
The transition to SHA has also placed a financial strain on healthcare facilities.
According to the scorecard, 59 percent of providers received payments in October but the funds often only covered essential payroll, leaving operational costs unmet. These financial pressures are affecting the ability of facilities to function optimally, impacting patient care.
Contracting-related matters have seen mixed results, with 71.4 percent of facilities having successfully signed e-contracts. However, 40 percent of providers reported navigation issues, such as login difficulties and inadequate support.
Outpatient services in particular are facing significant hurdles. The scorecard noted that outpatient claims had the lowest submission success rate, at just nine percent, indicating that this area requires more focused intervention to streamline the claims process.
“Outpatient claims challenges and tracking issues remain a concern, but the upward trend in other areas of the claims process is a promising sign of progress,” the report stated.
