Hospitals submit over 1.6bn worth of claims on SHA portal
The Social Health Authority building in Nairobi.
What you need to know:
- Hospitals and clinics are cautious about engaging with SHIF in some areas due to concerns over reimbursement rates or delays.
- Over the last month, the transition from the National Health Insurance Fund (NHIF) to SHA has shown a notable improvement.
More than 2,598 health facilities had submitted claims totaling more than Sh1.6 billion by the end of last month, according to information on the Social Health Authority (SHA) portal.
The breakdown of these claims reveals that inpatient services represented the largest segment, substantially exceeding Sh1.3 billion. Following closely were outpatient services, which accounted for approximately Sh242 million. Additionally, capitation claims, though significantly lower, amounted to Sh1.3 million, illustrating the diverse range of services for which healthcare providers are seeking reimbursement.
Maternity, neonatal and child services recorded 9,200 visits totaling around Sh152.3 million. Over the past month, more than Sh213 million in claims for dialysis services were lodged at various hospitals nationwide, with over 18,000 recorded visits on the portal.
Hematology-oncology treatments saw claim values reaching Sh161 million from over 5,000 visits, while mental wellness services accounted for Sh100 million. Other claims included surgical services: orthopaedics at Sh75 million, general surgery at Sh59 million, gynaecological surgery at Sh31 million, and neurosurgery at Sh22 million.
The portal also reveals that private hospitals lodged the highest claim values at Sh773 million, public hospitals at Sh674 million, faith-based hospitals at Sh204 million, and community hospitals at Sh17,000.
More than 4,540 healthcare providers are enrolled in the portal, with approximately 3,963 having successfully logged in.
The last month's transition presented several challenges, with patients requiring critical or ongoing care like dialysis experiencing temporary service interruptions or delays in accessing health services as hospitals and clinics adjust to new SHIF protocols and payment systems.
Overall, while the Social Health Insurance Fund (SHIF) transition aimed at broadening health coverage and equity, the immediate effects on patients underscore the need for smoother procedural transitions and support for those most affected.
Health facilities have been reporting delays in claims processing, affecting patients' ability to quickly receive necessary treatments, particularly for costly services such as dialysis, oncology, and surgical care. This has created out-of-pocket expenses for some patients while waiting for SHIF approvals or reimbursements.
Hospitals and clinics are cautious about engaging with SHIF in some areas due to concerns over reimbursement rates or delays. This affects patients' access to facilities as some healthcare providers limit services to SHIF enrollees until processes are more consistent.
Over the last month, the transition from the National Health Insurance Fund (NHIF) to SHA has shown a notable improvement of 12 per cent, reflecting efforts to address issues raised by healthcare providers, although significant challenges remain.
A fourth survey conducted by the Rural and Urban Private Hospitals Association of Kenya (RUPHA) on November 1 showed an increase in system efficiency from 34 per cent on October 12 to 46 per cent in the current survey.
The scorecard was designed to comprehensively survey providers' experiences during the transition from the defunct NHIF to SHA.
However, providers and patients recognise that the journey towards a seamless healthcare system is incomplete. The report shows that while progress has been made, the system still operates below the desired average.
The new system presents new hurdles for patients, with many experiencing delays in accessing timely care. Long waiting times at clinics and claim backlogs impede access to essential services.
Providers also face challenges in dealing with complex new administrative processes that divert time and resources from patient care.
The report shows that persistent technical issues, processing delays and limited provider options are still hampering SHA's goal of universal coverage 30 days after the launch.
In terms of the functionality of the SHA portal, 60 per cent of respondents reported problems with system downtime, sluggish performance and frequent updates, while a further 20 per cent noted OTP (One-Time Passwords) delays.
"This result reflects ongoing issues with portal functionality and shows limited improvement from previous findings," said Dr Brian Lishenga, chairperson of RUPHA.
The report notes some progress on e-contracting, but it remains a barrier for many. Half of providers have not signed the e-contract, with 57 per cent citing data discrepancies and 29 per cent a lack of awareness.
The report also shows that reaching the SHA contact centre still remains a challenge, with 73 per cent of providers experiencing difficulties. Of these, 37 per cent lacked SHA contact details and 26 per cent reported unanswered calls.
Only 43 per cent of providers said they had received payments from SHA within the last seven days. Of these, 68 per cent reported that the payments covered less than 10 per cent of the outstanding amount owed by the SHA.
"This metric has improved slightly due to recent payments, but low payment amounts remain a concern. The overall score reflects modest improvements in claims submission and training attendance but underscores significant ongoing problems with billing, system functionality and patient verification," said Dr Lishenga.
Despite these obstacles, there are glimmers of hope in SHA's progress. As SHA addresses these critical issues, healthcare advocates remain cautiously optimistic. Providers, patients and the SHA share the goal of building a better health system, one update, fix and improvement at a time.
About 80 per cent of providers have credentials for the SHA portal, with the remaining 20 per cent lacking access. Of those with access, 13 per cent face access issues due to limited ICT infrastructure and frequent portal downtime. This is an improvement on the previous month when only 36 per cent were able to log into the system.
Sixty-one per cent of accredited providers reported successful claims submission, a significant improvement from the previous month when only dialysis claims were easily processed.
Meanwhile, as of November 1, the Ministry of Health reported that about 13 million Kenyans, including former NHIF members, had enrolled on the SHA platform.
