Why outpatient care in public hospitals is now out of reach

Access to outpatient care in major public hospitals has become more difficult due to the rigid implementation of the Social Health Authority (SHA) Act, which discourages walk-in patients in Level 4, 5 and 6 facilities. 

And patients are bearing the brunt, as the lower level facilities where they are supposed to receive outpatient care have inadequate drugs and equipment and are understaffed.

When the SHA Act was passed, it introduced the Primary Health Care Act, which restructured the provision of primary health care services, which are normally accessed at the community level (Level 1), dispensary (Level 2) or health centre (Level 3).

The Primary Health Care Act introduced the Primary Health Care Fund, which provides funding only for Level 2 and Level 3 hospitals. Under this law, patients must first seek outpatient care at these lower-level facilities and cannot go directly to Level 4, 5 or 6 hospitals without a referral. This has changed the way outpatient services are now provided.

With the introduction of the Social Health Insurance Fund (SHIF), patients seeking out-patient care in any hospital in the country are now redirected to Level 2 and 3 hospitals, which often lack the necessary infrastructure, records and resources to cope with the increased demand.

Another hurdle for patients is that lower-level hospitals are not staffed or equipped to handle the more complex outpatient cases traditionally seen at higher-level facilities. The current infrastructure lacks digital patient records, diagnostic tools and specialised equipment, further complicating treatment.

For many Kenyans, the shift to lower-level hospitals creates unnecessary hardship. Level 2 and 3 facilities, traditionally used for basic and preventative care, are now expected to handle a wide range of outpatient cases.

“Without the specialised infrastructure and patient records required for effective treatment, many of these hospitals are ill-equipped for the influx. As a result, patients are experiencing delays in receiving care, inadequate treatment, and a general sense of frustration,” said Dr Brian Lishenga, national chairman of the Rural Urban Private Hospitals Association.

"Now we are in a situation where many Kenyans who require outpatient care in higher levels have to either pay cash or make a local arrangement with the hospitals to be treated as an inpatient case if they do not have the money.”

He said the challenge with the lower levels is that they are not digitised, have no infrastructure and no human resources to handle the influx of patients.

“We did not prepare the hospitals for the transition and the majority of them are not even run as hospitals and now we are mandating that patients must be treated there with no proper patient referral system,” Dr Lishenga said.

He said patients with chronic illnesses who need outpatient services will bear the consequences because the lower levels have no history of their condition and they may miss out on critical treatment.

“If we had a proper patient registry, then their history would have been captured in the SHA portal, which then would allow them to be treated and seen at a Level 4 hospital because it is only at the higher levels that their conditions can be managed,” the doctor said.

“But because we do not have a patient register, they will be forced to start their treatment at the lower levels and then get a referral to the higher level before they are seen. That is if they want to use the SHA card. If not, they are required to pay cash”.

Unfortunately, if the higher levels attend to an outpatient case without a referral from the lower levels, they will not be reimbursed for the services offered.

To make matter worse, there is no proper referral system in place.

“When a patient needs a referral, all they will be given is a piece of paper which can as well be gotten from anywhere. What we are wondering is whether SHA will honour the pieces of paper in the name of referral letters that will be filed by the hospitals,” Dr Lishenga said.

“The outpatient care in the country is a mess and not working. The referral system is not there, this is why a lot of patients feel that they are on their own.”

Ms Winnie*, a diabetic, recently went to a Level 4 hospital in Siaya County where for years she has been getting her treatment. She was surprised that the hospital demanded a referral note from a Level two or three hospital before treating her.

“The hospital does not have my mother’s medical history. She has been treated here for the longest time. How do we again risk her life starting to explain her condition over and over again?” says her daughter.

Dr Davji Atellah, Secretary-General of the Kenya Medical Practitioners and Dentists Union, emphasised the government's responsibility to ensure the quality of healthcare in the country.

“The current approach has left significant gaps that impact patient care on a large scale. A thorough assessment and necessary adjustments are essential to ensure the system doesn’t compromise healthcare quality,” he said. “We won’t stand by and allow patients to miss out on care or doctors to be overwhelmed by issues that could have been addressed before rushing the implementation.”

Dr Atellah added, “The government should have allowed time to build capacity in lower-level hospitals before fully transferring outpatient care responsibilities. They would have improved infrastructure, staffing, and digital record-keeping. And now that they refused to listen, patients will continue to bear the consequences as they milk millions from Kenyans.”