Sylvia picks the call outside a hospital in Machakos County. On the other end, someone waits for an update about a crisis that has become all too familiar across Kenya’s healthcare landscape.
Beside her, her mother watches with the quiet concern of someone who understands that in this moment, hope hinges on money they don’t have.
Sylvia’s cousin delivered via caesarean section the night before following a medical emergency at a smaller facility in Nairobi County. What should have brought relief has become another chapter in the healthcare nightmare plaguing the country.
“We got here yesterday using an ambulance. We had to pay for it out of pocket. We were hoping that since it was an emergency case, they would refer my cousin to the Kenyatta National Hospital. We don’t know what happened, but this facility was the only one available at the time,” Sylvia says.
The obstacle blocking their path to care is the Social Health Authority (SHA) system, designed to provide universal healthcare coverage but now leaving patients and hospitals stranded in a web of bureaucratic failures and unpaid bills.
“We were asked to make a down payment of Sh13,200 because SHA was not, and still is not working,” she explains. The family doesn’t have that money and has to make several calls to friends and relatives to raise the amount before her cousin can receive treatment.
Now, with the newborn in critical condition, the hospital is making fresh demands.
“My cousin was supposed to be discharged tomorrow. She can’t go home without her child. We have been asked to pay another Sh10,700. The hospital insists SHA is not working,” Sylvia says.
This unfolding drama stems from Monday’s directive by the Rural and Urban Private Hospitals Association (Rupha) to its members to accept patients only on a cash basis due to mounting government debt.
At a hospital in Kajiado, frustration fills the administrator’s office. A patient sits demanding answers about why she faces co-charges despite being a fully paid SHA member.
“I have pain all over my body. My legs hurt. I was in an accident, and I have been having physiotherapy. When I came here, I was first told that there was a system delay with SHA and that I had to wait. When it finally worked, I was asked to go to the lab and pay out of pocket,” she says. At the lab, she faces a Sh1,600 bill.
“I don’t have that money. I have seen on the internet that the president said we should go to the hospital and we will be treated for free. This is not free,” she adds.
The woman has already paid Sh7,800 for her parents in the village for the annual SHA amount. As the Nation interviews her, she receives a call informing her that her parents are unwell and need money for treatment.
“They are over 90 years old. I am now confused. What will I do? Who will I run to? I am now very stranded, and I don’t know where to get the money for the lab. I’m not sure if I’ll even get money for treatment and drugs,” she says.
At the same facility, another man brought his wife for delivery on Monday evening. As a fully paid-up SHA member, he expected the government insurer to cover his bills.
“I was told SHA is not working. In the news, we are told SHA is working very well. Here at the hospital, we have been asked to pay Sh7,800 for my wife to deliver. We are deducted every month, but when we come to the hospital, we still have to pay,” he says.
An administrator of a private facility, speaking anonymously for fear of reprisal by the Health ministry and SHA, reveals the extent of the crisis facing healthcare providers.
“Since SHA came on board, we have been suffering. The truth is, NHIF [National Health Insurance Fund] had our money. SHA had a legal obligation to pay that debt. To date, we have no clue about what SHA is doing about it,” he says.
Under the SHA system, hospitals cannot track when they might receive payment for their claims. During the NHIF era, providers could monitor the system, and payments were made twice a month.
Hospitals also face numerous rejected claims, with SHA unwilling to address their concerns. There is no provision for uploading evidence to prove that a hospital actually treated a patient when SHA raises queries.
“You can clearly see that the claim was at the payment stage, and then someone just says ‘declined,’” he adds.
“If they[SHA] don’t rectify this, most private hospitals will have to close. This means all these people will lose jobs, and access to healthcare will be a pipe dream. How are they going to achieve universal health care? If this continues, we are going to be bankrupt,” he says.
In Kisumu County, some Rupha facilities continue offering services to SHA beneficiaries despite the association’s directive. A Nation spot check at facilities like Nightingale Medical Centre, Synergy Medical Centre and Salama Cancer Centre shows smooth service delivery.
Nancy Akinyi, a caregiver to a patient seeking services, says the hospital only asked if her ailing father is registered under SHA before admitting him.
However, a staff member at Kisumu Heart Centre says the facility is following Rupha’s directive and has been taking cash payments for outpatient services since September 23.
“For inpatient services, SHA only settles patients’ bed fees; the rest of the payment is done in cash,” the staff member says. “The hospital is struggling financially. We have not received SHA disbursements, but hospital activities must continue. We need the funds to keep us going.”
In Mombasa County, facilities the Nation visited say they are on the brink of shutting down key services. A director of one hospital in Mikindani says the biggest concern is claim rejection without explanation.
“Almost a third of the claims we made, some dating back to February and March, were rejected in August without any concrete reason,” the director says. “We are doing cancer screenings and very expensive tests that require external providers. We even signed MoUs, but now our credit limits with suppliers are exhausted. At this point, we can only offer emergency services.”
At a facility in Chaani, a director admits they are struggling to keep the hospital running.
“We don’t want to be quoted because we fear Health Cabinet Secretary Aden Duale might come after us,” he says.
In Bamburi, a representative of a Rupha-affiliated hospital says: “When SHA replaced NHIF, we were told that outstanding NHIF debts would be settled. The president said debts below Sh10 million would be verified and paid so that we could continue serving. We had borrowed heavily from suppliers, hoping that once NHIF arrears were cleared, we would pay back. But up to now, that has not been done.”
Services at Kerio View Hospital in Kabarnet, Baringo Central, continue normally, with dozens of patients queuing for treatment. This is despite being among health facilities directed by Rupha to serve patients only on a cash basis
“That is the directive, but we have freedom on how we will execute it,” the hospital’s administrator, Jackson Ronoh, says.
In Nakuru County, most Rupha facilities stand at a crossroads on whether to continue serving patients under SHA or demand cash payments. At Graceheal Health Care, in Njoro, CEO Abigael Nyanchera says SHA owes them Sh6.7 million.
“We do not have drugs or suppliers, and our staff are on our necks. Even electricity bills have gone unpaid, leading to disconnection,” she says.
In Nyandarua County, Milka Njonjo, proprietor of Manguo Hospital at Mairo-inya market, has halted the SHA services. She adds that health service providers cannot follow up on payments from individual patients when SHA fails to pay.
Reporting by Hellen Shikanda, Angeline Ochieng, Elizabeth Ojina, Fatuma Bugu, Waikwa Maina, Leleti Jassor, Florah Koech and Lilys Njeru
