How can I register without an ID? Teen mothers left behind in healthcare reforms
Caught between childhood and motherhood: Many teen mothers remain unaware of their entitlements or how to navigate the complex health insurance system.
What you need to know:
- Teen mothers struggle to navigate the complex health insurance system due to lack of IDs.
- Despite being eligible for government support through the SHIF, many face significant barriers to accessing maternal healthcare services.
- The SHA has implemented a unique identification number system for them, but challenges persist due to information gaps, stigma, and late presentation for care.
A few days ago, 17-year-old Nelder* walked into a Level 4 Sub-County Hospital in Mathare, Nairobi City County, carrying her eight-month-old son.
She was there for the routine mother and child check-up. But she lacked one critical thing: health insurance.
Before the visit, a social worker at a local non-governmental organisation had informed her that she was eligible for enrolment under the Social Health Insurance Fund (SHIF). But Nelder had no idea where to go or what steps were required to be enlisted.
“I told the nurse attending to me to register me,” she recalls.
“She told me to return with my child’s birth notification to facilitate the registration.”
Similarly, Esalia*, another 17-year-old from Mathare, had gone to a Level 3 facility- health centre- hoping to be registered for SHIF, managed by the Social Health Authority (SHA).
“They told me to go to Huduma Centre to register. But how can I do that when I don’t have an identity card?” she asks.
While Nelder and Esalia may eventually get registered, what worries them most is how they will afford the premium required to access maternal health services.
Nelder says she might be forced to do casual laundry work to raise the money. Esalia is uncertain who will pay for her, as her mother, a green grocer, is not enrolled either.
Understanding how SHA or SHIF operates can be confusing. Kenya’s universal health coverage is delivered under two separate funds-the Primary Healthcare Fund (PHCF) and SHIF.
Based on the Social Health Insurance Act (2023), SHA uses PHCF to purchase primary healthcare services from registered facilities, which include Level 2 (dispensaries and clinics), Level 3 (health centres, maternity homes, and nursing homes), and selected Level 4 (sub-county and medium-sized private hospitals) designated as primary healthcare referral centres.
This fund is financed through monies appropriated by the National Assembly, grants, donations, and fees or levies collected. In principle, services offered at these facilities are paid for by the government.
However, according to the Act, expenditure from the fund is limited to the annual budget estimates prepared by SHA at the beginning of the financial year. This means that when the allocated budget is depleted, users may be forced to pay for services out-of-pocket.
SHIF, on the other hand, applies to higher-level facilities, from Level 4 to Level 6. Level 5 includes county referral hospitals and large private hospitals, while Level 6 refers to national teaching and referral hospitals.
SHIF is financed through contributions from registered individuals, allocations from the National Assembly for indigent and vulnerable groups, as well as donations and other innovative funding mechanisms.
New-born care
Under the most recent SHA guidelines, antenatal and post-natal care services fall under outpatient services at primary level facilities. These include dispensaries, health centres, maternity and nursing homes, and some sub-county and private hospitals.
Additional maternity, neonatal, and child health services are available at Levels 2 to 6, with tariffs as follows: Sh10,000 for normal delivery and essential new born care, Sh30,000 for caesarean section and essential new-born care, and Sh6,000 for anti-D serum.
When asked whether they understood how the health system and its facilities were organised, the teenagers said they had no clue.
For them, the only option was to go to the nearest hospital, without knowing whether they were eligible for government support. Their oblivion is not unique to these two teenagers; it reflects the reality of thousands of others across Kenya.
More importantly, for those living in the most remote villages, where such facilities are a rare miracle, and access to these services remains just a story told in the media.
In the middle of this confusion, how can they be helped?
According to the acting chief executive officer of the SHA, Robert Ingasira, teenage mothers can no longer be registered under their guardians, as was previously the case.
Instead, hospitals now assign teenage mothers a unique identification number, allowing them to be registered independently and access services directly.
“They can’t register into the system on their own. They must go through a hospital where verification is done,” Robert explained.
“But the good news is that hospitals now know what to expect when handling teenage mothers. We are expanding their scope.”
Registration for SHIF automatically qualifies one for coverage under PHCF, and registration is possible at Level 4 and Level 5 hospitals.
As for the issue of paying premiums, he explained that teen mothers fall under a category eligible for government support.
If they are unable to pay and are classified as vulnerable through a means-testing tool, their premium may be paid by the national or county government, an elected leader, or even a well-wisher, he said.
Under the law regulating the funds, the contribution model depends on a household’s source of income. Salaried workers will have 2.75 per cent of their gross salary deducted monthly, with no one paying less than Sh300 a month.
Households not relying on salaried income including casual labourers, small-scale traders, and the self-employed, will contribute an annual sum equivalent to 2.75 per cent of their income, as determined by a government means-testing instrument.
This tool assesses income using various indicators, including housing conditions, household size, phone usage, mobile money and banking transactions, credit records, retail purchases, and even utility bills.
In this case, every household must pay at least Sh300 per month, and the full annual amount must be paid no later than 14 days before the end of the coverage year to avoid disruption.
“As long as you are registered for primary health, you can access services at Level 2 and 3 facilities,” Robert said.
“However, if a teenager needs to go to a referral facility (Level 4 or above), she must be a paid-up member or fall under a sponsored group.”
Despite these strides, one challenge remains: late presentation. Many teenage mothers only show up at the hospital when labour begins, he said.
“Very many don’t show up in good time to start enjoying prenatal care. They arrive during delivery,” Robert noted.
“There’s still a level of stigmatisation in communities. When a young girl becomes pregnant, people want to hide it. But we must allow the young mother to be known and supported. We need to work with communities so that the moment a girl is known to be pregnant, she is registered and starts attending clinics.”
Teen mothers have already registered for the unique identification number.
“I checked the system recently at selected Level 4 and 5 hospitals, and the number was approaching 100,” he said.
Names have been changed to protect their privacy.