Beginning October 1, Kenyans will part with 2.75 per cent of their income as the Social Health Authority (SHA) and its supporting institutions roll out universal health coverage, but the design of the programme is facing resistance.
The State creation will replace the National Health Insurance Fund (NHIF) as government promises to ease the burden of medical bills by providing healthcare to all Kenyans through the steep increase in individual monthly contributions.
SHA will be the administrator of three funds—Primary Healthcare Fund, Social Health Insurance Fund (SHIF), and the Emergency, Chronic and Critical Illness Fund.
But as the government raids payslips looking for Sh133 billion each year to fund the ambitious universal healthcare plan, it emerges that Kenyans will fork out much more, for much less.
For instance, after giving birth, mothers will be limited to only two free post-natal visits. Under the NHIF, mothers and their children had access to post-natal and other related services at no cost for up to six months after delivery.
The government says that in the event of an accident, you will be evacuated from the point of the incident to the nearest facility with an accident and emergency centre. Patients requiring emergency and further clinical care from the facility will be transferred to more advanced facilities, regardless of registration or premium payment status.
In the same breath, the government admits that road evacuation services have been suspended for the past two years due to the limited resource pool and unsustainability of the cover.
SHA will also inherit the same systems and environment that NHIF was operating in, such as ill-equipped hospitals with demoralised doctors and nurses, which begs the question, what will be different?
Questions are also being raised about the extent of public participation for the project, exclusion of major interest groups and possible double steep deductions for workers already paying for other schemes, which will further deplete incomes amid the high cost of living.
“Without public participatio,n there’s no mandate. SHIF is unconstitutional and has no basis in law. We urge Kenyans not to succumb to pressure from the Kenya Kwanza government, they should not pay. We will be going to court to defend the rights of all those who refuse to pay,” Law Society of Kenya Vice-President Mwaura Kabata said.
“The feeling among teachers on the SHIF 2.75 per cent deduction is not positive. We are already being deducted in another comprehensive medical cover and there’s no one happy about being deducted twice. It is the same way the issue of housing levy is of a negative significance to us,” said Kenya National Union of Teachers Secretary General Collins Oyuu.
Federation of Kenyan Employers Chief Executive Officer Jacqueline Mugo said: “Employers, who play a critical role in supporting this transition and subsequent management of the scheme, have unfortunately been excluded from the SHA board. This is meant to be a tripartite board where the government, workers and employers are all represented. This exclusion raises concerns.”
Mr William Kiamia, a general manager at the Association of Kenyan Insurers (AKI) said that with SHIF, they “expect a reduction in disposable income and reduced demand for services such as private insurance”.
“Average premium per household is Sh100,000, anyone earning Sh300,000 will contribute Sh99,000 per year. Services offered in the public sector should therefore match the private sector. Any person who has a private insurance should be given an opt out option and contribute an agreed minimum like Sh1,000 to cater for those who cannot afford. This will ensure we do not discourage private arrangements,” Mr Kiamia suggested.
Questions have also been raised about the capacity to extend medical cover to all with existing infrastructure challenges, including hospitals without facilities and shortage of health workers.
As per the Kenya National Bureau of Statistics, the population projection for Kenya as of mid-2024 stood at 52,428,290. Their data also shows that currently, Kenya has a doctor-to-patient ratio of 1 to 5,263. The World Health Organization recommends a ratio of 1 to 1,000.
SHA has a very ambitious target of capping administrative expenditure at 5 per cent of annual expenditure, yet NHIF barely managed 15 per cent.
Social Health Insurance regulations have embraced contracting private claims settling agents and medical insurance providers to process claims. The effect on administrative costs remains to be seen.
Infiltration of such systems and collusion with insiders saw such processes turned into a conduit for grand corruption at NHIF.
However, Health Cabinet Secretary Deborah Barasa has said the state will invest in making the programme work.
“The government has allocated Sh6.1 billion for SHA, which is just a fraction of the Sh168 billion needed for full implementation. In addition, the government is partnering with Safaricom to digitalise healthcare services, which will enhance efficiency and data management,” she said.
In an interview with the Nation , Dr Samson Kuhora, the Head of Design and Benefits Management at NHIF said NHIF was entirely on contributions but SHIF splits costs between contributions and tax-based financing.
“So overall, the resource pool is bigger and can be able to absorb more shocks. As to whether Treasury has allocated what is needed to supplement the member contributions, that’s the challenge,” Dr Kuhora said. He admitted that public hospitals are still having challenges because of low re-injection of the funds that NHIF usually reimburses to the providers.
“These monies go to the county central pool and are used to buy other services instead of developing a revolving fund for the hospital to restock and generate more revenue. Frequent industrial action and poor customer interphase make it worse,” he said.
Dr Kuhora further observed that there are significant gaps in human resources for health that need to be addressed.
According to the Kenya Medical Association President Simon Kigondu, digitisation, a vital component of SHA under the Digital Health Act, is a hindrance to traditional doctor-patient interaction.
“It shifts patient care away from touching the patient to touching the computer because at the end of a doctor-patient interaction something must be keyed in and slowly by slowly health workers are treating the computer more than the patient,” he said.
