How knowledge gaps, misinformation limits access to SHA services

Standing, Kenyan Obudsman Chairman Charles Dulo and CEO Mercy Wambua were talking to patients about SHA at Homa Bay County Referral Hospital on March 11, 2025. (James Omoro, Standard) It has been a long treatment journey for Mercy Nasieku, a 23-year-old from Kajiado, since she was diagnosed with lupus-an autoimmune disease-in 2016. Since her diagnosis, Mercy has made frequent hospital visits due to complications related to the condition. Recently, she developed kidney stones that required surgery at a private facility, costing Sh350,000. Fortunately, the bill was fully covered by the Social Health Authority (SHA). "I'm happy my treatment was covered by SHA," Mercy told The Standard. "I was shocked that the approval was granted instantly." However, despite this financial relief, Mercy still spends approximately Sh35,000 each month on medication not included in SHA's coverage. "I take medicine every day, but I have to buy them myself because they are not covered by SHA," she says. She warns that skipping her medication poses serious health risks. "If I don't take my drugs, I risk developing complications, including heart and lung problems," she explains. John*, a Nairobi-based patient managing an autoimmune condition, must raise between Sh200,000 and Sh300,000 for a single injection critical to his treatment. Previously, the National Health Insurance Fund (NHIF) covered at least Sh80,000 of this cost. Now, with the transition to SHA, he is unsure of the support available-but is fortunate to have private insurance. The injection he requires is administered once every 12 to 18 months. Unequal burdens Dr Fred Otieno, a rheumatologist, emphasises that patients with autoimmune disorders such as lupus cannot afford to skip treatment. "Lupus is an autoimmune disease where the immune system turns against the body's own tissues," he explains. "It can affect multiple organs-including the heart, kidneys, and brain. Without proper medication, patients face serious, sometimes life-threatening complications." Dr Otieno adds that while lupus is manageable, the costs are significant, especially without consistent insurance support. "Even a missed dose can lead to flares that trigger irreversible damage." Mercy and John's experiences are not isolated-across the country, confusion and inconsistencies continue to plague SHA's rollout. While some patients benefit fully, others are left paying hefty bills out of pocket. Herbert, a Nairobi resident, recently welcomed a child at a private hospital in Buruburu. His wife's delivery was partially covered by SHA after he registered her as a dependent. "Out of the total bill, I was surprised when I was told that SHA had paid part of it. It was such a relief," says Herbert. But a colleague whose wife delivered at the same facility paid the entire Sh150,000 out of pocket. "The only difference was that he didn't know how to register his wife under SHA," Herbert adds. "We used the same hospital, same services, but had very different experiences." These disparities in access point to a broader issue-a lack of public awareness and inconsistent implementation of SHA guidelines across healthcare facilities. Health experts warn that unless the government swiftly streamlines SHA services and enhances public communication, thousands will continue to shoulder out-of-pocket expenses, despite the scheme being designed to ease the financial burden of care. This is especially concerning given that SHA offers significantly enhanced benefits compared to the now-defunct NHIF. For example, SHA's pharmacy package for chronic illnesses includes essential medications for diabetes (Types 1 and 2), hypertension, asthma, chronic renal disease for patients on dialysis, post-transplant immunosuppressants, chronic obstructive pulmonary disease (COPD), and sickle cell disease. The package also extends to oncology medications, anti-D immunoglobulin, anti-snake venom, anti-rabies vaccines, long-acting mental health drugs, and epilepsy treatments-all of which were previously not covered by NHIF. Critical care services are also comprehensively included, such as admissions to the Intensive Care Unit (ICU), High Dependency Unit (HDU), Neonatal Intensive Care Unit (NICU), Paediatric ICU (PICU), and burns units. Access challenge However, access to these services is restricted to SHA-accredited facilities only. Additionally, SHA covers longitudinal care for chronic illnesses beyond the limits of the Social Health Insurance Fund (SHIF), including management of cardiovascular diseases, COPD, dialysis, pre-transplant evaluations, and post-transplant therapies. Kidney patients on their part applaud SHA for raising dialysis tariffs from the previous Sh9,500 per session under NHIF to Sh10,650 easing the financial burden on those undergoing treatment. However, access to dialysis services remains limited. In Kisumu, for instance, patients mostly rely on Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) or expensive private facilities. JOOTRH serves Kisumu and neighboring counties, often leading to delays in care."SHA has really improved dialysis coverage. My only concern is the limited number of facilities. Given the high demand, expanding access is crucial. I wouldn't blame SHA when it comes to renal coverage," says Kennedy Anjejo, a kidney patient in Kisumu. Despite the improved dialysis funding, many patients still pay out-of-pocket for epoetin injections, used to boost blood levels. These injections, typically administered at least three times a month, cost between Sh3,000 and Sh10,000 per dose. According to SHA's standard renal care package, blood boosters are supposed to be included alongside dialysis. However, implementation is inconsistent, especially outside Nairobi. SHA's package also caters for kidney transplants, and immunosuppressant drugs are now covered-unlike under NHIF. Oncology package for patients in need of of cancer diagnosis and treatment services has been enhanced. Each patient, according to SHA now has access up to Sh550,000 per year. Of the allocation, Sh400,000 is available through SHA, and additional Sh150,000 accessed through Emergency, Chronic and Critical Illness Fund (ECCIF). Though the package for cancer has been enhanced Fridah Kambayi, from Soi in Kakamega County, has been unable to undergo regular check-ups due to financial constraints. The breast cancer survivor, currently on remission, relies on hormonal therapy following a mastectomy-medication she must take for 10 years. She needs Sh7,500 every month to purchase the drugs. "I was supposed to undergo a mammogram, but I cannot raise the Sh2,500 needed. I now fear a recurrence of cancer because I cannot afford the check-ups and medication," she says. Kambayi was registered under Universal Health Coverage (UHC) program that was provided under NHIF, under the indigents program. With repealing of NHIF, she is however not able to access care. Acting SHA CEO Robert Ingasira admits that some patients are not accessing care, while others are. He cites delayed remittance of deductions by employers as a key contributor to the lack of access. Under SHA regulations, employers must remit payments to the authority by the 9th of every month-yet many fail to comply. The SHA boss also blames misinformation abound the new health scheme and lack of requisite documents for registration like Identification Card, birth certificates, marriage certificates and alien cards. Ingasira asserts that in some cases, those seeking services are not registered, or have not added dependents on their cover. According to the SHA boss, there seem to be lack of awareness about the scheme, limiting access to care. "Awareness creation is continuos and SHA is working closely with respective ministry departments and agencies to identify, sensitise, register and pay for special groups like indigents, teenage mothers, those in lawful custody, children homes, street families and refugees," he says. John Juma, a health economist, says the burden of healthcare is growing heavier by the day, pushing low-income households deeper into poverty due to out-of-pocket spending on long-term treatments, diagnostic tests, and medicines. "Kenya still has a high out-of-pocket expenditure on health, accounting for over 20 per cent of national health spending," says Juma. While the government has a commitment to UHC and passed reforms like the SHIF, challenges persist in making chronic disease care affordable and accessible, he observes. To address the financial struggles Kenyans are facing while accessing care for chronic diseases, he observes that national and county governments should make chronic disease care free and routine at Primary Level (1-4), and integrate diseases such as hypertension, diabetes, and asthma care fully into Level 2 and 4 facilities. Juma's sentiments are echoed by Prof XN Iraki, an economist at the University of Nairobi who notes that special insurance cover should be provided for chronic diseases. "Government subsidy for such chronic diseases would be handy," says Iraki. Juma adds that there is need to provide free screening and routine medications as part of primary care, not only at referral hospitals. "We need shift investment from hospital-based care to primary care where treatment is cheaper and early detection is possible," says the health economist. With the actualisation of new health scheme, he adds that there is need to ensure SHIF delivers comprehensive non-communicable diseases coverage. "SHIF must explicitly cover essential NCD services, including diagnostic tests, drugs, and specialist care without hidden costs or out-of-pocket charges," he says. On financing, Juma asserts that public Financing and Bulk Procurement of NCD Medicines is key. This can be attained through pooling of resources to centrally purchase NCD medications like it is done in Rwanda and Thailand, lowering prices and ensuring consistent availability in all counties and facilities. Similarity, he applauds the government of rolling out Community Health promoters who oversees preventive and promotive health. This, he says should come handy with early detection programs that entails scaling up nationwide screening campaigns in workplaces, schools, and community gatherings. "To reduce financial burden as a country, we need to invest in community health workers to follow up with patients and ensure they stick to treatment plans," says Juma. Additionally, he says there is need to truck results and hold SHIF accountable by monitor how many Kenyans with chronic diseases are covered and protected from financial catastrophe. The sentiments on research are shared by Iraki, "In the long run let's prevent such diseases with more research on causes".

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