Insurance gap leaves cancer patients paying out of pocket for endoscopy

Dr Russ White, a cardiothoracic surgeon and director of the AGC Tenwek Cardiothoracic Centre in Bomet County. [File, Standard]

For Oscar Gwala, the journey from Central Seme in Kisumu County to Bomet County was driven by urgency, not choice.

His cousin, Jane Anyango Ouma, is battling cancer, and each referral along the way, including from Jaramogi Odinga Teaching and Referral Hospital, brought renewed hope for answers—and the fear that time was slipping away.

When we met them at the AGC Tenwek Cardiothoracic Centre, that hope collided with a harsh reality.

Doctors had recommended an urgent endoscopy, a critical diagnostic procedure, but the Sh51,000 required to carry it out was beyond the family’s reach.

Despite being registered under the Social Health Authority (SHA), they were informed that the procedure was not covered, leaving Ouma in pain as her family desperately searched for funds.

“We were told to either pay cash or use insurance, but endoscopy is not covered,” Gwala said. “I went back home and sold a cow, but it only fetched Sh40,000. I still had a balance of Sh11,000, which I had to clear through fundraising so that the procedure could proceed.”

The experience left Gwala questioning the value of an insurance system that excludes essential diagnostic services, even for life-threatening illnesses. “We pay for the premium option under SHA, yet we are suffering,” he said. “The government should ensure that SHA covers all medical procedures, especially endoscopy. Patients coming to level six hospitals are left stranded because some procedures are excluded.”

Gwala’s ordeal mirrors the struggles of many cancer patients across the country, particularly in the South Rift region, where doctors and patients are now openly challenging gaps in the national health insurance system.

Cardiothoracic surgeons and cancer patients have petitioned the government to urgently include endoscopy among the procedures covered by SHA, warning that its exclusion delays diagnosis, worsens outcomes, and pushes families into crippling debt.

Dr Russ White, a cardiothoracic surgeon and director of the AGC Tenwek Cardiothoracic Centre in Bomet County, described the omission as a major setback in Kenya’s fight against cancer.

“Esophageal cancer is the most common cancer among men and the leading cancer among women in Kenya,” Dr White said. “The only way to diagnose it is through endoscopy, where a scope is passed down the throat to examine the oesophagus. Unfortunately, the Social Health Authority does not pay for this procedure.”

AGC Tenwek Cardiothoracic Centre serves as a national and regional referral hospital for patients with oesophageal cancer, drawing cases from across Kenya and neighbouring countries. According to Dr White, while SHA pays for chemotherapy and surgery, it fails to cover the most crucial first step—diagnosis.

“SHA pays for chemotherapy and surgery, but it does not pay to diagnose the cancer. As a result, many patients delay coming for endoscopy until the disease is too advanced and cure is no longer an option,” he said.

He warned that this gap is costing lives, insisting that early detection could significantly improve survival rates. “Esophageal cancer patients do not have to die if we can diagnose them early,” Dr White said.

Beyond insurance coverage, the surgeon also highlighted systemic challenges facing specialised healthcare facilities. He urged the government to streamline bureaucratic processes involved in importing medical equipment, noting that while tax exemptions exist, the procedures are long and discouraging. “Sometimes it feels like the system is designed to make you give up before you even begin,” he said.

Dr White also appealed for the urgent release of Sh115 million owed to the hospital by the Social Health Authority, warning that continued delays threaten service delivery. “We need this money to pay salaries for our 320 employees and to settle suppliers who provide drugs and essential items,” he said. “Payments must be sped up so that services are not disrupted.”

While acknowledging that SHA improved its payments last year, covering about 64 per cent of billed amounts, Dr White said this was still insufficient.

“We would wish to receive 100 per cent payment for all approved cases. To maintain our services and grow, we need full support from SHA,” he said, while appreciating third-party payers, patients’ families, and surrounding communities for their continued support.

He further noted that cardiac surgery remains among the most expensive medical interventions due to the high cost of implants and disposable items, such as artificial heart valves. “Cardiac surgery is extremely costly. We are barely scraping through, but our goal remains to treat patients and keep costs as low as possible,” he said.

For families like that of Jane Anyango Ouma, these policy gaps are not abstract debates, but painful daily realities—selling livestock, organising fundraisers, and waiting in hospital corridors as precious time slips away.

As pressure mounts on the Social Health Authority to reform its coverage, patients and doctors alike hope these stories will finally prompt action, ensuring that no Kenyan is denied a life-saving diagnosis simply because they cannot afford the cost of a test.