Patient Service Access Survey Reveals Major Challenges in Social Health Authority Rollout in Selected Counties in Kenya

By James Mutua 

A recent survey conducted by the Caucus of Patient-Led Organizations of Non-Communicable Diseases (NCDs) has uncovered significant barriers to patient access to essential health services under the Social Health Authority (SHA) and Social Health Insurance Fund (SHIF). The survey, which took place between October 24 and 25, 2024, included responses from healthcare facilities across Nairobi, Kiambu, Meru, and Bomet Counties. The findings reveal that the rollout of the SHA and SHIF has faced systemic challenges, leaving many patients, particularly those with chronic conditions, struggling to access timely and affordable care.

One of the most pressing issues identified in the survey was the delay in access to essential services due to systemic inefficiencies in public hospitals. Major institutions like Kenyatta National Hospital and Kenyatta University Referral Hospital reported frequent technical failures and system malfunctions, which led to prolonged waiting times for crucial services such as diagnostic imaging and specialized medical procedures. These delays, often caused by "system hangs," were found to contribute to increasing patient distress and frustration, significantly affecting the quality of care for those in need of urgent attention.

In addition to the challenges in public hospitals, the survey revealed a troubling gap in SHIF coverage at private health facilities. Prominent private hospitals, including Nairobi Hospital and Rurai Family Hospital, were found to limit SHIF coverage to civil servants within specific job groups. This restriction excluded the majority of NCD patients from accessing services under SHIF, forcing them to rely on out-of-pocket payments for necessary treatments. This limitation was particularly concerning for high-risk patient groups, such as cancer patients and transplant recipients, who now face increased financial burdens. Prior to the SHA rollout, these conditions were typically covered under the National Hospital Insurance Fund (NHIF), leaving many patients with fewer options for care.

Mission hospitals, especially in rural areas, also reported limited or no SHIF coverage, further exacerbating the healthcare divide between urban and rural populations. For instance, Tenwek Hospital, which serves a large rural population, was unable to offer SHIF benefits, creating a significant gap in access to specialized care. Public hospitals such as Mama Lucy Kibaki and Mbagathi, which serve a large number of SHA patients, were also unable to perform advanced procedures such as cardiac surgeries, leaving NCD patients without critical, life-saving interventions. These deficiencies have led to a growing concern about the system's ability to meet the needs of patients with complex medical conditions.

Beyond access to specialized care, the survey highlighted several other systemic challenges. Many patients now face out-of-pocket expenses for basic outpatient services and drug refills, which were previously covered under NHIF. This financial strain is particularly burdensome for those with chronic conditions who require regular treatment. Healthcare providers also reported significant issues with unpaid NHIF bills, which have created confusion and reluctance to offer services to SHA patients. The lack of clarity around SHA benefits, coupled with the mounting debts from NHIF, has made it difficult for many facilities to provide consistent care under the new system.

Another major concern raised by the survey was the suspension of overseas treatment coverage under SHA. This decision has left many patients, particularly those requiring specialized treatments unavailable within Kenya, without viable options for care. In addition, the limited public awareness about the SHA program, including its benefit structures, premium rates, and eligibility criteria, has left many patients confused and unprepared to navigate the new system effectively.I

In light of these findings, the Caucus of Patient-Led Organizations of NCDs has called on the Ministry of Health and SHA leadership to take immediate action to address these challenges. The organization has recommended that SHIF coverage for overseas treatments be reinstated to ensure that patients who require specialized care not available in Kenya are not left without options. Furthermore, it is critical that SHA benefits be clearly defined and communicated to the public to restore patient trust and ensure transparency. The survey also stressed the importance of addressing technical system failures promptly to reduce waiting times and improve the efficiency of care delivery.

Another key recommendation was for the Ministry of Health to settle the outstanding NHIF debts owed to healthcare providers, which would allow them to accept SHA patients with greater confidence and reduce the financial burden on both providers and patients. The Caucus also called for public awareness campaigns to better educate patients about SHA benefits, registration requirements, and financing options, which would help ease the transition to the new system.

Evans M. Majau, the Chair of the Caucus of Patient-Led Organizations of NCDs, emphasized the urgent need for reform, stating, "The findings from this survey reveal critical gaps in SHA’s ability to serve Kenyan patients, particularly those facing chronic and complex conditions like cancer, diabetes, and cardiovascular diseases. The SHA rollout must prioritize transparency, access to specialized care, and patient inclusion in order to fulfill the promise of universal health coverage in Kenya. We call on the Ministry of Health and SHA leadership to engage with patients, listen to their concerns, and take swift corrective action to address these pressing issues."