IEA flags funding gaps, implementation flaws in SHA rollout

One and a half years into the implementation of the government’s universal health coverage programme, operated through the three Social Health Authority (SHA) funds, the ambitious undertaking continues to run into headwinds, with the biggest challenge remaining financial.

As at the end of last year, the primary healthcare fund, the emergency, chronic and critical illness fund, and the social health insurance fund remained underfunded to the collective tune of Ksh.116.1 billion.

"If the resources that are generated are not sufficient, that raises the issue of financial sustainability, which results in delays in payment to facilities and subsequently affects service delivery,” warned John Mutua, programmes coordinator at IEA Kenya

Beyond the cash crunch, the report reveals that while millions of Kenyans have registered for SHA, contributions to the fund are not commensurate with the numbers enrolled.

The authority is also grappling with what it says is the reluctance by the public to seek medical care from lower-level facilities covered under the primary healthcare fund, instead overburdening facilities financed through the social health insurance fund.

“People tend to bypass primary healthcare and go to seek healthcare either at county or national level facilities. What that means is that it inflates claims for SHIF, but it also affects early detection of chronic diseases, and payouts from SHIF and the emergency, chronic and critical illness fund tend to increase,” Mutua noted.

Implementation challenges on the ground are even more stark. Many hospitals are reportedly opting out of the scheme or demanding co-payments, arguing that SHA tariffs often do not cover the real cost of medication, consumables or specialist fees.

Health facilities are also still finding their way around SHA’s digital operating systems, further compounding the challenges facing the authority.

“The benefits package is quite ambitious. There is a huge challenge with claims and reimbursement, affecting facilities and service provision. We also still have operational and capacity gaps, including sub-optimal digital connectivity,” Mutua said.

To prevent the scheme from collapsing, the IEA is proposing a series of radical reforms. These include rationalising the benefits package to align it with available financial resources, strengthening means testing through integrated and verifiable data systems, exploring innovative funding options to boost the primary healthcare and emergency funds, and deliberately clearing outstanding debts inherited from the now-defunct NHIF.

The authority has also been urged to strengthen its reporting and monitoring systems to curb emerging avenues for fraud.

These include claims for more expensive procedures than those performed, falsification of records, converting outpatient cases into inpatient claims, multiple billing, and the use of ghost patients.