State adopts new guidelines to address rural private hospitals' concerns on SHIF payments
These include clear accreditation guidelines, a standardised claims submission process, and a digital tracking system to streamline payments.
In response to concerns raised by the Rural Private Hospitals Association (RUPHA) over delays in claims processing and reimbursements, the Ministry of Health has introduced key reforms to enhance efficiency and transparency in the State Health Insurance Fund (SHIF).
These include clear accreditation guidelines, a standardised claims submission process, and a digital tracking system to streamline payments.
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Addressing the Senate Committee on Wednesday, Health Cabinet Secretary Deborah Barasa affirmed that all RUPHA claims under SHIF and the Primary Healthcare (PHC) Fund have been settled as of January 31, 2025.
This includes a Sh5.1 billion disbursement made on Monday. Additionally, the Ministry has committed to clearing outstanding debts from the defunct NHIF, having already paid Sh8.1 billion, with ongoing efforts to settle the remaining balance.
“Recognising the critical role of private healthcare providers in delivering services to rural and underserved communities, the government remains committed to a collaborative approach under the Social Health Authority (SHA). Through structured engagements with stakeholders, including RUPHA, the Ministry has prioritized addressing concerns related to payment timelines, facility accreditation, and service-level agreements,” said Barasa
To enhance efficiency, SHA has implemented a real-time digital claims tracking system, ensuring that service providers receive timely reimbursements. While SHA has a legal mandate to process payments within 90 days, it has consistently disbursed verified claims monthly, with payments up to January 31, 2025, now completed.
Capitation-based model
Between October and December 2024, the government adopted a capitation-based model to fund PHC services, providing fixed payments per enrolled beneficiary.
The Ministry has also reaffirmed its commitment to clearing NHIF debts, having already paid Sh8.1 billion and is actively working to offset the remaining balance.
As of January 2025, the Ministry transitioned to the Global Budget Model under the Taifa Care strategy. Unlike capitation, this model allocates pre-determined budgets to healthcare facilities based on anticipated patient volumes and service demand.
Among the issues raised by RUPHA is the Sh30 billion debt inherited from the defunct NHIF, which the Ministry of Health acknowledges as a major financial challenge for the healthcare system.
Last week, RUPHA chairperson Dr. Brian Lishenga expressed concerns that the challenges surrounding the new healthcare system have been overlooked, jeopardizing patient care.
He highlighted prolonged system downtimes, delays in One-Time Password (OTP) verification, and difficulties in tracking claim approvals as the most pressing issues, noting that these problems have worsened over the past month.
Dr Lishenga urged the government to fully settle the Sh30 billion in outstanding NHIF arrears, emphasizing that hospitals are struggling with bank defaults, shortages of essential medicines, and unpaid consultant fees dating back to 2017.
With over 600 hospitals registered under RUPHA, the association warns that continued financial strain could lead to a healthcare crisis, severely impacting service delivery in rural and underserved areas.
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