SHA platform receives over 940 claims worth Sh12 million amid faltering system

The Social Health Authority (SHA) platform has received over 940 claims worth more than Sh12 million from healthcare providers since its launch on October 1, 2024.

A survey by the Rural Urban and Private Hospitals Associations shows the SHA portal, designed to handle claims under the new health insurance scheme, registered submissions from over 288 healthcare providers.

Kenyatta National Hospital submitted the highest number of claims, totalling Sh2.3 million for reimbursement within the first nine days of the new system's operation.

The data revealed that inpatient claims accounted for the majority of costs, with 343 claims amounting to Sh7.2 million, while outpatient claims reached Sh5.2 million from 567 submissions.

The government has paid Sh1.5 million for 94 claims so far, but concerns over the system's readiness remain. The report notes that many hospitals reported issues accessing the SHA portal, resulting in delays in submitting claims.

Kenyatta National Hospital led the claims submissions with 87 claims, followed by Rapha Dialysis and Diagnostic Centre, which submitted 60 claims worth Sh682,000.

Cure and Cure Hospital recorded 37 claims totaling Sh626,000. Other facilities, including Tophill Hospital in Eldoret, PCEA Chogoria Hospital, Ladman Hospital, and Tenwek Hospital, also submitted significant claims ranging from Sh362,000 to Sh534,000.

Transition slowed down

However, technical issues have slowed the transition to the new platform, impacting patient care and raising doubts about the system’s efficiency.

“Numerous health facilities, especially those contracted to deliver services under the SHA scheme, have struggled to process claims due to system malfunctions,” reads the report.

This has left some patients without coverage, forcing them to pay out-of-pocket for services that should have been covered.

Kenya Medical Practitioners and Dentists Union (KMPDU) Secretary-General Davji Atellah, expressed concern over the challenges calling for a solution.

"For a health plan meant to cover millions, this oversight has caused chaos and confusion, with patients being forced to pay out-of-pocket for services that should have been covered under SHA. We need to make it work or drop it," he said.

The SHA officially replaced the National Health Insurance Fund (NHIF) on October 1. It manages three funds: the Primary Healthcare Fund, the Social Health Insurance Fund (SHIF), and the Emergency and Chronic Illness Fund. Individuals are required to contribute 2.75 per cent of their household income to the SHIF fund, while the government finances the other two funds.

Renal Society of Kenya President, John Gikonyo, highlighted the ongoing issues with the SHA system, noting that the extent of the problem could be larger than anticipated.

“It's true that in some hospitals the system is working; however, in others, it is severely affected. We have had to ferry our patients from one hospital to another in search of health care. Why do we need to do that if this thing is working everywhere?" he posed.

Gikonyo pointed out that some hospitals in Nakuru County, including all four dialysis centres, were not offering services due to the system malfunction, forcing patients to pay in cash.

The survey further highlighted only 40 per cent of private hospitals had fully transitioned to the SHA portal, further underscoring the slow adoption of the new system amid widespread technical challenges.