Kenya’s healthcare system is undergoing significant changes as the government prepares to roll out the Social Health Insurance Fund (SHIF). The program is aimed at providing universal health coverage to Kenyans and reducing the financial burden associated with healthcare. However, the program has been met with growing concerns over the perceived low benefits, especially in comparison to private medical insurance schemes that many citizens have come to rely on.
While the SHIF is intended to provide access to essential health services for millions of Kenyans, including those who are underserved, various stakeholders have raised alarm over the low payout limits and coverage restrictions. These concerns have centered on maternity care, inpatient services, outpatient services, dental and optical coverage, as well as benefits for emergency and chronic illness care. The limitations of the SHIF, critics argue, may leave many Kenyans underinsured, potentially exacerbating the challenges of healthcare access rather than alleviating them.
The Cost to Employees and Limited Benefits
One of the central criticisms of the SHIF revolves around the cost-to-benefit ratio. Under the new scheme, an employee earning Ksh. 100,000 in monthly take-home pay will face a 2.75% deduction, contributing Ksh. 2,750 per month or Ksh. 33,000 annually to the medical insurance fund. While this amount may seem reasonable on the surface, the benefits provided under the SHIF are being seen as disproportionately low, especially when compared to private insurance schemes with similar contribution scales.
For example, maternity care under the SHIF offers Ksh. 10,000 for a normal delivery and Ksh. 30,000 for a caesarean section. This is in stark contrast to private medical insurance providers, which typically offer Ksh. 20,000 more for a normal delivery and an additional Ksh. 20,000 for a caesarean section. Maternity costs in Kenya can be substantial, and the SHIF’s low payout leaves many families with a significant financial burden to cover the gap, undermining the goal of financial protection in healthcare.
Inpatient and Outpatient Coverage Gaps
The coverage for inpatient services under the SHIF is similarly limited, with a daily allowance of Ksh. 2,240 for a maximum of 180 days per household annually. This translates to Ksh. 403,200 per household per year, but only if the full 180 days are used. By comparison, private insurers typically offer much higher limits, with some providing coverage of up to half a million shillings annually. This discrepancy becomes even more critical when considering the cost of healthcare in private hospitals, which can quickly escalate beyond the SHIF’s maximum limit, leaving Kenyans to make up the difference or forego necessary care.
For outpatient services, dental and optical care are among the most criticized aspects of the SHIF. The new program allocates only Ksh. 2,000 per household annually for dental care, while private insurers offer up to Ksh. 10,000 for similar coverage. Similarly, for optical care, the SHIF provides Ksh. 950 for eyeglasses and a maximum of Ksh. 1,000 per household annually, far below the Ksh. 7,000 to Ksh. 10,000 offered by private providers. Given the high costs associated with dental and optical treatments, these low limits may lead to Kenyans either paying out of pocket or delaying necessary care, potentially exacerbating health problems in the long run.
Critical Illness and Emergency Coverage Concerns
Perhaps the most significant concerns surrounding the SHIF are the provisions for emergency services and chronic or critical illness care. Under the new scheme, emergency services are only covered for a maximum of 24 hours, with the SHIF kicking in after that period. This limitation has raised alarms among healthcare providers and the public alike, as many emergency situations require immediate and substantial financial support to ensure timely and life-saving interventions.
Critical illnesses, such as cancer and kidney disease, are covered for a maximum of 180 days under the SHIF, which may be insufficient for individuals requiring long-term treatment. Chronic illness management is often a long-term commitment, requiring ongoing treatment, medication, and specialized care that extends well beyond the 180-day limit. Critics argue that the SHIF’s limits are out of step with the realities of managing such diseases, potentially leaving patients unable to afford essential care once the coverage period ends.
Exclusions and Limitations in Coverage
The SHIF also contains several notable exclusions, including assisted fertility treatments such as in vitro fertilization (IVF), cosmetic procedures, and weight management treatment drugs. While these exclusions may be justifiable on the grounds of cost and necessity, other exclusions, such as vaccines, nutritional supplements, and coverage for epidemics and pandemics, are more troubling. Given the global experience with the COVID-19 pandemic, the exclusion of coverage for epidemics and pandemics is seen as a significant oversight, potentially leaving Kenyans without financial support during future public health crises.
Additionally, the SHIF excludes professional fees above prescribed rates, costs for diagnostic equipment, and nutritional supplements, all of which are essential components of comprehensive healthcare. These exclusions place additional financial burdens on patients, particularly those with complex medical needs or those seeking specialized treatments.
Comparison to Private Insurance Providers
The discrepancies between the SHIF and private insurance providers have been widely discussed, with many Kenyans questioning the value of the new scheme. While the SHIF aims to provide universal health coverage, its low benefit limits and extensive exclusions leave it far behind private schemes in terms of the financial protection offered. For example, private insurers typically provide much higher coverage limits for inpatient and outpatient services, as well as more generous allowances for maternity, dental, and optical care.
For those who can afford private insurance, the SHIF may offer little incentive to switch, given the lower level of coverage and more restrictive terms. This raises concerns that the SHIF may become primarily a safety net for the most vulnerable, while middle- and upper-income earners continue to rely on private insurance to meet their healthcare needs.
Public Perception and Potential Reforms
The SHIF has sparked significant debate in Kenya, with public perception largely focused on the inadequacies of the scheme in providing comprehensive healthcare coverage. As the government moves forward with the implementation of the program, there have been calls for reforms to address the gaps in coverage and improve the overall benefits provided.
One potential solution is to increase the contribution rates to the SHIF, allowing for higher payout limits and more comprehensive coverage. However, this would likely be met with resistance from employees and employers alike, who may be reluctant to face higher deductions without a corresponding increase in benefits. Another option is to negotiate better rates with healthcare providers, enabling the SHIF to offer more competitive coverage while keeping costs manageable.
There is also the possibility of introducing a tiered system, where different levels of coverage are available depending on income and contribution levels. This would allow higher earners to access more comprehensive benefits, while still ensuring that the most vulnerable Kenyans receive basic healthcare services.
Conclusion
As Kenya prepares to roll out the Social Health Insurance Fund, the concerns raised over the low benefits offered under the program highlight the challenges of implementing universal health coverage in a country with diverse healthcare needs. While the SHIF is a step in the right direction toward improving access to healthcare, its limitations, particularly in comparison to private insurance schemes, may leave many Kenyans underinsured.
For the SHIF to succeed in its mission of providing financial protection and access to quality healthcare, reforms will be necessary to address the gaps in coverage and improve the benefits provided. Only then can the program fulfill its promise of ensuring that all Kenyans, regardless of income, have access to the care they need without facing financial hardship.
