Members of Parliament (MPs) in Kenya are calling for annual revisions of the Social Health Insurance Fund (SHIF) coverage limits to ensure that Kenyans can access essential medical services without financial strain. Lawmakers argue that the current limits are inadequate, especially for critical services like renal and dental care, leaving patients with significant out-of-pocket costs.
During a parliamentary session, Principal Secretary of Medical Services Harry Kimtai outlined the current SHIF limits, revealing significant gaps in coverage. The cap for optical services is Sh1,000 per family per year, but only children under 18 are eligible. Dental care is capped at Sh2,000 per year, which, according to MPs, barely covers basic procedures like tooth extraction.
Essential outpatient services, including laboratory tests, imaging, medication, and counseling, are capped at Sh900 per beneficiary, while maternity care has a limit of Sh10,000 for normal delivery and Sh30,000 for a Caesarean section.
For patients requiring renal care, haemodialysis is covered at Sh10,650 per week, while peritoneal dialysis receives a monthly allocation of Sh85,200. However, any additional costs must be covered by the patients themselves, making access to specialized treatment financially burdensome.
Nyeri Town MP Duncan Mathenge was particularly vocal about the inadequacy of SHIF’s dental coverage. He emphasized that the Sh2,000 cap only covers extractions, yet modern dentistry prioritizes saving teeth through procedures like fillings and root canals.
“For dental care, the cap is Sh2,000 per year, which only covers tooth extraction. This is unacceptable because modern dentistry focuses on saving teeth rather than extractions,” Mathenge stated.
Committee Chair Robert Pukose also criticized the Sh1,000 limit for optical care, questioning whether it was realistic in covering essential eye treatments and corrective measures.
Mogotio MP Reuben Kiborek raised concerns about the Sh500,000 cap for overseas treatment, stating that it is insufficient for specialized procedures. The MPs argue that these limits do not reflect the actual costs of medical care and must be adjusted annually to keep up with inflation and changing medical needs.
The discussion also highlighted allegations of corruption and preferential treatment in referrals for overseas medical care. Mathenge questioned why some patients are directed to specific hospitals in India under the SHA system, raising concerns about possible collusion between ministry officials and foreign hospitals.
“Mr. PS, explain why patients are being directed to specific hospitals facilitated by SHA. My mother required endocrine services, and despite requesting treatment at a different hospital, we were denied. We had to pay out of pocket to take her to a hospital of our choice,” Mathenge lamented.
Kitutu Chache South MP Anthony Kibagendi echoed these concerns, accusing SHA of frustrating patients who need specialized treatment abroad. He pointed out delays in the formation of review committees responsible for approving overseas treatment, which further disadvantages patients in need.
The ongoing financial constraints in the healthcare sector have left many Kenyans paying out of pocket for chronic and critical illnesses. Despite the transition from the National Health Insurance Fund (NHIF) to SHIF in October 2023, many critical services remain partially operational.
PS Kimtai acknowledged that SHIF currently provides coverage only for emergency services within the first 24 hours of a patient’s admission. Chronic and critical illness coverage has yet to be fully implemented due to budgetary limitations.
“The fund provides coverage for urgent care, resuscitation, and stabilization for specific emergency services as outlined in the Gazetted benefit package,” Kimtai explained.
According to Tracy John, the acting director for benefits and claims management, the system for chronic and critical illness services was only activated in December 2023, beginning with level five and six hospitals. This delay has left many patients struggling to access life-saving care.
The CEO of the Digital Health Agency, Anthony Lenaiyara, reported that, as of January 2024, 21.6 million claims had been submitted under SHIF, with the fund receiving Sh2 billion in the current financial year. He highlighted the growing financial strain on the healthcare system and emphasized the need for increased funding to ensure sustainable healthcare access for all Kenyans.
MPs and healthcare experts agree that timely and transparent revisions of SHIF coverage limits are necessary to prevent patients from being locked out of essential medical services. Without annual adjustments, Kenya’s healthcare system risks further inequality, where only those who can afford private medical care receive adequate treatment.
As discussions continue, all eyes will be on the government to see whether it will act on the MPs’ recommendations and revise SHIF limits to better reflect the needs of the population.
