MPs lay bare rot in SHA as Duale defends programme

MPs have exposed deep-rooted challenges hindering the delivery of health services under the new Social Health Authority.

The revelations came as Health CS Aden Duale defended the Taifa Care programme, describing it as a game changer in Kenya’s healthcare system.

In a report tabled by the National Assembly’s Health Committee, the panel outlined numerous obstacles impairing the smooth rollout of the programme.

The committee, chaired by Seme MP James Nyikal, identified 19 challenges delaying the implementation of the scheme.

The report cited issues such as delayed and withheld payments, arbitrary rejection of claims, ICT system failures, exclusion of vulnerable populations, tariff misalignments and a limited benefits package.

Other challenges included delayed reimbursements to facilities, erroneous payments, governance gaps, difficulties in identifying indigent persons and delays in establishing a functional claims management office.

Speaking during a meeting with CS Duale and the Council of Governors at Parliament Buildings in Nairobi, Nyikal said the committee compiled the report after visiting 10 health facilities across selected counties.

The facilities visited were Ladnan Hospital Ltd and Mbagathi County Hospital in Nairobi county; and Matata Nursing Hospital, Nyandiwa Level 4 Hospital, St Elizabeth Swindon, Rachuonyo County Hospital and Nyandiwa Health Centre in Homa Bay.

Others were St Mary’s Hospital, Mumias, in Kakamega; Nyahururu County Referral Hospital and Sipili Hospital in Laikipia; and PCEA Tumutumu Hospital and Nyeri County Referral Hospital in Nyeri.

According to the report, reimbursements to health facilities through SHA have been inconsistent, with some months recording no disbursements at all.

A substantial backlog of arrears from the defunct NHIF also remains unresolved, while approved claims under SHA continue to pile up.

“Moreover, the committee noted a lack of transparency in SHA’s payment systems, as reimbursements are often issued as lump sums without breakdown by fund type,” the report states.

The committee also raised concerns about the high rate of claim rejections, even in cases where health facilities had provided adequate documentation.

“Hospitals reported the absence of a clear and transparent mechanism for claim resubmission, with feedback on rejected claims often delayed well beyond the 90-day statutory period,” the report adds.

The committee found that SHA’s overreliance on AI-driven claim processing and approval—without sufficient human oversight—has led to unjust denials, resulting in significant financial strain on facilities.

The SHA ICT system, the MPs noted, experiences frequent downtimes—sometimes up to four times a month—disrupting hospital operations and delaying services.

“Biometric verification challenges were also highlighted, particularly for patients without ID cards or those with faint fingerprints,” the committee stated.

Delayed and rejected claims have strained hospitals financially, leading to strikes, low morale, and an overreliance on volunteer workers.

The report cited St Mary’s Mumias Hospital, which is owed Sh19.2 million. Several facilities, the MPs noted, have been forced to suspend admissions due to system malfunctions.

Additionally, vulnerable groups such as teenage mothers remain marginalised in accessing SHA benefits. Teenage mothers without IDs, prisoners, indigent persons, and individuals with chronic conditions continue to face barriers to coverage.

“The requirement for lump sum annual premium payments has further excluded many poor households, undermining the principles of equity and Universal Health Coverage,” the report says.

The committee also pointed to the absence of a clear national framework for identifying and enrolling vulnerable populations, particularly teenage mothers.

It further highlighted discrepancies between the actual cost of care and SHA reimbursement rates, with some packages failing to meet the true cost of service delivery. For instance, SHA pays Sh30,000 for cesarean deliveries.

“The benefit packages and tariffs undermine quality service delivery and discourage providers from offering specialised care,” the report reads.

The MPs also flagged erroneous SHA payments that have strained health facilities financially. For example, the Nyeri County Referral Hospital reportedly lost more than Sh16 million to a neighbouring private hospital due to payment processing errors, with recovery efforts proving unsuccessful.

The committee further noted governance and coordination gaps among key regulatory agencies, including Kenya Medical Practitioners and Dentists Council (KMPDC), SHA, the Digital Health Authority and county governments.

It added that inadequate training on the SHA system among health facility staff has contributed to inefficiencies in claims processing and service delivery.

The MPs also cited frequent stockouts of essential commodities due to delayed supplies from Kemsa, whose fill rate stands at just 30 per cent.

“The resulting shortage of drugs, oxygen, and critical consumables has compromised patient care and contributed to preventable deaths,” the report warns.

In addition, the committee said SHA has yet to establish a clear and transparent mechanism for identifying indigent and vulnerable persons through means testing. Consequently, many deserving citizens remain excluded from social health protection, undermining the goal of UHC.

In his response, CS Duale lauded the programme, saying it has transformed healthcare delivery across the country.

He revealed that about 7.3 million informal sector members have undergone means testing, with an average premium contribution of Sh660.

According to Duale, SHA has collected Sh673.8 million since its launch in June this year from 323,629 “Lipa Pole Pole” members, some of whom contribute as little as Sh10 per day.

“Under the Social Health Insurance Act, contributions for the informal sector are to be paid annually. This was meant to address the great challenge of adverse selection,” the CS said.

He said the requirement for annual contributions—under Section 27 of the Social Health Insurance Act, 2023—is justifiable and proportionate as a measure to prevent adverse selection.

Duale further explained the annual payment model allows new and reinstated members to access services immediately, eliminating waiting periods that often act as barriers to care.

“Waiting periods are often regarded as barriers to access in social health insurance schemes. Their removal reflects SHA’s commitment to promoting equity and uninterrupted access to care,” he said.

On delayed payments and pending arrears, Duale told MPs that SHA pays providers on the 14th day of each month. He attributed delays to incomplete or improperly filled claim documents, missing signatures, incorrect patient details, and incomplete medical records.

“Before settlement, claims must be verified and adjudicated by SHA to confirm that they are complete, accurate, and properly supported,” he said.

He disclosed that SHA is conducting a comprehensive arrears verification exercise, jointly with providers, to review resubmitted claims and ensure fairness and accuracy.

 INSTANT ANALYSIS

CS Aden Duale also revealed that the Social Health Insurance Fund (SHIF)—a component of SHA—has so far collected Sh79.2 billion. To enhance flexibility and affordability, especially for informal sector members, SHA has introduced the Lipa Pole Pole platform, which allows contributors to pay in manageable instalments—covering the first four months upfront, and then choosing to pay daily, weekly, or monthly thereafter.