Answers to Frequently Asked Questions about SHA {Best Guide}

Looking for answers to Frequently Asked Questions about Social Health Authority (SHA)? Look no further. Get all the answers below.

About SHA

The Social Health Authority (SHA) is a State Corporation of the Government of Kenya established to manage and provide public health insurance in the country.

It was created by the Social Health Insurance Act of November 22, 2023, and officially replaced the previous National Health Insurance Fund (NHIF). The SHA’s core mandate is to ensure accessible, affordable, sustainable, and quality health insurance for all Kenyan citizens and, where applicable, foreigners.

Key Features of the SHA

The SHA manages three distinct funds:

1. Primary Healthcare Fund (PHCF): Directly financed by the Kenyan government. It funds services available at lower-level healthcare facilities (Levels 1, 2, 3, and select Level 4 hospitals).

2. Social Health Insurance Fund (SHIF): Funded by mandatory member contributions. This fund pays for services at higher-level hospitals (Levels 4, 5, and 6), covering a comprehensive range of benefits including specialized services like oncology, radiology, and surgery.

   • Contributions: Salaried individuals contribute 2.75% of their monthly salary, while self-employed individuals can pay a minimum of KES 300 per month, based on a means-testing process.

3. Emergency, Chronic and Critical Illness Fund (ECCIF): Funded through taxes. This fund is designed to cover the high costs associated with emergency, chronic, and critical illnesses, addressing a major financial barrier in the previous system.

Transition and Registration

• The SHA officially began operations on October 1, 2024.

• Registration is mandatory for all Kenyan residents and non-Kenyans residing in Kenya. Registration can be done through the Afya Yangu website or via USSD code *147#.

• All paid-up members and running contracts with the former NHIF were managed through a transition process.

SHA Frequently Asked Questions and Answers

Question: Should I carry my old NHIF card when I go to the hospital?

Answer: You don’t need a card, you will use your national ID. That’s what you will register with (to SHA) and that’s what you will use.

Will I get all the services at my local facility?

You have an option to go to any of the following healthcare providers: Public, private, or Mission.

Is my nearest hospital well-equipped to provide all the services?

If a facility is not equipped enough to provide the services, you are allowed to go to the next facility that has the services you need. SHA does not limit you to one facility.

Can I lie about my income when registering for the Social Health Authority (SHA)?

You can’t lie because you will be asked questions that will determine your premium… You will answer some questions, and the system will triangulate what your premium is based on the answers that you have given.

How will I know how much hospitals in my primary care network charge for the services I am seeking?

For primary healthcare networks, you don’t need to know what they are charging, because there will be no co-payments in your primary care network. All you need is to register and go to the nearest Level 2 or Level 3 facility that is within your area. But for services that are beyond that, we have gazetted the prices and the benefits that you are entitled to. So, when you go to that facility for services, they will tell you what amount you are entitled to, and what they charge for the service.

What happens if someone falls sick and they are far from the selected facility?

You go to the nearest facility.

How will citizens file SHA complaints?

You raise the first complaint with the management at the branch level or the headquarters depending on where you are. If you are not satisfied with the answers or the way the issue has been addressed, then you can escalate it to the tribunal that has been set up to address complaints.

How often can I update my details on the system?

If you are employed, it’s not up to you to update, it’s for your Human Resources manager who will upload because this is a statutory deduction. For someone who is in the self-employed category, because you pay your premiums annually, you will be able to do a Proxy Means Testing (PMT) again to update your new premiums. PMT is a way of calculating what your premium is based on the answers that you have given.

What happens when you lose your job?

You move from the category of salaried individuals and into the category of non-salaried individuals. Under the non-salaried category, you will do a Proxy Means Testing (PMT) and it will give you premiums based on the results of the PMT.

How Do I Register For SHA?

The subscription is made through the USSD code *147# or through the Afya Yangu website: www.afyayangu.go.ke.

How are Monthly Payments Determined?

The payments are determined through means-testing to establish individuals’ contribution capability. Self-employed people can pay as low as Kes . 300 a month, while salaried individuals pay 2.75% of their monthly salary through statutory deductions.

What about SHIF and the others?

There are three funds under SHA:

• the Primary Health Care Fund,
• the Social Health Insurance Fund (SHIF),
• and the Emergency, Critical, and Chronic Illness Fund (ECCIF).

The primary Health Care Fund

The primary Health Care Fund is directly financed by the Kenyan government. It funds health care services available at Levels 1, 2, 3 and select Level 4 hospitals. SHA seeks to facilitate the optimum use of lower-level health facilities.

SHA does not fund Primary Health Care at levels 4, 5, and 6 of the Social Health Authority care facilities.

However, if receiving primary health care at lower levels, one can be referred to higher level health care facilities, for instance, a level 6 hospital for Essential laboratory investigations of diabetes, cardiovascular, sickle cell, and chronic pulmonary/asthmatic diseases, which are partially paid by the Social Health Insurance Fund (SHIF). After the tests, the patient is supposed to return to treatment at a level one, two, or three health facility.

The Social Health Insurance Fund (SHIF)

The Social Health Insurance Fund (SHIF) is funded by member contributions and pays for various services at levels 4, 5, and 6 hospitals, including radiology, inpatient treatment, surgical, dialysis, and oncology. Salaried and self-employed persons can join the Fund.

The Social Health Authority fully covers PET Scans and PSMA (Prostate-specific membrane antigen positron emission tomography) scans. For oncology services, diagnostic tests are allocated Kes. 100,000, while treatment is Kes. 300,000 per person, amounting to Kes. 400,000 per person per year.

SHA vs NHIF

The SHA differs from the NHIF in that it pays up to Kes. 300,000 for cancer treatment, while the NHIF used to pay partially per session, up to 6 sessions. This means one had to top up for each session and fully pay for any sessions after the sixth one.

SHA’s benefits increased 12% above the NHIF payments.

Under SHA, cardiology surgery patients (open heart surgery) receive an allocation of Kes. 952,000, up from the maximum of Kes. 450,000 offered by the NHIF.

Kidney transplants were fixed at Kes. 480,000 under NHIF, but SHA is catering for the recipient’s surgery, donor nephrectomy, post-renal replacement therapy, and pre-transplant evaluation. Post-renal replacement therapy costs have been a hindrance to transplant candidates.

Under SHA, there is also the Emergency, Critical Care, and Chronic Illness Fund, which is funded through taxes. This fund is a remedy for the past scenario, where patients would reach a limit after which they would have to top up.

Learn more about the Emergency, Critical, and Chronic Illness Fund (ECCIF).

NHIF did not cover cancer diagnosis; it only covered screening and treatment. SHA covers the cost of consultation, preventive, and restorative treatments such as extractions, scaling, and infection management.