The Social Health Authority (SHA) stands as a pillar of contemporary health governance, designed to bridge gaps between public health policy and community health needs.
The SHA plays a crucial role in ensuring that health services are equitable, accessible, and responsive to the unique demographics they serve.
By fostering collaboration among healthcare providers, policymakers, and the public, the SHA works to create a health system that is both resilient and adaptive to changing health landscapes.
This blog delves into the various facets of the Social Health Authority and its pivotal role in transforming healthcare delivery for communities everywhere.
SOCIAL HEALTH INSURANCE ACT 2023 & SOCIAL HEALTH INSURANCE REGULATIONS 2024
Ensuring that all Kenyans have access to quality, affordable, and comprehensive health services without financial hardship is the primary goal of the Social Health Insurance Act 2023 and the subsequent Social Health Insurance Regulations 2024.
Here’s an in-depth look at some critical areas to understand about these regulations.
Understanding Social Health Authority (SHA)
The shift to Universal Health Coverage was necessary to ensure all Kenyans receive high-quality health services, from health promotion and prevention to curative, rehabilitative, and palliative care.
The Social Health Insurance (SHI) system pools risks and resources to improve the healthcare system’s efficiency, allowing for the payment of premiums into a common fund used to cover the cost of services when needed.
The principles of Social Health Insurance include accessible, quality, and affordable healthcare services for all, a well-defined benefit package anchored in law, mandatory registration and contribution, and equity.
Social Health Insurance is an efficient and equitable way to manage health funds, allowing for targeted funding based on need and improved transparency through direct contributions from beneficiaries.
Universal Health Coverage Laws and Transition Process
There are four critical health laws under the Universal Health Coverage framework:
- The Social Health Insurance Law (2023) establishes institutions and procedures for managing social health insurance in Kenya.
- The Digital Health Act (2023) creates an enabling environment for developing digital platforms that integrate health system needs and provide a database for citizens’ healthcare access.
- The Facility Improvement Financing Law (2023) ensures public health facilities are well-financed to offer quality services and compete with private healthcare facilities.
- The Primary Care Networks Law (2023) develops collaborative mechanisms for healthcare providers at the sub-county level, ensuring service delivery and referral system coordination.
The transition from NHIF to SHA is driven by the need for equitable and affordable healthcare access for all Kenyans and the consolidation of fragmented health insurance pools.
The transition process includes transferring rights, powers, liabilities, and duties from NHIF to SHA and establishing a transition committee to ensure seamless integration.
Primary Health Care & the PHC Fund
Primary health care is a cornerstone of the SHA, with a dedicated Primary Care Fund (PHCF) that ensures accessible and quality healthcare services at the community level.
Emergency, Chronic, and Critical Illness Fund
The Emergency, Chronic, and Critical Illness Fund is a vital component of SHA, designed to enhance access to urgent medical care. It covers emergency services, chronic illnesses, and critical care, ensuring Kenyans have access to essential healthcare services.
The fund finances medical treatments, compensates healthcare providers based on prescribed tariffs, and supports the sustainability of emergency services.
Additionally, it offers comprehensive ambulance evacuation services, including transporting patients from incident sites to equipped facilities and managing transfers through a National Ambulance Call Center.
Registration, Means Testing & Contributions
Registration with SHA requires capturing personal information, contact details, medical history, and documentation. Means testing determines appropriate contribution rates, ensuring equitable access to healthcare services based on individuals’ financial capabilities.
Benefits, Tariffs & Claims Management
SHA provides a wide range of benefits, including emergency and critical illness coverage, intensive care services, and comprehensive primary healthcare.
It ensures that healthcare providers are fairly compensated through a well-defined tariff system, promoting sustainability and quality care. Claims management under SHA is streamlined to ensure efficient processing and timely reimbursement for services rendered.
SHA is committed to ensuring high standards of healthcare service provision, with a focus on accessibility and quality. The transition process aims to maintain continuity of services, with all NHIF contracts running until June 30, 2024, before SHA takes over with new rates and benefits starting July 1, 2024. The SHA framework ensures that healthcare services are uninterrupted during the transition, promoting a seamless shift to improved healthcare access for all Kenyans.
Understanding these aspects of the Social Health Insurance Act 2023 and the Social Health Insurance Regulations 2024 is crucial for navigating the new healthcare landscape in Kenya. By focusing on equitable, affordable, and comprehensive health services, SHA aims to achieve Universal Health Coverage and improve the health and well-being of all Kenyans.
Primary Health Care and the PHC Fund
Primary Health Care (PHC) is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible. The Primary Health Care Fund (PHCF) will be used to purchase primary healthcare services from health facilities. All persons residing in Kenya are eligible for the PHCF, and registration for Social Health Insurance will be automatic for this fund.
There will be no individual contributions, as the primary source of funding will be government allocations and grants. Patients will use the fund when visiting level 2 and 3 facilities or upon referral by community health promoters, with treatment provided for free.
Emergency, Chronic, and Critical Illness Fund
The Emergency, Chronic, and Critical Illness Fund is established to cover the costs of managing chronic illnesses and emergency treatment.
Individuals registered with the Social Health Authority will be eligible for this fund, which will be activated once the Social Health Insurance Fund limits are depleted.
The fund will cover healthcare services specified in the essential benefits package provided in the SHI Regulations 2024. The Social Health Authority will manage the fund, with expenditures limited to annual budget estimates.
Registration, Means Testing, and Contributions
Every Kenyan and non-Kenyan residing in Kenya will be required to register for SHA. NHIF members will need to register afresh, but there will be no associated costs.
Social Health Insurance is mandatory, with contributions determined through means testing. Registration involves filling out an SHA form, accompanied by a copy of the national identification document or an approved alternative.
Dependents will be declared during registration, with no limits on the number of children under a contributor. The SHI Act allows for multiple spouses, provided the total income is captured for premium determination.
Premium contributions will be decided by household members for non-salaried members and deducted from each salaried member’s income. In the event of a member’s demise, the Social Health Authority must be notified with the accompanying death notification documents.
Conclusion
The Social Health Authority embodies the principles of inclusivity, accountability, and proactive health governance. By addressing the social determinants of health and advocating for patient-centered care, the SHA sets the stage for a more just and efficient health system.
Its commitment to continuous improvement and public engagement ensures that health policies not only meet the current demands but are also prepared for future challenges.
As we move forward, the SHA remains an essential entity in our collective journey towards achieving comprehensive and equitable healthcare for all. Supporting and enhancing the efforts of the Social Health Authority is vital for a healthier, more united society.
