The Government has assured CHAK health facilities of a smooth transition to the Social Health Authority (SHA/SHIF) whose implementation will kick off in July 2024. The assurance comes in the wake of heightened engagement between CHAK facilities and NHIF to address delayed claims payments.

Delegates at the CHAK Annual Health Conference 2024 were informed that every Kenyan would be required to register afresh for SHA/SHIF. Bio metric registration would be done for all beneficiaries while every child would be registered within 14 days of birth.

The SHA/SHIF is mandated by the law to:

• Register beneficiaries
• Manage funds received under the Social Health Insurance Act 2023
• Receive all contributions
• Empanel and contract healthcare providers and healthcare facilities
• Make payments to contracted healthcare providers and healthcare facilities out of the relevant fund as provided in the Act.

According to Julia Ouko who delivered a presentation on behalf of Dr Samson Kuhora, a law on empanelment and contracting would be formulated and a body put in place to run this function. A benefits panel would review benefits after every two years in consultation with CS-Health.

The delegates were further informed that although empanelment was not guaranteed, licensed health facilities in the country would be central to the implementation of the new policy direction.

Claims management would be done through claim settling agents and medical insurance providers. A tribunal would be set up to settle disputes although any decision could be appealed in law.

Speaking at the Annual Health Conference, Mr Chrisostim Wafula, Manager, Claims Management, NHIF/SHA told representatives of CHAK health facilities and other delegates that a multi-disciplinary team has been formed to support high volume hospitals in the claims reconciliation process as the transition process continued. The reconciliations were expected to be completed by June 30 with the process coordinated from NHIF/SHA head office.

Surgical claims flagged in 2023, some of which were way above the contract rates, had already been released to NHIF branches for processing and would follow the normal payment routes while old e-claims would be released at the end of April 2024 for processing.

Further, NHIF had received money from Government and would be processing Linda Mama claims. Capitation would be paid to the health facilities in the month of May.

Some CHAK member health units confirmed that they had received NHIF payments during the third week of April. However, the facilities continued to express reservations at the slow pace of claims payments, especially given the short time period left before the start of SHA implementation.

According to the delegates, some claims had been pending for over seven years and there were cases of capitation being paid using a wrong formula. The health facility representatives termed this unfair given that the capitation was already too low for the services offered.

The challenges had further been compounded by the on-going doctors’ strike that had pushed huge numbers of patients, especially those critically ill, to the CHAK facilities, given that county health services had ground to a halt.

Further, lower level health facilities were struggling with claims and there was no guarantee they would be empaneled for SHIF due to challenges with internet connectivity. Although the Government had embarked on installation of fibre optic cables, this was mainly serving county and sub county offices and adjacent areas. Lack of internet connectivity would greatly impact Level 3 health facilities which served a large number of clients.

The CHAK member health units also expressed concern that many clients were unaware of the NHIF benefits package and called on the Government to address this shortcoming during the SHA/SHIF implementation. The delegates were informed that there was a plan to communicate the SHA/SHIF package through the division of benefits.
Further, the delegates were briefed on the referral system in the new system. Patients would be referred to Level 4 and 5 health facilities from Level 2 and 3.

The Social Health Insurance Act 2023 establishes three new funds, namely, the Primary Healthcare Fund (PHF) which will be accessed in Level 2 and 3 health facilities upon registration to SHIF, the Social Health Insurance Fund (SHIF) which will be accessed in Level 4, 5 and 6 health facilities upon registration and up to date premiums, and the Emergency, Chronic and Critical Illness Fund (ECCIF) to be accessed upon depletion of SHIF cover.