This is how you will benefit under the new health plan

Pregnant woman

SHIF will cover a standard delivery fee of Sh10,000 for expectant mothers.

Photo credit: Shutterstock

What you need to know:

  • SHIF will cover a standard delivery fee of Sh10,000 for expectant mothers.
  • Kidney patients in need of dialysis will have the procedures fully covered by SHIF.

The Social Health Authority (SHA) has revealed the proposed benefit packages that will be covered by the Social Health Insurance Fund (SHIF) as the Ministry of Health transitions from the National Health Insurance Fund (NHIF). 

This move is expected to ensure that everyone has access to universal healthcare.

According to the proposals, SHIF will cover a standard delivery fee of Sh10,000 for expectant mothers undergoing normal delivery.

For those undergoing a caesarean section, coverage will be at Sh34,200 for a maximum stay of three days.

Kidney patients in need of dialysis will find relief as their procedures will be fully covered by SHIF. Patients with acute kidney injury will have access to up to five dialysis sessions, with three being paid for by the SHIF and two by the Emergency, Chronic, and Critical Illness Fund (ECCIF).

Services to be provided at level 4 to 6 facilities, include dialysis, ambulance, and intensive care units (ICU).

For oncology services, SHIF will cover up to Sh400,000 for surgery, chemotherapy, radiotherapy, hormone therapy, and immunotherapy, while ECCIF will cover up to Sh250,000. 

The services will include screening and treatment for cancers such as breast, prostate, colorectal, cervical and childhood cancers.

Mental health care has also been enhanced, with SHIF expected to provide treatment for enrolled beneficiaries dealing with chronic drug use, including alcohol, tobacco, cannabis, heroin, mandrax, and cocaine, among others.

The cover includes a three-stage treatment programme encompassing rehabilitation, addressing a previously costly aspect of patient care.

The insurance cover will provide up to Sh139,000 for rehabilitation, drug and substance addiction disorders, including detoxification. Mental health services will be available at level 4, 5, and 6 facilities.

However, some services will not be covered, and patients will have to pay for them out of pocket. These services include fertility treatment, weight management drugs, and nutritional supplements. 

Other exclusions from benefits are vaccines not included in the Kenya Expanded Programme on Immunisation (KEPI), products not listed in the Kenya Essential Medicine List (EML) and the Kenya Essential Diagnostics List (EDL), medical costs associated with or incurred in a research environment and clinical trials, smoking cessation aids, epidemics and pandemics, admission to a private ward, stay in a sanatorium or old people’s home, among others.

The healthcare providers will receive a capitation rate of Sh900 per year per person. Capitation is a healthcare payment model in which providers receive a fixed rate to deliver services to each enrolled individual. 

Providers are paid a fixed amount per person for accessing the services. If a provider’s costs exceed the per capita budget, they cover the difference.