Disclaimer
In this article I speak on MY OWN CAPACITY as Simon Kigondu and do not purport to speak for Kenya Medical Association
Kigondu and Social Health Authority
I am Dr Simon Kigondu, an obstetrician gynaecologist working at Kigumo Sub-County Hospital, a Murang’a County Government facility. The facility sees SHA patients.
I also run a private obstetrics and gynaecology private practice, Excella Healthcare at KMA Centre. I do not see SHA.
I also visit facilities where SHA patients are treated and sometimes SHA does not pay.
I’m also a director of a health facility that offers care to patients who may be partly covered by SHA.
I’ve in the past made submissions to the process that birthed the SHA Act. I’m also the President of Kenya Medical Association (KMA) which nominates a board member to SHA for a three-year term. I do not speak for the member.
I also participated in the improvements of National Health Insurance Fund (NHIF) that birthed the added benefits of surgery, renal and oncology care.
I personally support several close members with chronic illnesses who depend on daily medication for survival.
I’m grateful to God that I have remained in good health.
I have colleagues who run facilities treating SHA patients.
These realities place me at the intersection of provider, contributor, and caregiver — making my experience a microcosm of what many Kenyans are silently enduring. Let’s just say I know SHA. The views expressed below are the sum of my experiences with SHA.
Universal Health Coverage: Promise Versus Reality
Universal Health Coverage (UHC) means that all people can access the full range of quality health services — from promotion and prevention to treatment, rehabilitation and palliation — without suffering financial hardship. It is meant to protect citizens from catastrophic health expenditure.
However, under the current SHA model, this promise is increasingly being undermined by rising out-of-pocket expenditure, delayed reimbursements, and restrictive service definitions that disadvantage both patients and healthcare providers.
The Financial Burden on the Contributor
I contribute 2.75% of my gross salary to SHA premiums, in addition to 30% PAYE and 1.5% Housing Levy. I pay SHA premiums for my retired parents. Under NHIF, their outpatient medications were accessible at Level 4 facility near their residence. Under SHA, outpatient chronic care at Level 4 and 5 facilities is no longer considered primary healthcare and is therefore not reimbursed. Yet nearby Level 3 facilities lack both the medications and capacity to manage these chronic conditions. The result is simple: despite regular premium deductions, I must now purchase these medications out-of-pocket for my parents from the already haemorrhaged pay slip.
Similarly, I support other relatives who require multiple medications, none of which are adequately covered by SHA. So in my experience this transforms insurance (SHA) from a protective mechanism into a symbolic contribution with no tangible benefit.
The Collapse of Provider Confidence
As a healthcare provider I’ve submitted claims to SHA for services rendered. Many providers where I provide care have done so too. These claims frequently go through an AI and digital claims processing system that rejects legitimate claims due to technical submission errors rather than absence of service delivery. Once rejected, SHA declines payment citing audit risks.
The consequences are severe:
• Facilities are forced to absorb unpaid costs.
• Providers seek bank loans to bridge operational gaps.
• Interest payments accumulate.
• Staff are downsized, contributing to unemployment.
• Facilities eventually face closure.
The irony is stark: a provider who faithfully contributes to the health financing system, pays taxes, and supports employees is denied payment for verified services, yet expected to continue operating sustainably.
The Core Problem
SHA has shifted from being a healthcare financier to an overly prescriptive regulator of where care should be provided. In doing so, it has:
• Disrupted continuity of care for chronic patients.
• Increased out-of-pocket expenditure.
• Driven providers away from the system.
• Weakened public trust in UHC.
In essence, the system now punishes both the patient and the provider.
SHA must work. So, I chose to continue giving positive recommendations to salvage the program. I do so as a concerned patriot.
The Way Forward: Practical Policy Recommendations
1. Restore Coverage for Chronic Care and antenatal care at Level 4 and 5 Facilities. Chronic illness management must follow patient reality, not bureaucratic categorisation. SHA should reimburse services based on care delivered, not the tier of facility.
2. Separate Financing from Service Location Control
SHA should focus on its core function: strategic purchasing and reimbursement. Clinical decisions on where care is best delivered must be guided by patient need, not administrative rigidity.
3. Claims Review Reform
Introduce a human clinical validation layer for rejected claims and allow structured appeal mechanisms with defined timelines to protect providers from arbitrary system rejections.
4. Timely and Predictable Payments
Establish a legally binding reimbursement timeline (e.g. 30–45 days) with penalties for delayed payments to protect facility cash flow.
5. Transparent Public Reporting
SHA should publicly disclose claims payment performance and outstanding debts to enhance accountability.
6. Targeted Protection for Chronic Illness and Vulnerable Groups
Create special benefit packages for chronic disease patients, the elderly, persons with disabilities, and those requiring lifelong medication.
7. Stakeholder Engagement and Co-creation
Integrate professional bodies such as the Kenya Medical Association into SHA policy design to ensure reforms are grounded in practical clinical realities.
8. Independent Oversight and Audit Mechanism
Establish an external body including healthcare professionals, patient representatives, and economists to evaluate SHA’s impact on UHC outcomes.
In Conclusion
The current SHA operational framework has shifted healthcare financing risk from the State to the individual Kenyan. Those who should be protected are instead forced to dig deeper into their pockets, borrowing, selling assets, or foregoing treatment altogether.
Universal Health Coverage cannot exist where contribution is mandatory, but access is conditional, unreliable, and geographically impractical. A system that impoverishes its contributors while denying providers fair reimbursement is unsustainable.
If Kenya is to truly achieve Universal Health Coverage, SHA must decisively realign its operations to prioritise patient access, provider sustainability, and financial protection — not administrative rigidity.
I write not only as a clinician and policy advocate, but as a Kenyan whose lived experience reflects the silent burden of millions of Kenyans.
Picture caption: The receipt above is an out-of-pocket medicine purchase that SHA should take care of but does not
Dr Simon Kigondu, Husband, Dad, Son, Brother, Director, Obstetrician Gynaecologist, HRD