SHIF – INCREASED TAXATION, INCREASED OUT OF POCKET EXPENDITURE – A CASE STUDY

A close relative was diagnosed with Glaucoma, a sight threatening condition where fluid builds up in front of the eye, increasing pressures in the eye. This could damage the optic nerve if left untreated. An ophthalmologist recommended an urgent surgery called Ahmed Glaucoma valve Implant Surgery. Hoping that SHIF would cater for the bill, my close relative filled the Social Health Authority (SHA) preauthorization forms. The hospital said that that surgery was not covered in their contract by SHA. This was shocking, noting that the hospital is specialized in eye care. The hospital here felt that because the procedure was not expressly stated in the list gazetted by SHA, SHA would simply not pay. Moreover if they stated a similar procedure for preauthorization (costwise) they would be accused of corruption as the medical report may not match the claim. That being the case we were asked to pay out of pocket

This you would think is the typical medical emergency that the Social Health Insurance Fund (SHIF) was meant to take care of. It has all the hallmarks of a case that deserves to be paid for. It is an emergency. It has a primary healthcare component – prevention of blindness and full recovery of the patient would help the patient become productive citizens of the country to work and pay tax.

On contacting SHA, they said that there is a list of 65 eye operations that had been listed and gazetted, but unfortunately that particular operation was not in the list. It is unclear what a hospital is supposed to do when a procedure is not gazetted. This thus leads to lack of access of crucial healthcare to deserving Kenyans. Before passing on the Ophthalmology Society of Kenya (OSK) President Dr Kibata (RIP) fought very hard to have all ophthalmology operations listed by SHA.

In 2017 KMA convened a meeting with NHIF to address similar issues. The solution to an unlisted procedure, was that procedures that was not expressly mentioned in the NHIF list of procedures, could be described as either a minor or major procedure not expressly stated, that would then get preauthorized, and a medical report would accompany the claim. Maybe SHA should adopt this.

Having little fiscal leeway and wanting to ensure that we attempted to prevent blindness, I opened the famous medical fund-raising WhatsApp group and roped in family members and a few friends. It is ironic that medical appeal WhatsApp groups was what SHA purported would to eliminated by taxing SHIF. In context, in the month of October 2024, I have paid KES 126,000 as PAYE, SHI and Housing Levy to the government. Yet I was forced to open a Medical WhatsApp group to pay for a bill that should have been paid by SHA. The question therefore is, why should the state deduct a lot of my money and still make me government, by forcing me to pay out of pocket for what SHIF should pay?

When the Kenya Kwanza government came up with this Social Health Insurance Fund idea to be run by Social Health Authority (SHA) the Kenya Medical Association gave a lot of input into the bill in the form of memoranda and spoken submissions in meetings called by The Ministry of Health and SHA. Personally, I’ve made my views known on many platforms including simonkigondu.co.ke . Moreover, after a long struggle, the KMA nominee was eventually gazetted into the SHA board albeit eleven months late. Coincidentally, the KMA nominee is an ophthalmologist, and yet he was not immune from the challenges that I have faced trying to get an emergency eye treatment for a dependent. I have asked him to pass on my recommendations to the SHA board for consideration and improvement during their next meeting.

SHIF has led to an increase in taxation. I used to pay 1,700 as mandatory NHIF deductions (and paid for my parents KES 500). In the month of October 2024, the government has slapped me with a SHIF deduction of 10,845 KES and I still must pay for my parents. Salaries have not increased. In fact, the government has allowed banks to double their interest rates by removing the interest rate capping previously present and ridiculously increasing the Central Bank Rates (CBR) that the banks claim to be using as their base.

SHIF has led to an increase in Out-Of-Pocket expenditure. My parents used to receive their medications at a tertiary hospital that acted as their primary care centre. Now the hospital has said that they do not have a primary care contract. So, I have been forced to purchase the medicines that were previously covered by NHIF.

There are hospitals that are owed monies by NHIF/SHIF. These hospitals owe doctors monies for services rendered. Every time the doctors claim from these hospitals, the reply is always the same, NHIF / SHA has not paid.

The government is claiming equity in deductions to the social health insurance, but it is evident there is no equity in service delivery. It is no wonder that the faith-based institutions are calling for a return to NHIF.

A tax-funded UHC is what we have always advocated for. We did not ask to be taxed not to get care. The government really needs to get its act together. I still advocate for capping of SHIF deductions. I advocate for capping of CBR rates to single digits. The cost of living is a function of government. The impact of theories of economists impacts directly on wananchi.

Do you have a personal story about the impact of government healthcare polices on you. Email me on simonkigondu@gmail.com.
Make your voice heard. Kenya in yetu. Hatuhami!

Dr Simon Mucara Kigondu
Medical Fund WhatsApp Administrator