Kenya’s ambition to provide affordable, comprehensive health coverage through a national insurance system, now known as the Social Health Authority (SHA), has faced persistent challenges. Despite reform efforts, many Kenyans continue to struggle to access needed services, and the system’s finances have been strained by fraud and inefficiencies.
What Is SHA?
The Social Health Authority (SHA) is a state corporation established by the Social Health Insurance Act, 2023 to replace the former National Hospital Insurance Fund (NHIF). Its mandate is to manage public healthcare financing in Kenya and to ensure accessible, affordable, and quality health insurance for all Kenyans.
SHA oversees several funds, including the Primary Health Care Fund, the Social Health Insurance Fund, and the Emergency, Chronic, and Critical Illness Fund, all designed to broaden coverage and reduce financial risk for Kenyans.
SHA Fraud is a Setback
One of the biggest threats to the SHA’s effectiveness is fraudulent claims. In 2025, the authority reportedly nearly lost KSh 10.6 billion to fraudulent payouts , a huge loss in a system that is still trying to expand services. When public funds are diverted through inflated or fake claims, less money remains for genuine patient care.
Fraud often arises when:
- payment systems lack transparency,
- enforcement and auditing are weak, and
- some health providers collude with intermediaries to claim unjustified reimbursements.
Without stronger controls and accountability, public funds are at risk while service delivery remains inadequate.
At the same time, fake hospital registrations and misconduct have been flagged by SHA itself, and the authority has even provided reporting channels for the public to report suspected fraud.
Poor Services
Despite significant contributions by Kenyan workers and employers, many beneficiaries feel that the services they receive are insufficient.
Common complaints include:
- Frequent medicine shortages even basic drugs like paracetamol and antibiotics are often unavailable in many facilities.
- Long waiting times and limited outpatient care , which should be core elements of a functioning insurance system.
- Benefit gaps some members report minimal reimbursement caps that hardly cover actual costs in many clinics.
These frustrations persist even as the SHA expands, highlighting the gap between health financing and effective service delivery.
Not for All
The promise of SHA is universal coverage, but in practice access still varies.
For example:
- Children under five typically receive free care at most public hospitals. a policy that has provided real relief to many families.
- However, not all outpatient services are covered widely, and many Kenyans feel that the contributions they make are not yielding proportional benefits.
Some argue that specific groups — like civil servants — receive more complete access under current rules, while others face limited benefits. This discrepancy affects public perception of fairness in the system.
But Why?
The government reportedly spent KSh 104.8 billion on a billing system intended for public healthcare facilities. Critics argue that such systems should be standardized across both public and private facilities to improve claims tracking, reduce fraud, and increase oversight.
When every facility uses a unified digital billing and claims system, it becomes easier to monitor where funds are going and to flag anomalies before they become huge losses.
Zero Transparency
A recurring problem is weak enforcement of laws and weak accountability for fraud and misuse of funds. Even when irregularities are identified, few responsible parties face consequences. Without robust leadership and commitment to justice, the system will continue to leak resources.
Effective governance could push Kenya closer to a system where basic healthcare is truly affordable and reliably available.
It is Still Little
SHA collects roughly KSh 5.4 billion per month in contributions. While this is a significant amount, it still may not be enough to cover the full cost of comprehensive healthcare, especially if losses from fraud and inefficiencies continue. A more efficient, transparent system could make these funds go further for patients.
Way Forward
Kenya’s Social Health Authority represents an important step toward universal health coverage, but significant reforms are still required. Strengthening fraud prevention, standardizing billing systems, ensuring consistent availability of essential medicines, expanding equitable access to benefits, and enforcing accountability are all critical to the success of the system.
If these issues are addressed, SHA has the potential to evolve into a healthcare financing system that genuinely protects Kenyans from the financial burden of illness and delivers meaningful health outcomes.