How PWDs, unidentified patients are exposed under SHA emergency cover

Members of Parliament are concerned that unconscious patients or those unable to identify themselves in health emergencies risk being left with huge medical bills, amid the ongoing rollout of the Universal Health Coverage (UHC) reforms.

The MPs were concerned over numerous cases of stranded patients whose medical claims were partially rejected by the Social Health Authority (SHA) due to delays in identification.

The legislators made the remarks during a meeting between National Assembly Departmental Committee on Health, the Ministry of Health, and SHA.

Led by Nandi Woman Representative Cynthia Muge, the MPs condemned UHC policies that restrict emergency medical coverage for patients who remain unidentified upon admission.

Muge cited cases where critically ill patients are rushed to hospital unconscious and receive lifesaving care and once identified, SHA only assumes part of the bill, corresponding to the days the patient is formally recognised in the system.

“A patient may accumulate a bill of say about Sh600,000, but SHA only pays around Sh116,000, the portion covering days when their identity had been confirmed even if they were admitted for eight days,” she said.

“Why doesn’t the emergency fund cater for full duration even when the patient was unknown? The situation is even more traumatic when the patient dies before identification, forcing grieving families to bear the entire hospital and mortuary costs” she added.

Committee Chairman, Seme MP James Nyikal was also concerned over the plight of severely disabled individuals unable to register as principal members of SHA, some of whom may not possess national identification documents.

He cited a recent case in one of the hospitals involving a 22-year-old man with disability whose family has had to care for him as a child.

When he was taken for admission, however, Nyikal said the hospital staff declined to enroll him under the standard cover because the SHA system classified him as an adult who must register independently.

“He has no ID, he is sick, and the family is told to go and obtain documentation before treatment. Hospitals may want to assist, but the system automatically rejects such claims,” Dr Nyikal said.

Nyikal said that frontline health workers have been expressing frustration over their inability to override the system, even in critical emergencies.

“They suggested placing the patient under emergency care while resolving the registration challenge but admitted they had no legal authority to do so. So when the digital system fails in an emergency, who protects these people?” Nyikal posed.

Nyeri Town MP Duncan Mathenge said the newly enacted Persons with Disabilities Act, 2025 grants all persons with disabilities the legal right to free medical care in public health facilities.

He however warned that the current digital registration and benefits systems are not yet aligned with this new requirement.

“Section 25 of the PWD Act states clearly that PWDs are entitled to free treatment in public hospitals. The law is already in place, now the system must be reconfigured to fully comply and ensure that these citizens receive the care they are entitled to without barriers,” Mathenge said.

SHA Chief Executive Officer Dr Mercy Mwangangi acknowledged the concerns, saying the authority has already identified gaps affecting persons with disabilities under the new UHC framework.

She assured that policy reforms are underway to ensure patients with severe disabilities including those who remain under guardianship into adulthood — can be properly registered and covered.

“For instance, a cerebral palsy patient who is 30 years old should still be recognised under a guardian where appropriate,” Dr Mwangangi said.

She added: “A board-led process is ongoing to enable guardians to register such individuals without forcing them to be listed as principal members. We recognise the challenges and are addressing them.”

Mwangangi also stated that SHA is expanding assisted registration for PWDs, similar to the support offered to teenage mothers, while ensuring verification safeguards remain strong.

On emergency coverage for unidentified patients, Dr Mwangangi admitted that hospitals have not consistently issued mandatory notifications, resulting in unpaid claims and disputes with families.

Under current rules, SHA pays for the first 24 hours of emergency care for an unidentified patient.

If the patient is later confirmed to be a SHA member and remains unconscious in critical care, the authority can cover up to 12 days in HDU or ICU a system upgrade that is still being streamlined.

“Where the patient is not a registered SHA member, the cost of care beyond the first 24 hours unfortunately falls to the family,” she explained.

To improve accountability and reduce wrongful billing, she said the authority has introduced a national whitelist to track unknown patients admitted in emergencies especially when biometric identification fails due to lack of phone numbers or inability to generate OTP authentication.

Dr Mwangangi acknowledged that the issue becomes more complex when a patient passes away before identification is confirmed.

“We have seen cases where a deceased patient is later found to have been covered, but because no notification was made, the bill cannot be processed. We are fixing the system to prevent such distressing outcomes. The goal is that no Kenyan in an emergency is left without support from SHA,” she said.

This comes against the backdrop of Government’s move to make legal reforms to make it an offense to demand payment prior to providing emergency services both in public and health facility.

A letter dated October 6 by Solicitor General, Shadrack Mose to Parliament on Health(Amendment) Bill 2024 also called for prescribing penalty for an officer in charge of a public health facility, who demands payment prior to providing emergency services.

The proposal applies to public health facilities only, with Mose saying that Section 12 of the Health Act imposes a duty upon healthcare providers, whether public or private, to provide emergency medical treatment.

“Clause 3(1) proposes to amend Section 7 of the Act to introduce new subsection (4) to create an offense and prescribe penalty for an officer in charge of a public health facility who demands payment prior to providing emergency medical treatment… therefore, the proposal should be amended to apply to both public and private health facilities,” Mose said in the letter to the Clerk of the National Assembly.

To protect the healthcare providers, Mose said Section 28 of the Social Health Insurance Act establishes the emergency, chronic and critical illness fund to cover the cost of emergency treatment.

To this end, all healthcare providers, whether in public or private, should be able to provide emergency medical treatment and recover the cost from the Fund.

At the same time, Mose has proposed amendments to the Section 7 of the Act by adding a new subsection 5 to create an offense and prescribe penalty in relation to detention of bodies of deceased persons by public health facilities.