Why SHA won't pay for patients treated abroad

Kenyans who have already sought treatment overseas will have to foot their bills.

The Social Health Authority (SHA) will not finance their treatment until a process to procure services abroad is ready.

SHA Chief Executive Officer Mercy Mwangangi yesterday told the National Assembly the process includes getting into contractual engagement with hospitals and ensuring the facilities have a local agents for referrals.

“This process should be concluded at the end of this month, February, and once it's concluded, it will now enable Kenyans to be able to access overseas package at Sh500,000. It is important that I clarify that under the new SHIF Act, a different process was introduced of contracting hospitals for overseas treatment,” she told the Public Investments Committee on Social Services, Administration and Agriculture.

But the committee members raised concern that Kenyans who have travelled abroad for treatment may be stuck because some of the hospitals have declined to offer them services until they get paid their dues.

“What about the people who are overseas right now? Before you do the contractual arrangements, what happens to their claims? Are you planning to reimburse to the tune of Sh500,000 in the claims? Or are you saying that they should take care of the debts? The situation is very sad because you don’t know when a patient will get sick. It is my suggestion that the government should settle the claims if the patient has receipts,” said Caleb Mule (Machakos Town).

Dr Mwangangi said those who were already abroad could not be helped since the hospitals are not yet contracted.

She told the committee that the defunct National Health Insurance Fund (NHIF) owed the overseas hospitals Sh146.3 million.

“Through SHA, unfortunately, because SHA does not have a contractual obligation, any Kenyan who left to go for treatment overseas with those providers may not be able to satisfy the contract. Those bills would have to be met by the Kenyans who have gone abroad to seek healthcare.”

Unlike the NHIF where a guaranteed payment was issued to certain number of hospitals, a procurement process has been introduced.

According to Mwangangi, the new process includes getting into contractual engagement with hospitals and ensuring the facilities have a local agents for referrals.

The procurement process has received approval from the National Treasury. The authority is now in the process of opening up submissions from the hospitals and extending contracts.

“With regards to issues to do with travel overseas, it will be important to emphasize that, unlike the NHIF at the time, SHA has now opened up to all facilities, even beyond India,” she said.

She had appeared to respond to the Auditor General's reports for 2021/2022 to 2024/2025.

She confirmed the authority has pending bills  owed by the NHIF amounting to Sh33 billion.

“We have started the verification of pending bills. We have already paid the end term and probably in a week's time, we will be completing pending bills for close to 5,000 providers who had claims under Sh10 billion. And these pending bills will start with an allocation to supplementary Sh33 million to be able to settle these claims,” said Mwangangi.

SHA said the new overseas package will cover 36 specific and complex medical procedures, some not available in the country. They include liver, bone marrow and pediatric kidney transplants, joint repairs, and bone replacement, bone marrow transplants for blood cancers, voice box transplants, fetal blood transfusions and treatment, stem cell transplant, complex congenital heart surgery, nerve treatment, and modern cancer treatment.

“Previously, NHIF had a guarantee for hospitals and that is why patients could get treatment. Under SHA now we have to follow all the rules of procurement, which means that SHA can only pay once the contractual obligations are in place.”

Already, Health Cabinet Secretary Aden Duale has indicated that SHA would only cover treatment costs for medical procedures not available in Kenya as part of stopping medical tourism and corruption between local and foreign doctors as well as ensuring the sustainability of SHA’s overseas treatment.

“We have introduced a robust, transparent framework for overseas referrals that puts the patient first and protects our resources.”

Committee Chairman Emmanuel Wangwe urged the quick signing of the contracts.

“Can you move quickly and settle this because if someone travels abroad and they get sick, they will have to be treated,” he said.