Kenya’s private hospitals are calling for full disclosure of the Social Health Authority’s (SHA) reimbursement formula, raising concerns that secrecy could lead to unpredictable payments and reduced healthcare quality. Under SHA’s disease weights model for outpatient services, payments are determined by a predefined formula rather than actual treatment costs, prompting fears that healthcare providers may prioritize conditions with higher reimbursements.
The Rural-Urban Private Hospitals Association (RUPHA) warns that a lack of transparency could erode trust and compromise patient care. Dr. Brian Lishenga, RUPHA chairman, argues that hospitals should have clarity on how reimbursements are calculated to ensure fair and predictable compensation. He cautions that undisclosed formulas may force hospitals to focus on more lucrative treatments while neglecting less profitable but essential services.
Despite concerns, Medical Services Principal Secretary Harry Kimtai reassures that the system is designed to prevent fraudulent claims, ensuring standardized reimbursement across facilities. However, healthcare providers remain skeptical, citing unpaid claims amounting to Sh30 billion from the defunct NHIF, which SHA replaced.
Beyond reimbursement issues, the SHA model has also complicated outpatient access in public hospitals, limiting walk-in visits at Level 4, 5, and 6 facilities. Patients are directed to lower-level hospitals, which often lack sufficient medical staff, equipment, and essential drugs. The shift has increased delays and compromised the quality of outpatient care, creating new barriers for Kenyans seeking medical treatment.
As hospitals continue to press for policy adjustments, the future of Kenya’s healthcare financing remains uncertain, with urgent calls for transparency, equitable reimbursement, and improved healthcare infrastructure.