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Discover the comprehensive benefits covered under Kenya's Social Health Authority (SHA), including primary care, inpatient services and emergency treatment.

Benefits Covered Under Social Health Authority (SHA)

Posted on by Tutorials Handbook

The Social Health Authority (SHA) plays a crucial role in enhancing healthcare access and affordability for Kenyan citizens. By establishing various health funds, SHA ensures that individuals, regardless of their financial circumstances, can receive necessary medical services.

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Below, we explore the benefits covered under three key funds managed by SHA: the Primary Health Care Fund (PHF), the Social Health Insurance Fund (SHIF), and the Emergency, Chronic, and Critical Illness Fund.

What are Benefits Covered Under Social Health Authority (SHA)?

The Social Health Authority (SHA) is an initiative designed to provide comprehensive healthcare services to citizens by offering various health benefits through specialized funds. These benefits ensure that individuals across different economic backgrounds can access essential medical services without the burden of high out-of-pocket expenses. The SHA’s key goal is to enhance public health by making healthcare services more affordable and accessible to everyone in Kenya, with the ultimate aim of achieving universal health coverage.

The benefits covered under SHA are divided into three main funds: the Primary Health Care Fund (PHF), the Social Health Insurance Fund (SHIF), and the Emergency, Chronic, and Critical Illness Fund. The PHF covers basic and essential healthcare services at no cost to the individual, including treatment at dispensaries and health centers. The SHIF offers more advanced medical services such as inpatient care, maternity services, and specialized treatments like surgery, mental health care, and oncology services. These funds help ensure that even for more complex healthcare needs, individuals have access to quality medical services.

In addition, the Emergency, Chronic, and Critical Illness Fund steps in when patients face life-threatening emergencies or have long-term chronic illnesses. This fund provides coverage for emergency medical treatment across Kenya and offers support for managing chronic conditions, especially after the SHIF benefits are exhausted. Together, these benefits provided by SHA form a well-rounded safety net that addresses a wide range of healthcare needs, ensuring that individuals can receive the care they need without facing financial hardship.

Benefits Covered Under Social Health Authority (SHA)

1. Primary Health Care Fund (PHF)

The Primary Health Care Fund (PHF) is a fundamental pillar of SHA’s commitment to universal health coverage in Kenya. The PHF aims to remove financial barriers that prevent people from accessing essential health services, especially at the primary level.

Free Treatment at Dispensaries and Health Centers

One of the standout features of the PHF is its provision of free treatment at dispensaries and health centers across the country. These facilities are often the first point of contact for individuals seeking medical care, particularly in rural and underserved regions. The services covered under the PHF include:

  • Preventive and Promotive Health Services: This involves routine check-ups, immunizations, and health education aimed at preventing diseases.
  • Basic Diagnostic Services: Patients can access basic laboratory and diagnostic services to determine their health status and initiate appropriate treatment early.
  • Treatment of Common Illnesses: The PHF covers the treatment of common ailments such as malaria, respiratory infections, and diarrheal diseases, which are prevalent in many parts of Kenya.
  • Maternal and Child Health Services: The PHF prioritizes the health of mothers and children by covering services such as prenatal care, immunizations, and child nutrition programs.

Funding

Unlike many health insurance programs that require individual contributions, the PHF is fully funded through government allocations and grants. This ensures that every Kenyan, regardless of income level, can access basic health services without having to worry about payment. The government’s decision to fund the PHF underscores its commitment to achieving universal health coverage.

2. Social Health Insurance Fund (SHIF)

While the PHF focuses on primary healthcare, the Social Health Insurance Fund (SHIF) is designed to cover more advanced medical services, including inpatient care, maternity services, and specialized treatments. SHIF ensures that individuals who require more intensive healthcare services, such as hospital admissions or complex treatments, can receive them without facing overwhelming financial burdens.

Inpatient Services

Inpatient care can be financially burdensome, especially for those requiring extended hospital stays. SHIF steps in by covering the following inpatient services:

  • Pre-admission Evaluation: Before admission to a hospital, patients often require evaluations, which can include diagnostic tests and consultations with specialists. These costs are covered under SHIF, ensuring a smooth transition into inpatient care.
  • Hospital Accommodation: SHIF covers the costs of staying in a hospital, including the use of a hospital bed and room charges. This benefit is essential, as hospital accommodation fees can quickly accumulate, particularly during long stays.
  • Meals: Inpatient meals, which are necessary for patients’ recovery, are also included under SHIF.
  • Nursing Care and Ward Bed Charges: Patients in hospitals receive nursing care around the clock. SHIF covers the costs of this essential service, as well as the charges associated with staying in a hospital ward.

Maternity and Neonatal Care

Maternal and neonatal care is a high priority under the SHIF. The fund provides coverage for all services related to childbirth, ensuring that mothers and their newborns receive adequate care without financial strain.

  • Antenatal Care: SHIF covers routine check-ups and services that monitor the health of expectant mothers throughout pregnancy.
  • Delivery Services: Whether a mother requires a normal delivery or a cesarean section, SHIF provides financial coverage for the associated medical costs.
  • Neonatal Care: Once the child is born, SHIF continues to cover essential services such as newborn vaccinations, early health evaluations, and care for any immediate health conditions.

Specialized Treatments

SHIF goes beyond basic inpatient services by offering coverage for a wide range of specialized treatments, which can be prohibitively expensive for many patients. These specialized treatments include:

  • Renal Care: For patients with kidney diseases, SHIF covers services such as dialysis and other kidney treatments.
  • Mental Wellness: Mental health care is often overlooked, but SHIF ensures that patients can access necessary psychological services and therapies.
  • Surgical Services: SHIF provides coverage for surgeries, including both elective and emergency operations.
  • Haematology and Oncology: Patients suffering from blood disorders or cancer can receive treatment without worrying about the steep costs, as SHIF covers these areas as well.
  • Medical Imaging: Expensive diagnostic procedures such as MRIs, X-rays, and CT scans are included under SHIF, allowing patients to receive proper diagnoses.
  • Oral Health: SHIF also covers oral health services, including dental surgeries and treatments, ensuring comprehensive healthcare coverage.

3. Emergency, Chronic and Critical Illness Fund

The Emergency, Chronic, and Critical Illness Fund is the third essential component of SHA’s healthcare coverage. This fund is designed to support individuals who face life-threatening emergencies, manage chronic illnesses, or require ongoing treatment for critical health conditions.

Chronic Illness Management

Chronic illnesses such as diabetes, heart disease, and hypertension often require long-term management and frequent medical attention. After the benefits of SHIF are exhausted, the Emergency, Chronic, and Critical Illness Fund steps in to provide continued coverage for chronic illness management. This ensures that individuals with long-term health conditions can receive ongoing care without depleting their financial resources.

  • Medication Coverage: Patients with chronic illnesses often need daily medications, which can be costly. The fund covers the costs of these medications, ensuring that patients do not have to compromise on their treatment due to financial constraints.
  • Routine Monitoring and Specialist Consultations: Individuals with chronic conditions need regular check-ups and consultations with specialists. The fund ensures that these ongoing expenses are covered.

Emergency Treatment

Medical emergencies, by nature, are unexpected and can lead to severe financial distress. The Emergency Treatment benefit under this fund covers the costs of urgent medical care, including ambulance services, emergency room treatments, and life-saving procedures.

  • Ambulance Services: The fund covers the costs of emergency transportation, ensuring that patients in critical condition can reach hospitals quickly.
  • Emergency Room Care: Once at the hospital, the costs of emergency treatments, including immediate surgeries or interventions, are covered under this fund.
  • Nationwide Coverage: One of the key features of this benefit is that it provides coverage for emergency medical services across Kenya, ensuring that all citizens can receive prompt care during emergencies, regardless of their location.

Critical Illness Coverage

For individuals suffering from severe, life-threatening conditions such as cancer, heart disease, or organ failure, the fund provides coverage for critical illness treatment. This ensures that patients facing high medical costs for life-saving treatments, including surgeries, chemotherapy, or organ transplants, receive the care they need without incurring unbearable expenses.

Conclusion

The Social Health Authority (SHA) in Kenya is a vital institution that helps provide comprehensive healthcare services through its various funds. The Primary Health Care Fund (PHF) ensures that every citizen can access essential health services for free at dispensaries and health centers, while the Social Health Insurance Fund (SHIF) covers inpatient services, maternity and neonatal care, and specialized treatments. For individuals facing emergencies, chronic illnesses, or critical health conditions, the Emergency, Chronic, and Critical Illness Fund provides ongoing coverage even when SHIF benefits are exhausted.

READ ALSO: The Complete Social Health Authority (SHA) Guide

Through these three funds, SHA continues to make healthcare accessible and affordable for all, playing a critical role in Kenya’s journey toward achieving universal health coverage. This comprehensive health coverage not only promotes public health but also reduces the financial burden on individuals and families, contributing to the overall well-being of Kenyan society.

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