The Social Health Insurance Fund (SHIF) plays a crucial role in Kenya’s healthcare system by providing comprehensive coverage to those who contribute premiums. Unlike the Primary Healthcare Fund (PHF), which is fully government-funded and accessible to all registered members, SHIF requires members to contribute regularly to access its benefits. These contributions enable the fund to offer a more extensive range of medical services, ensuring Kenyans receive high-quality healthcare that covers advanced treatments, specialized care, and hospitalization.
READ ALSO: Benefits Financed by the Primary Healthcare Fund (PHF)
SHIF has become a lifeline for many individuals and families, offering financial protection and reducing the burden of out-of-pocket expenses for medical care. This article delves into the various services and benefits financed by SHIF, highlighting its key features and explaining who stands to gain from this fund.
Key Features of Social Health Insurance Fund (SHIF)
- Individual Contributions: SHIF is a premium-based insurance scheme, where members must contribute regularly to maintain their membership. Contributions are determined based on income levels, ensuring affordability for all income groups.
- Paid-up Membership: To access SHIF’s benefits, members must be up-to-date with their contributions. Only paid-up members can receive coverage for the services offered under SHIF.
- Comprehensive Coverage: SHIF provides coverage for more advanced medical treatments, including specialist care, surgeries, chronic illness management, and hospitalization. This ensures that members have access to the care they need for a wide range of medical conditions.
Who Benefits from Social Health Insurance Fund (SHIF)?
SHIF is particularly beneficial for Kenyans who are financially capable of contributing toward their healthcare. This fund offers enhanced protection, covering advanced medical treatments and reducing out-of-pocket expenses.
SHIF is ideal for individuals and families seeking financial security against the high costs of healthcare, particularly in cases where specialized care is needed.
Benefits Financed by the Social Health Insurance Fund (SHIF)
Let’s explore the detailed benefits financed by SHIF across various healthcare services:
1. Outpatient Care Services
Scope of Cover: SHIF covers essential diagnostic laboratory investigations for chronic conditions such as Diabetes, Hypertension, Sickle Cell Anemia, and Chronic Obstructive Pulmonary Disease (COPD)/Asthma. The goal is to build a chronic disease registry for better disease management and prevention.
Tariff:
- Diabetes: KES 4,300
- Sickle Cell Anemia: KES 6,800
- Hypertension: KES 2,850
- COPD/Asthma: KES 700
Access Rules: These services are available once per year per person. SHIF covers up to the specified tariff, and members are responsible for topping up any additional charges beyond the cover.
2. Inpatient Care Services
Scope of Cover: SHIF covers inpatient services, including consultation fees, bed and nursing charges, laboratory and radiology examinations, prescription medication, post-discharge care, and physiotherapy. Blood products administration is also covered.
Tariff:
- Level 4 Hospitals: KES 3,360 per diem
- Level 5 Hospitals: KES 3,920 per diem
- Level 6 Hospitals: KES 4,480 per diem
Access Rules: There is a limit of 180 days of inpatient care per household each year.
3. Maternity, Newborn, and Child Health Services
Scope of Cover: SHIF covers comprehensive maternal and newborn health services, including Antenatal Care (ANC), normal deliveries, Caesarean sections, postnatal care, immunization, family planning, management of postpartum infections, neonatal care, and Anti-D serum administration for Rhesus-negative mothers.
Tariff:
- Normal Delivery & Essential Newborn Care: KES 10,000
- Caesarean Section & Essential Newborn Care: KES 30,000
Access Rules: These services are available in Level 2 to Level 6 facilities. ANC and postnatal services will be covered under the PHF’s outpatient care.
4. Renal Care Services – Dialysis
Scope of Cover: SHIF covers consultation, temporary catheter insertion, laboratory investigations, nursing care, dialysis services, and medication for members requiring haemodialysis or peritoneal dialysis.
Tariff:
- Haemodialysis/Haemodiafiltration: KES 10,650 (two sessions per week)
- Peritoneal Dialysis: KES 85,200 per month
Access Rules: Members will need to top up any amount exceeding the cover limit. Dialysis services are available in facilities with the necessary equipment.
5. Renal Replacement Therapies
Scope of Cover: SHIF covers pre-transplant evaluations, kidney transplants, and post-renal replacement therapy.
Tariff:
- Pre-transplant Evaluation: KES 150,000 per household
- Recipient Surgery: KES 700,000
- Donor Nephrectomy: KES 168,000
- Post-Renal Replacement Therapy: KES 200,000 per household
Access Rules: Available at facilities with renal transplant services.
6. Mental Wellness Services
Scope of Cover: SHIF provides mental health services, including mental health education, counseling, psychosocial support, and treatment for various mental health conditions such as behavioral, neurodevelopmental, and affective disorders. Rehabilitation for substance-related disorders is also covered.
Tariff:
- Outpatient Services: Covered under PHC outpatient services
- Inpatient Services: KES 67,200 for rehabilitation
Access Rules: Diagnosis and management of mental disorders have a limit of 180 days per household annually.
7. Surgical Services
Scope of Cover: SHIF covers minor, major, and specialized surgical procedures, including post-procedure care and rehabilitation services for critical surgeries. Immunosuppressive therapy for organ transplants is also included.
Access Rules: Three minor procedures, two major procedures, and one specialized procedure are covered per household per year.
8. Hematology and Oncology Services
Scope of Cover: SHIF covers cancer treatments such as chemotherapy, radiation therapy, hormonal therapy, and immunotherapy. It also covers diagnostics, surgical interventions, and management of pre-cancerous conditions.
Access Rules: Facilities with oncology services will provide the care with a cover limit of KES 400,000 per case.
9. Medical Imaging and Other Investigations
Scope of Cover: SHIF provides coverage for advanced medical imaging, including MRI, CT scans, mammography, fluoroscopy, ECHO, EEG, and specialized ultrasounds.
Tariff:
- MRI: KES 11,000
- CT Scan: KES 6,900
- Mammography: KES 3,000
Access Rules: Limit of two imaging sessions per household per year.
10. Oral Health Services
Scope of Cover: SHIF finances oral health services, including dental health education, consultations, tooth extractions, management of infections, and procedures such as scaling and polishing.
Access Rules: A limit of KES 2,000 per household is provided.
11. Overseas Treatment Services
Scope of Services: SHIF covers medical and surgical procedures not available in Kenya. The services will be provided by empanelled and contracted overseas healthcare providers.
Tariff: Limit of KES 500,000 per person.
Access Rules: This service will roll out 6–12 months after SHIF’s implementation.
Conclusion
The Social Health Insurance Fund (SHIF) is designed to provide Kenyans with advanced healthcare services, from outpatient care to complex surgical procedures and specialized treatments. By contributing to SHIF, members gain access to comprehensive healthcare services, ensuring financial protection from expensive treatments.
READ ALSO: The Complete SHA Funds Guide
Through SHIF, the Kenyan government continues to enhance the nation’s healthcare system, offering citizens high-quality medical care and reducing the financial strain of medical emergencies.
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