Navigating Kenya’s healthcare transition from the old NHIF to the Social Health Authority (SHA) can feel overwhelming, especially when managing long-term health conditions.
If you or a loved one is battling a chronic illness like cancer, diabetes, or kidney disease, knowing how to access the government’s dedicated chronic care fund is critical.
In a major move to protect families from catastrophic health expenditures, Health Cabinet Secretary Aden Duale signed Legal Notice No. 78 of 2026 (published in the Kenya Gazette Supplement No. 114). This directive radically upgraded the financial limits and added specific packages for previously neglected conditions like sickle cell disease.
Unlike the old system, SHA splits chronic disease management into a multi-tiered framework funded primarily by the Social Health Insurance Fund (SHIF) and the beefed-up Emergency, Chronic, and Critical Illness Fund (ECCIF). Here is the complete blueprint on how to claim these benefits at any empanelled hospital across Kenya.
The 3-tier chronic care framework
To claim effectively, you must understand where your treatment falls within the updated structure:
- Primary Healthcare Fund (PHC): Covers initial screening, routine management, and daily maintenance drugs for conditions like hypertension or asthma at Level 2 and Level 3 local clinics for free.
- Social Health Insurance Fund (SHIF): Funds advanced diagnostics, specialized medication, and inpatient surgeries at Level 4 to Level 6 referral hospitals.
- Emergency, Chronic, and Critical Illness Fund (ECCIF): Actively kicks in as a seamless safety net once your annual SHIF limits are exhausted. Under the 2026 adjustments, the ECCIF allocation for chronic illnesses has nearly tripled to ensure life-saving treatments do not stop.
Step-by-Step: How to access and claim your chronic package
Follow this verified procedural pathway to ensure your hospital bill is successfully processed through the SHA system without out-of-pocket hitches:
1.Verify Registration and Premium Compliance:Prerequisite.
Ensure you are fully registered under SHA. Dial *147# or log into the official Afya Yangu portal to confirm your active status. For formal employees, this is linked via your 2.75% gross salary deduction. For informal workers, ensure your means-tested premium (minimum KES 300 monthly) is active.
2.Obtain an Electronic Referral Link:System Requirement.
Except for life-threatening emergencies, specialized chronic care claims require a strict referral pathway. Visit your local Level 2 or 3 primary care facility first. The attending medical officer will upload a digital referral notice onto the SHA Health Information Exchange (HIE) system, routing you to an empanelled Level 4, 5, or 6 hospital.
3.Biometric Authentication at the SHA Desk:Hospital Check-in.
Upon arrival at the referral hospital, proceed directly to the dedicated SHA desk before undergoing specialized treatment. Present your National ID card or Social Health Insurance Number. The hospital clerk will conduct a biometric fingerprint scan to authenticate your identity and link your session to the live digital referral.
4.Pre-Authorization and Benefit Allocation:Treatment Approval.
For high-cost interventions like chemotherapy cycles, dialysis sessions, or surgeries, the hospital’s medical team submits a digital pre-authorization request via the SHA portal. The SHA system checks your remaining annual benefit limits and issues an automated approval token code within hours.
5.Automatic Transition to ECCIF Top-Up:Final Step.
If your ongoing chronic treatment exhausts your base SHIF allocation, the hospital billing system automatically routes the residual costs to the Emergency, Chronic, and Critical Illness Fund (ECCIF). You do not need to fill out separate paperwork; the backend system switches funds seamlessly based on your live medical records.
SHA Chronic Disease Benefit & Coverage Matrix (2026 Updates)
The latest 2026 gazetted adjustments expanded maximum caps and introduced highly requested granular coverages.
| Chronic Condition | What SHA Covers Under 2026 Rules | Maximum Financial Cap |
| Oncology (Cancer Care) | Consultations, chemo, radiotherapy, Brachytherapy, SBRT/SBRS, and diagnostics (PET, PSMA PET, CT, and MRI scans). Also covers supportive care (nutritionist, mental health, social worker) up to KES 2,500 per visit (max 4 sessions). | KES 800,000 total ceiling per beneficiary (Up from KES 550,000). The ECCIF portion alone was raised from KES 150,000 to KES 400,000. |
| Sickle Cell Disease | Specialized management interventions, including diagnostic tracking, severe pain crisis support, and specific blood element therapies. | KES 20,000 for apheresis platelets and KES 70,000 for Red Cell exchange procedures (each accessible up to 3 times per year). |
| Renal Care (Kidney) | Bi-weekly hemodialysis, peritoneal dialysis sessions, pre-transplant evaluations, and post-renal replacement therapies. | Full operational coverage per session at empanelled facilities; up to KES 480,000 allocated explicitly for the kidney transplant procedure. |
| Cardiology (Heart Care) | Open heart surgeries, angioplasty, pacemaker installations, and specialized cardiovascular interventions. | Up to KES 952,000 for major cardiac surgeries, managed fully via case-based billing. |
| Routine Management | Daily maintenance drugs for type 2 diabetes, epilepsy, and chronic asthma. | Fully covered on a walk-in, walk-out basis under the Primary Healthcare Fund at lower-tier facilities without out-of-pocket costs. |
Crucial care limits to remember
SHA has introduced stricter caps on high-end imaging to prevent hospital system abuse.
- Diagnostic Scan Limits: CT scans, MRI scans, bone scans, and PET scans are strictly limited to one scan per policy period (one year) per patient. The standardized SHA reimbursement rates are fixed at KES 6,900 for CT scans, KES 11,000 for MRIs, and KES 53,500 for PET scans.
- Supportive Medicines: Up to KES 10,000 has been set aside within the cancer package specifically for supportive medicines—the vital drugs that manage treatment side effects like severe nausea, chronic pain, and fatigue.
- Radiotherapy Sessions: Capped at a maximum of 30 sessions per year, reimbursed at KES 3,600 per session.
Critical Legal Warning for Patients: Under the Social Health Insurance Act, any empanelled facility attempting to force an active SHA member to buy chronic medications or pay for services out-of-pocket when those treatments are listed in the official SHA formulary is liable for direct administrative penalties. If a hospital claims a service is “not covered,” demand a formal pre-authorization review through the SHA hospital representative or call the official SHA customer care lines immediately.
