Kenya’s healthcare system has undergone a major transformation with the introduction of the Social Health Authority (SHA). Designed to deliver universal health coverage, SHA replaces the old National Hospital Insurance Fund (NHIF) and introduces a more structured, inclusive approach to healthcare access.
At the core of SHA is a three-tier benefit system that ensures Kenyans can access everything from basic outpatient services to advanced critical care. Here’s a clear breakdown of what SHA covers and how it works.
Primary Healthcare Fund (PHF): Free Basic Care for All
The Primary Healthcare Fund focuses on essential health services offered at Level 2 and Level 3 facilities such as dispensaries and health centres. One of its biggest advantages is that it is accessible to all registered Kenyans, even if they have not started making monthly contributions.
This level covers outpatient consultations, basic laboratory tests such as malaria, tuberculosis, and HIV screening, as well as access to essential medicines. Preventive services are also included, such as vaccinations under the Kenya Expanded Programme on Immunization (KEPI), family planning, and routine screenings for conditions like cervical and breast cancer.
This fund ensures that no Kenyan is locked out of basic healthcare, making it a critical foundation of universal health coverage.
Social Health Insurance Fund (SHIF): Core Hospital Coverage
The Social Health Insurance Fund is the main contributory component of SHA and applies to services offered at Level 4 to Level 6 hospitals. To access these services, individuals must have an active account with up-to-date contributions.
For salaried employees, contributions are set at 2.75% of gross income, while self-employed individuals pay based on a means-tested system, with a minimum contribution starting from KSh 300 per month.
Under SHIF, inpatient services are covered, including bed charges, nursing care, and meals. Maternity services are also included, with defined limits for normal deliveries and Caesarean sections.
In addition, SHIF covers specialised treatments such as dialysis, chemotherapy, and major surgeries, including high-cost procedures like kidney transplants. Optical and dental services are also partially covered, although with specific limits and conditions.
This fund forms the backbone of hospital-based care, ensuring that Kenyans can access more advanced medical treatment without overwhelming financial strain.
Emergency, Chronic and Critical Illness Fund (ECCIF)
The third tier focuses on high-cost and life-threatening conditions. The Emergency, Chronic and Critical Illness Fund is designed to step in when healthcare needs go beyond standard coverage.
Emergency services include free stabilisation for up to 24 hours in life-threatening situations such as accidents, strokes, or cardiac events. This ensures that patients receive immediate care regardless of their financial status.
For critical care, the fund covers ICU and HDU services within set limits, helping manage the high costs associated with intensive treatment. It also supports long-term care for chronic illnesses such as cancer and kidney disease.
In some cases, SHA even covers overseas treatment for specialised conditions that cannot be handled locally, offering a financial safety net for complex medical needs.
What SHA Does Not Fully Cover
While SHA offers broad coverage, there are still some limitations. Cosmetic procedures are generally excluded unless medically necessary, such as reconstructive surgery after an accident.
There are also limits on services like optical care, with restrictions on how often benefits can be accessed. Mortuary services are partially covered but only up to a capped number of days.
Understanding these limits is important to avoid surprises when seeking care.
Final Thoughts
The Social Health Authority represents one of the most ambitious healthcare reforms in Kenya’s history. By dividing coverage into three structured funds, it ensures that every Kenyan—from those needing basic care to those facing critical illness—has access to essential health services.
While the system is still evolving, its goal is clear: to make healthcare a right, not a privilege. By understanding SHA benefits and coverage, you can make informed decisions and fully take advantage of what the system offers.
