Pay Upfront or No Treatment: Hospitals Halt Credit to SHA for Teachers

Private hospitals under the Rural Urban Private Hospitals Association (Rupha) will stop offering services to teachers and police officers once their medical cover moves to the Social Health Authority (SHA) in December, citing unpaid debts and unresolved policy issues.

Rupha chairperson Dr Brian Lishenga announced the decision during a press briefing in Nairobi, stating that hospitals have not received payments from the current medical schemes, run by Medical Administrators Kenya Limited and Minet, for over a year. The teachers’ scheme, covering around 450,000 beneficiaries, and the police scheme are valued at Sh20 billion and Sh8.9 billion annually, respectively.  

Dr Lishenga called for a halt to the transition until all outstanding payments are cleared. He warned that the planned migration risks repeating the failures of the now-defunct National Health Insurance Fund (NHIF), which left hospitals with Sh33 billion in unpaid claims when public sector health schemes were transferred to private insurers. 

“They must come to SHA on a clean slate,” he said, emphasising the need for a smooth and accountable transition.

In response to continued non-payment, Rupha has also suspended all credit services to SHA, meaning patients must now pay upfront for non-emergency treatment. The association said it had issued a 14-day ultimatum earlier this month, which SHA failed to address. Dr Lishenga said hospitals are now facing financial distress due to the prolonged delays in claim settlements.

Rupha further criticised SHA’s operational procedures, particularly its rejection of valid claims and denial of treatment for patients with chronic illnesses. According to Dr Lishenga, SHA has repeatedly flagged legitimate claims as fraudulent and limited care for conditions such as cancer and kidney failure by restricting access once patients reach their allocated session limits. 

He highlighted the case of 70-year-old cancer patient Gatamu Waigwa, who was forced to delay treatment due to a lack of funds and limited coverage. The transition of the teachers’ scheme to the Public Officers’ Medical Scheme under SHA is set to take effect at the end of November. 

While the government aims to streamline public health insurance under SHA, Rupha warned that the move could worsen existing challenges if financial and administrative reforms are not implemented. Dr Lishenga called on Health Cabinet Secretary Aden Duale to reverse the Sh10.6 billion in rejected claims and to ensure greater transparency in the claim verification process. 

He said hospitals have not been given the chance to clarify or correct disputed claims, resulting in significant financial losses. While Rupha confirmed that it will continue providing emergency and critical care services, the association remains firm in its decision to withhold credit facilities from SHA. 

It attributed the move to the authority’s failure to meet its financial obligations and concerns over the sustainability of its funding model.