The Social Health Authority (SHA) Chairperson, Dr. Abdi Mohamed, has explained the rationale for maintaining limits on teachers’ healthcare insurance coverage and why the teachers’ capping cannot be scrapped.
Speaking in an interview on April 27, Dr. Mohamed noted that the system expanded access from about 800 to 10,000 facilities nationwide.
According to the SHA Chair, the expanded network has improved access by allowing beneficiaries, including teachers, to seek services from a wider range of healthcare providers without strict geographical restrictions.
“Teachers were previously limited to being treated in only 800 health facilities across the country. With SHA coverage, that number has increased to 10,000 facilities,” he said.
SHA Chairperson Explains SHA capping for teachers’ cover
The Chairperson noted that unrestricted access to services has led to increased utilization, a phenomenon referred to as moral hazard in insurance systems.
He explained that insured individuals may overuse services because costs are covered, whereas out-of-pocket patients tend to regulate their use more carefully.
“So, moral hazard occurs where the insured person does not care how they use the cover. They will go back as many times as they wish,” Dr. Abdi explained.
The authority further stated that insurance systems typically include benefit caps, such as outpatient limits, to ensure sustainability and controlled utilization of services.
“If you have two people, one is insured, and the other is paying out of pocket… the one paying out of pocket will be very careful how they use the services. But the insured one will not care; they will go as many times as they want because they are not paying.”
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SHA maintained that such limits are necessary to balance access to healthcare with the financial sustainability of the insurance scheme.
KUPPET Issues Strike Warning Ahead Of SHA Tariff Talks Tomorrow
Teachers in Vihiga County have announced a 14-day strike, citing dissatisfaction with the Social Health Authority (SHA) medical insurance system and calling for the removal of benefit caps ahead of the SHA tariff negotiations set for April 28.
The teachers claim that the current SHA arrangement is not functioning effectively and requires urgent reforms.
Addressing the media in Mbale Town, Vihiga, teacher representatives expressed concerns about challenges experienced under SHA, stating that the insurance scheme does not meet their healthcare needs.
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In a separate development in Isinya, Kajiado County, teachers under the Kenya Union of Post-Primary Education Teachers (KUPPET) have also threatened to down tools, citing similar grievances over the insurance performance.
The teachers reported dissatisfaction with the access and reliability of healthcare services under the SHA, arguing that the system has created operational difficulties for beneficiaries.
KUPPET officials in Kajiado further stated that the previous Minet health insurance scheme was more effective compared to the current SHA arrangement.
The unions are demanding an urgent resolution of the reported challenges, including a review of the capping model, as tensions over the healthcare scheme continue to rise among educators.
