The Social Health Authority (SHA) has unveiled new guidelines for Kenyans seeking specialized medical treatment abroad under the Social Health Insurance (SHI) scheme.
In a notice on September 20, the Cabinet Secretary for Health, Aden Duale, said the new framework—anchored in the Social Health Insurance Act, 2023—aims to ensure transparency, accountability, and value for money, while guaranteeing that no Kenyan is denied access to life-saving care unavailable locally.
“The Ministry of Health, through the Social Health Authority (SHA), is proud to announce a new era for specialized medical care for all Kenyans under the Social Health Insurance (SHI) scheme. This milestone is a testament to the government’s commitment to ensuring that no Kenyan is denied access to lifesaving, specialized medical and surgical procedures not yet available locally, while simultaneously strengthening our national health system,” read part of the notice.
The announcement comes after a rigorous, systematic, and evidence-based assessment by the Benefits Package and Tariffs Advisory Panel (BPTAP) to identify services eligible for overseas referral.
SHA Unveils Guidelines for Overseas Treatment
The new guidelines for overseas treatment are as follows:
- Legal Mandate: The Social Health Insurance Act mandates that SHA can only make payments to healthcare providers who are empanelled and have a contract with the Authority.
- Eligibility for Treatment Abroad: A beneficiary can only access treatment outside Kenya if the healthcare service is not available locally. The beneficiary’s contributions must also be up-to-date. The treatment must also be provided by an SHA-contracted health facility.
- Provider Requirements: Overseas facilities must be accredited in their home country and officially recognized by the relevant regulatory body in Kenya. A key requirement is that the overseas providers must be linked to a contracted health facility in Kenya to ensure continuous follow-up care upon the beneficiary’s return.
Also Read: Ruto Unveils 2.2 Million Kenyans Who Will Enjoy FREE SHA Services
- List of Services: The Benefits Package and Tariffs Advisory Panel (BPTAP) has already developed an initial list of 36 healthcare services not available in Kenya, which has been gazetted. This is a preliminary list, as the process of identifying additional interventions is continuous and will be guided by a comprehensive Health Technology Assessment (HTA).
- Approval Process: Referrals for overseas treatment will be subject to a peer review mechanism by the Claims Management Office to ensure medical necessity. The treatment sought must also fall within the financial limits of the benefits package and must not be an unproven, experimental, or unconventional therapy.
- Financial Limits: The maximum limit payable for overseas treatment/procedures is capped at Ksh500,000, subject to review upon completion of contracting and rate negotiations with accredited providers abroad.
Also Read: SHA Reveals Types of Treatments Govt Will Fund Abroad and Their Costs
Govt to Fund 39 Procedures for Overseas Treatment
Ministry of Health has also instructed the SHA Board of Directors to fast-track the empanelment and contracting of overseas facilities and to publish the list of contracted institutions, in order to facilitate approval of treatment requests abroad in line with the Regulations and Ministry guidelines.
Earlier, SHA CEO Dr. Mercy Mwangangi revealed that the government will cover 36 specific treatments that are unavailable in Kenya. The
Among the procedures to be covered abroad are complex pediatric cardiac surgeries, pregnancy-related intrauterine transfusions, and operations such as full femur and tibia replacements, all of which cannot currently be performed in Kenya.
At the same time, the SHA CEO clarified that the government will not cover treatments that can be performed locally.
“For example, if you decide you want to go for a hip replacement in India, it is not in the list of 39. That service is only reimbursable in Kenya because we have doctors and providers who can do it here. We have put a moratorium on such cases,” Dr. Mwangangi explained.
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