The Social Health Insurance Act funds include: the Primary Healthcare Fund, the Social Health Insurance Fund, and the Emergency, Chronic, and Critical Illness Fund. This eases the financial burden on Kenyans who cannot afford healthcare services.
Section 25 of the Act establishes the Social Health Authority(SHA), which pools all contributions made under the Act.This legislation aims to improve access to affordable healthcare by establishing various funds that target different aspects of healthcare financing. These funds—designed to support Kenyans who struggle with healthcare costs. They include The Primary Healthcare Fund, The Social Health Insurance Fund(SHIF), The Emergency, Chronic and Critical Illness Fund.
Primary Healthcare Fund
The Primary Healthcare Fund (PHC Fund) in Kenya was established as part of the government’s Universal Health Coverage (UHC) initiative. Every person resident in Kenya shall access healthcare services under the Primary Healthcare Fund in the manner provided under the Primary Health Care Act. Patients can access primary healthcare services through level 2 or level 3 health facilities that the Authority has empaneled and contracted .
The Primary Healthcare Fund shall be used to⸺
(a) purchase primary healthcare services from
primary healthcare facilities;
(b) pay health facilities for the provision of quality
primary healthcare services based on the tariffs
prescribed
and
(c) establish a pool for receipt and payment of funds
for primary healthcare in the country.
Social Health Insurance Fund
The Social Health Insurance Fund (SHIF) is established under Section 25 of the Act to manage and distribute healthcare resources effectively. Patients can access The Social Health Insurance Fund through level 4, 5 and 6 health facilities. This fund operates as the backbone of the country’s health insurance system.
The Social Health Insurance Fund shall be used to⸺
(a) Establish a pool of all contributions made under the Act.
(b) Purchase healthcare services from empanelled and contracted healthcare providers and health facilities, based on referrals from primary health facilities.
(c) Pay for quality healthcare services offered to beneficiaries under the Act, which includes:
- (i) Services from empanelled healthcare providers.
- (ii) Services from level 4, 5, and 6 health facilities.
(d) Receive funds appropriated by the National Assembly to support indigents, vulnerable persons, and individuals under lawful custody.
Emergency, Chronic, and Critical Illness Fund
This fund addresses the needs of individuals facing life-threatening conditions or chronic diseases that require costly medical care. It provides financial support for Kenyans battling conditions like cancer, heart disease, and other critical illnesses. Additionally, this fund steps in during medical emergencies, ensuring that patients receive immediate and necessary care without the concern of unaffordable hospital bills. To benefit from the Emergency, Chronic, and Critical Illness Fund, the beneficiary must transition from the Social Health Insurance Fund to the Emergency, Chronic, and Critical Illness Fund after depleting their benefits in the Social Health Insurance Fund’s benefits package.
The Emergency, Chronic, and Critical Illness Fund will:
(a) ensure access to quality emergency services and critical care;
(b) guarantee access to effective treatment for chronic and critical illnesses;
(c) finance the provision of emergency, chronic, and critical medical care; and
(d) pay healthcare providers and health facilities for emergency services based on the tariffs prescribed