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Health Insurers Given New Opportunity in Kenya

In this iPMI Global Country Guides Insights article, iPMI report author Ian Youngman, takes a look at the news that there are new opportunities arising in Kenya for health insurance companies.

  • In a move to bring in universal health insurance, the under performing National Health Insurance Fund will be replaced by a new Social Health Insurance Fund.
  • Kenya's President William Ruto has approved controversial legislation that will see the biggest shake-up of the health sector in more than 20 years.
  • This has been delayed by a court case.
  • The Kenyan Court of Appeal has given the go-ahead for a controversial healthcare insurance levy, overturning a previous ban.
  • Kenyans are to begin contributing to the SHIF soon, following the Appeal Court's ruling in January 2024 to allow the implementation of the scheme.
  • The Social Health Insurance Act 2023 repeals the National Health Insurance fund, establishing a social health authority that introduces three new funds that will secure publicly funded primary health care, universal health insurance, and equitable access to quality health services.
  • All three funds are managed by the Social Health Authority.
  • A primary care fund to pay for primary health care services will be set up.
  • The new Social Insurance Fund payment will enable low-income households to receive subsidised national health insurance to help pay for care, with an emphasis on primary care and prevention.

 

  • A third fund will pay the costs of management of chronic illnesses and pay for emergency treatment.
  • To support the primary care fund, employed Kenyans will make a monthly contribution of 2·75% of their salary capped at a minimum of Ksh 300 and a maximum of Ksh 5000.
  • Non-Kenyans resident in the country for more than 12 months are eligible to register.
  • The Social Health Insurance Fund (SHIF) Act 2023 removed the provision for enhanced covers that civil servants, public officers and employees of various government agencies have been enjoying over the years.
  • Details of financing for the other funds have not yet been established.
  • Social health insurance scheme presents new business for private health insurers.
  • The government plans to contract private medical insurance providers and claim settlement agents to review and process claims under the primary fund.
  • Insurers and claims settlement agents will be the link between hospitals and the Social Health Authority.
  • The insurers and agents will receive and review claims from healthcare providers.
  • Claims approved will then be forwarded to the Authority for payment while erroneous or incomplete ones will be returned to hospitals for correction.
  • The government has chosen this arrangement to speed up the claims management process.
  • This presents a new business for commercial medical insurers and claims settling agents.
  • The insurers and agents will have to be registered by the Insurance Regulatory Authority, have a valid licence and have at least two qualified and experienced medical doctors. They will submit bids that will be selected on a competitive basis.
  • The regulations have not specified the number of insurers or agents that SHIF will contract but these entities will manage the claims by zones.
  • No medical insurance provider and claim settling agent will be assigned to more than one zone. 
  • Eight zones are proposed in total, based on population size, disease burden, the geographical size of the area and estimated claims as informed by existing records and data.

About the Author

Ian Youngman is an independent writer and researcher specialising in insurance. He writes regularly for a variety of magazines, newsletters, and on-line services. He publishes a range of market reports, and undertakes research for companies. To read his latest report, International Health Insurance 2023, please click here, or visit the REPORTS section of iPMI Global.

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