How new SHIF is moving away from the NHIF model in favour of private insurers

Private medical insurance providers are poised to revolutionize healthcare in Kenya through their significant role in the planned Social Health Insurance Fund (SHIF).

The government's recent draft regulations reveal a shift from the National Health Insurance Fund (NHIF) to contracted private insurers and claims agents, aiming to streamline claims processing and enhance efficiency.

Under the proposed system, healthcare providers will submit claims within seven days of a patient's discharge to contracted insurers.

“A healthcare provider or health facility shall, within seven days from the date of discharge of the patient, lodge a claim to the claims management office or a medical insurance provider and claim settling agent, where applicable, for review and processing of the claim,” the draft read.

Approved claims will then be forwarded to the Social Health Authority for payment, addressing the persistent issue of delays in NHIF settlements.

Tom Gichuhi, CEO of the Association of Kenya Insurers, views this as a lucrative opportunity for private insurers, emphasizing that the new employee-based deductions are unlikely to impact private businesses adversely.

“This presents a new business for commercial medical insurers and claims settling agents,” Gichuhi stated.

"So if the authority is going to outsource, it certainly presents a new business."

Hospitals are mandated to provide insurers with patient details, and selection will be conducted through competitive bidding based on registration, licensing, and medical expertise.

The draft regulations outline a zonal approach with eight designated zones, ensuring effective and localized healthcare coverage.

In essence, this collaborative effort between the public and private sectors signals a transformative era in healthcare financing.

As the SHIF takes shape, private insurers emerge as catalysts for change, marking a significant leap forward in Kenya's healthcare landscape.