Report On The Assessment Of Utilization Of Funds By Social Health Authority And Challenges Faced By Medical Facilities

A report of Health (National Assembly)

Published: December 2025 · 13th

Read the report (OCR extract)

REPUBLICOFKENYA THENATIONALASSEMBLY

THIRTEENTHPARLIAMENT-FOURTHSESSION-2025 DIRECTORATEOFDEPARTMENTALCOMMITTEES DEPARTMENTALCOMMITTEEONHEALTH

REPORT ON THE ASSESSMENT OF SOCIAL HEALTH AUTHORITY (SHA) UTILIZATIONOFFUNDSDISBURSEDSINCEINCEPTIONANDCHALLENGES FACEDBYFACILITIES

PUBLISHEDBY:

THEDIRECTORATEOFDEPARTMENTALCOMMITTEES CLERK'SCHAMBERS PARLIAMENTBUILDINGS NAIROBI

NOVEMBER,2025

| CHAIRPERSON'SFOREWORD. | CHAIRPERSON'SFOREWORD. | |----------------------------------------------------------------|----------------------------------------------------------------| | CHAPTER ONE. | CHAPTER ONE. | | 1.0 PREFACE | 1.0 PREFACE | | 1.1Establishment andMandateoftheCommittee | 1.1Establishment andMandateoftheCommittee | | 1.2 Subjects under the Committee | 1.2 Subjects under the Committee | | 1.3 Oversight | 1.3 Oversight | | 1.4CommitteeMembership | 1.4CommitteeMembership | | CHAPTERTWO | CHAPTERTWO | | 2.0INTRODUCTIONANDBACKGROUND. | 2.0INTRODUCTIONANDBACKGROUND. | | CHAPTERTHREE | CHAPTERTHREE | | 3.0 THE ASSESSMENT OF SHA UTILIZATION OF FUNDSINSELECTEDHEALTH | 3.0 THE ASSESSMENT OF SHA UTILIZATION OF FUNDSINSELECTEDHEALTH | | FACILITIES | FACILITIES | | CHAPTERFOUR | .40 | | CHAPTERFIVE 43 | CHAPTERFIVE 43 | | 5.0 | COMMITTEERECOMMENDATIONS 43 |

LISTOFANNEXURES

ANNEXUREI:AdoptionList

ANNEXUREII:Minutes

ANNEXURE III: List of Hospitals Visited (with Dates)

ANNEXURE IV: Attendance Register of Stakeholders Engaged

ANNEXUREV:Submissionsby theSelected HealthFacilities

CHAIRPERSON'SFOREWORD

TheDepartmental Committee onHealthof theNational Assemblyisguided byits constitutional and parliamentary mandate to safeguard the health and well-being ofthe people of Kenya. Through its oversightrole,the Committee continues to ensure thatpublic resources allocated to the health sector are effectivelyutilized,thatservice deliverymeets therequiredstandards,and thatKenyans have access to affordable and quality healthcare in line with the objectives of Universal Health Coverage (UHC).

This fact-finding visit report is a product of the Committee's commitment to accountability, transparency, and responsiveness to issues of concern raised by the public. It reflects the Homa Bay, Kakamega, Laikipia, and Nyeri Counties. The Committee acknowledges the cooperation extended by the respective county governments, health facility management teams, and other stakeholdersduringthevisits.

We hope that the findings and recommendations herein will inform policy, strengthen health systems,and contribute towardsbuilding a resilient healthcare sector that meets the aspirationsof theKenyanpeople.

HON.DR.NYIKALJAMESWAMBURA,CBS,MP. CHAIRPERSON,DEPARTMENTALCOMMITTEEONHEALTH

CHAPTERONE

1.0PREFACE

1.1EstablishmentandMandateoftheCommittee

1. TheDepartmental Committee on Health is one oftheDepartmental Committeesof the National Assembly established under Standing Order 216 whose mandates pursuant to the Standing Order 216(5) are as follows:

i. To investigate, inquire into, and report on all matters relating to the mandate, management, activities, administration, operations and estimates of the assigned ministries and departments;
ii. To study the programme and policy objectives of ministries and departments and the effectiveness of theimplementation;
iii. on a quarterly basis, monitor and report on the implementation ofthe national budget in respect of its mandate;
iv. To study and review all legislation referred to it;
V. To study, assess and analyse the relative success of the ministries and departments as measured by the results obtained as compared with their stated objectives;
vi. Toinvestigate and inquire into all matters relating to the assigned ministries and departments as they may deem necessary, and as may be referred to them by the House;
vii. To vet and report on all appointments where the Constitution or any law requires the National Assembly to approve,except those under Standing Order 204 (Committee on Appointments);
viii. To examine treaties, agreements and conventions;
ix. To make reports and recommendations to the House as often as possible, including recommendations of proposed legislation;
X. To consider reports of Commissions and Independent Offices submitted to the Housepursuant to theprovisions of Article254 of the Constitution; and

12. Xxi. To examine any questions raised by Members on a matter within its mandate.

1.2 Subjectsunder the Committee

2.In accordance with the Second Schedule of the Standing Orders, the Committee is mandated to consider matters related tohealth,medical care and health insurance, including universal health coverage.

1.3 Oversight

3. In executing its mandate, the Committee on Health oversees the:

i. State Department for Medical Services
ii. StateDepartmentfor Public Health and Professional Standards.

1.4 CommitteeMembership

4. The Departmental Committee on Health was constituted by the House on 27th October2022andcomprises thefollowingMembers:

Chairperson

Hon.Dr.Nyikal James Wambura,CBS, MP Seme Constituency

ODM Party

Vice-Chairperson

Hon. Ntwiga, Patrick Munene MP Chuka/Igambang'ombe Constituency

UDA Party

Hon.(Dr) Robert Pukose,CBS MP Endebess Constituency UDA Party

Hon. Owino Martin Peters, MP Ndhiwa Constituency ODM Party

Hon. Muge Cynthia Jepkosgei, MP Nandi (CWR)

UDA Party

Hon. Wanyonyi Martin Pepela, MP WebuyeEast Constituency

Ford Kenya Party

Hon. Kipng'ok Reuben Kiborek , MP Mogotio Constituency

UDA Party

Hon. Kibagendi Antoney, MP Kitutu Chache South Constituency ODM Party

Hon. Julius Ole Sunkuli Lekakeny, MP Kilgoris Constituency KANU

Hon. Maingi Mary, MP Mwea Constituency UDA Party

Hon. Mathenge Duncan Maina, MP Nyeri Town Constituency UDA Party

Hon. Lenguris Pauline, MP Samburu (CWR)

UDA Party

Hon. Oron Joshua Odongo, MP Kisumu Central Constituency ODM Party

Hon. (Prof.) Jaldesa Guyo Waqo, MP Moyale Constituency

UPIA Party

Hon.Mukhwana Titus Khamala, MP Lurambi Constituency ODM Party

1.5CommitteeSecretariat

5. TheCommitteeisfacilitatedbythefollowingstaffsecretariat:

Mr.Hassan AbdullahiArale

ClerkAssistantI/HeadofSecretariat

Mr. Timothy Kimathi Samson ClerkAssistantIII

Ms. Gladys Jepkoech Kiprotich ClerkAssistantIII

Ms. Marlene Ayiro Principal Legal Counsel I

Ms.Sheila Chebotibin Senior Serjeant-At-Arms

Ms.Faith Chepkemoi Legal Counsel II

Ms. Abigel Muinde Research OfficerIII

Mr.Hiram Kimuhu Fiscal Analyst III

Ms.Rahab Chepkilim AudioRecording OfficerII

Mr Eric Lungai Hansard Reporter I

Mr. Hillary Mageka MediaRelationsOfficerIII

CHAPTERTWO

2.0INTRODUCTIONANDBACKGROUND

2.1Background on theSocial HealthAuthority(SHA)

6. The Social Health Insurance Act, No. 16 of 2023, was enacted to provide a legislative framework for social health insurance,promote Universal Health Coverage (UHC), and guarantee all Kenyans access to affordable and comprehensive quality healthcare.The Act establishes the Social Health Authority (SHA), mandated to manage three public funds: 2. 1.PrimaryHealthcareFund-finances services inLevel 2 and 3facilities.It is exchequer-funded,removing direct financial burden from Kenyans and strengthening preventive healthcare as a sustainable financing model. 3. Social Health Insurance Fund-covers services in Levels 4,5,and 6 facilities, financed by mandatory contributions of 2.75% of income from Kenyans. 4. Emergency, Chronic, and Critical Illness Fund - finances emergency care, 3. 24-hour stabilization, and treatment of chronic or critical illnesses once insurance benefits are depleted. It is exchequer-funded and provides critical financial protection, particularly against illnesses like cancer. 7. The SHA is responsible for registering beneficiaries, collecting contributions, contracting accredited healthcare providers, making payments, and advising the Cabinet Secretary on policy matters. The Act also provides for a Claims Management Office to process claims and a Dispute Resolution Tribunal to handle appeals and complaints. 8. By design, SHA supports national development priorities, including Kenya Vision 2030, the Bottom-up Economic Transformation Agenda (BETA), and the UHC Policy (2020-2030). Its mandate aligns with the constitutional principle of Leaving No One Behind by ensuring healthcare access for vulnerable groups, including the elderly, indigents, and persons in lawful custody. 9. The Act further introduces mandatory registration of all members and digitization of claims and service processes to enhance efficiency, transparency, and fraud prevention. Healthcare providers are empanelled and contracted in consultation with accreditationbodiesresponsiblefor thequality of care.

2.2TheDigitalHealthAct,2023

10.The Digital Health Act, No.15 of 2023, establishes a regulatory framework for digital health services and creates the Digital Health Agency to oversee implementation.Its mandateincludes developingand maintaininga Comprehensive Integrated Health Information System (CIHIS), ensuring data governance, and safeguarding patient privacy.

11. Key functions include:

i Establishing registries as a single source of truth for health information.
(ii)Certifying digital health solutions in line with global standards.
(ii) Facilitating collection, analysis, and sharing of health data for policy, research, andservicedelivery
(iv)Supporting innovations such as telemedicine,health tourism,and e-waste management.

2.3ContextoftheFact-FindingVisits

12.The Departmental Committee on Health is established under Standing Order 216(5) of the National Assembly with the mandate to investigate, inquire into, and report on all matters relating to the mandate, management, activities, administration, operation, and estimates of the Ministries and State Departments assigned to it.

13. In addition, Article 95 of the Constitution of Kenya empowers the National Assembly todeliberate and resolveissues of concern to the people.Inline with this mandate, the Committee, during its sitting held on Tuesday, 26th August 2025, resolved to undertake a fact-finding visit to selected health facilities in Nairobi, Homa Bay, Laikipia, and Nyeri Counties. 14. The objective of the visits was to;

(i)Assess the utilization of SHA funds since the inception of the scheme.
(ii)Examine the impact of SHA financing on service delivery particular focus on the timeliness of reimbursements and efficiency of fund management.
(ii)identify challenges faced by health facilities inthe implementation of UHC programs and;
(iv) To provide recommendations for improving SHA's efficiency and effectiveness.
15.The facilities visited were as follows:
a)Nairobi County: Ladnan Hospital Ltd and Mbagathi County Hospital,
b) Homa Bay County: Matata Nursing Hospital, Nyandiwa Level 4 Hospital, St. Elizabeth Swindon, Rachuonyo County Hospital and Nyandiwa Health Centre.
Kakamega County: St. Mary's Hospital, Mumias,
(p Laikipia County: Nyahururu County Referral Hospital and Sipili Hospital
Nyeri County: PCEA Tumutumu Hospital and Nyeri County Referral Hospital

16. The visits were undertaken from Tuesday, 2nd September 2025, to Friday, 5th September 2025. This report presents the Committee's findings, observations, and recommendations arising from the engagements during thevisits.

2.4Methodology

17. The Committee adopted a multi-pronged methodological approach to generate reliableinsightson theimplementationoftheSocial HealthInsurance(SHI)scheme and the utilization of payments from the Social Health Authority (SHA), particularly within the framework of the Facility Improvement Financing Act, 2023. The methodology involved the following: 2. (i)Document Review:The Committee undertook a review of the legal and regulatorydocuments,includingtheSocialHealthInsuranceAct,theFacility Improvement Financing Act, 2023, SHA guidelines, and facility-level financial reports. 3. (i) Selection of Facilities: A purposive sampling approach was applied for diverse perspectives across health service providers. The sample included: County referral hospitals representing government health facilities, Mission (faithbased) hospitals providing essential healthcare services under SHA accreditation and Private health facilities contracted bySHA. 4. (ii)Site Visits:The Committee conducted visits to the selected facilities to observefirst-hand theimplementation of SHI and theFacilityImprovement Financing framework. The visits allowed members to assess infrastructure, service delivery processes, claims management, and financial flow systems. 5. (iv)Stakeholder Engagements: During the visits, the Committee held consultative meetings with a range of stakeholders, including: 6. a.Facility administrators and finance officers,

b. Healthworkers across cadres,
C. County health officials,and

9. d.Representatives of faith-based and private sector health providers. 18. This methodology provided qualitative insights into operational challenges, successes, and gaps in the implementation ofSHI and facility financing mechanisms. The Committee triangulated data from reviewed documents, site observations, and stakeholderinputs todevelop therecommendations.

CHAPTERTHREE

3.OTHEASSESSMENTOFSHAUTILIZATIONOFFUNDSINSELECTED HEALTHFACILITIES

3.1LADNANHOSPITAL,PANGANI

a)Facility Overview

19. Ladan Hospital, located in Pangani, Nairobi County, is a private health facility accredited under the Social Health Authority (SHA). The hospital provides both outpatient and inpatient services. The facility operates with a 5o-bed capacity and is equipped with a maternity unit, two operating theatres, an intensive care/high dependency unit (ICU/HDU), a radiology department, a laboratory, and various specializedclinics. 20. The hospital was previouslycontracted and empaneled under NHIF,with continuity carried forward into SHA since its inception in October 2024.Ladnan Hospital continues to. provide uninterrupted services, including outpatient, inpatient, maternity,and emergency care,despite facing financial challenges with the new system. The facility.is owned and managed by Ladnan Hospital Limited,which is fully under Metro Group PLC, a now unlisted public company with over 500 protocolsandoversightmechanisms.

b)FundingandReimbursements

i. Claims

| | Amount (Ksh) | Percentage | |----------------------|----------------|--------------| | TotalClaimsSubmitted | 325,609,818 | 100% | | Total ClaimsReceived | 192,583,146 | 59% | | OutstandingClaims | 133,026,672 | 41% |

SummaryofSHAFundingandReimbursementsDisbursed toLadnanHospital(October 2024-August 31" 2025)

21. Since SHA's inception, Ladnan Hospital Limited has received Ksh 192,583,146 in reimbursements, representing only 59% of the total amount claimed for the period October 2024 toAugust 2025. The hospital reports that this recovery ratio is not sustainable because SHA packages were priced in advance with quite low margins. There have been months when the facility received no payments at all, severely affecting cash flow and operational planning. 22. The facility faces significant challenges with SHA's reimbursement system, which provides lump sum payments without breakdown by fund type,unlike the previous NHIF system that automatically provided remittance schedules per invoice. This makesreconciliation difficult and affectstimely allocation toprivate doctors.

1Membersof theHealthCommilteeonavisitat LadnanHospitalinPangami

ii. Debt Position:

| Debt | Amount (Ksh) | |---------------------|----------------| | NHIFOutstandingDebt | 360,000,000 | | SHAOutstandingDebt | 133,026,672 | | TotalDebtBurden | 493,026,672 |

Thefacility reports a total debt burden of Ksh 493 million,withNH1F owingKsh 360 million (ready for verification) and SHA owing Ksh 133 million as at 31st August 2025.

Key Findings

23. The following key findings were identified:

i. Ownership and Governance;The Committee confirmed,in line with hospital management and Metro Group's filings, that Ladnan Hospital Limited fell wholly under Metro Group PLC,now an unlisted public company with over 500 shareholders and strict governance protocols.

3. i1 Delayed and InconsistentReimbursements fromSHA;thehospital has only received approximately 59% of claims, with no predictable payment schedule. The absence of detailed remittance advice creates difficulties inreconciliation and financial planning.

iii. High Debt Burden; The facility carries a substantial debt burden totaling Ksh 493 million, with significant amounts owed by both NHIF and SHA, affecting operational sustainability.
iv. Lack of Transparency in Payment Systems; SHA provides lump sum reimbursements without breakdown by fund type (SHIF, PHCF, and ECCIF), making it impossible to track payments by fund category and affecting accurate financialreconciliation.

6. Consultant-Driven Referrals; as a subsidiary of the Metro Group,Ladnan V benefits from access to a wide pool of consultants. These specialists frequently refer patients to the facility for inpatient care, especially for surgical interventions, thereby boosting patient volumes and strengthening Ladnan's position in surgical servicedelivery. 7. V1. Empanelment Process; the facility has reported no challenges,since the facility waspreviously contracted and empaneled underNHIF,with continuity carried into SHA.

vii. GeofencingRequirementforDoctors and System Challenges;the current system requires doctors tobe within a 1km radius for the One-TimePassword (OTP)to be generated and sent. This geofencing restriction often creates delays and inconveniences, limiting flexibility for doctors and affecting timely service delivery. Occasional system downtimes affecting claim submissions
viii. Patient Understanding and Enrollment Barriers; Patients struggle to understand the outpatient model and what is covered vs. excluded, creating dissatisfaction.The requirement for annual lump-sum contributions for selfemployed membershas been a barrier to enrolment and continuityof care.
ix. · Limited Coverage for Multiple Injuries; Patients are only allowed to benefit from coverage for a single case. In situations where a patient sustains two fractures, only one is covered, while the second must be paid for in cash. This creates financial hardship for patients and undermines the principle of comprehensive health coverage.
X. Strong Performance in Surgical Cases;Ladnan has consistently attracted surgical clients both during the NHIF period and under SHA. This is largely driven by referrals from its network of consultants.Additionally,when NHIF clientswerereceivedunderthenationalcapitationscheme,manypatientsbecame aware of the inpatient benefits,particularly for surgical procedures.

12. X1. Alignment with SHA Tariffs;for surgical cases,Ladnan operates effectively within the approved SHA reimbursement rates without requiring co-payments from clients.This approach has icreased affordability and made the facility more attractive to SHA beneficiaries seeking surgical services.

d)RequestbyHospital totheCommittee

24. The hospital respectfully submitted the following requests to the Committee for policy interventions and engagement with the Social Health Authority (SHA):

i. Reinstate the practice of issuing remittance advice before payments(as practiced under NHIF) to improve transparency, reconciliation, and financial planning.

ii. Address payment inequities across county, faith-based, and private facilities.

ii. Facilitate structured negotiations for clearance of outstanding debts totaling Ksh493millionfrombothNHIFandSHA.
iv. Strengthen SHA civic education programs to improve patient awareness of entitlements and covered services,particularly regarding outpatient care models.

3. Review authorizationprotocolstoreducetreatment delayswithoutincreasing risk of abuse

vi. Consider implementing more flexible contribution models for self-employed members toreduce enrolment barriers and improve continuity of care.
vii. Increase transparency by requiring SHA to publish full claim information including total claims for each fund,returns,rejections,and payments to improveaccountability andoversight.
viii. Establishacomprehensiveaccountability yframeworkthatholdsall stakeholders (members,SHA,hospitals,and doctors)accountable without discrimination,while addressing fraud concerns across theentire system.

3.2 MBAGATHICOUNTYHOSPITAL

a Facility Overview

25. Mbagathi County Referral Hospitalis a Level 5publichealth facility servingNairobi and its neighboring counties. Itis accredited by the Kenya Medical Practitioners and Dentists Council (KMPDC) with a bed capacity of 416 beds. The hospital offers a wide range of inpatient and outpatient services,including surgery,maternity care, renal dialysis, management of chronic and critical illnesses, and emergency care. It also serves as a training site with medical interns posted regularly.. 26. The hospitalis currently contracted with the SocialHealth Authority(SHA)under the Social HealthInsurance Fund(SHIF) since SHA's inception in October 2024. Despite this engagement, it has not received any reimbursements under the Emergency, Chronic, and Critical Illness Fund. All claims are submitted through SHA's designated digital platform.

b)Funding and Reimbursements

i. Claims

| | Amount(Ksh) | Percentage | |----------------------|---------------|--------------| | TotalClaimsSubmitted | 383018857 | 100% | | TotalClaimsReceived | 194,097,910.5 | 51% | | Outstanding Claims | 188920946.5 | 49% |

Sumnary of SHA Funding and Reinbursements Disbursed to Mbagathi County Hospital (October 2024-Present)

27. Since SHA's inception, Mbagathi County Hospital has submitted claims totaling Ksh 383,018,857 and received Ksh 194,097,910.5 in reimbursements,representing 51% of total claims submitted. Outstanding claims total Ksh 188,920,946.5, representing 49% of submitted claims. Only a portion of reimbursements are disbursed within expected timelines,with the remainder released in staggered, delayed, and fragmented payments.Reimbursement processing typically takes 60 to 120 days,

severely constraining thehospital's cash flow and undermining effective budget execution and service delivery planning.

2Hon. Cynthia Muge, seehing clarification, when the Committee held a meeting at Mbagathi Coumty Hospital.

28. approximately 500 claims worth Ksh 6 million and 39 claims worth Ksh 4 million have been returned for incomplete patient records (such as missing theatre notes and claim forms). In total, rejected claims amount to Ksh 18.3 million.

ii. Debt Position:

29. The facility claims to have experienced persistent challenges in recovering outstanding debts from the Social Health Authority (SHA). It reports that there is no structured or transparent process for following up on these debts, which continues to impede financial planning and service delivery.

c) Key Findings

30. The following key findings were identified:

i. Delayed andPartialReimbursementsfromSHA;thehospitalcontinues to experience delayed and fragmented disbursements from the Social Health

7. Authority (SHA), with only 57.2% of reimbursements made on time. This significantly affects cash flow,financial planning,and timelyimplementation of hospitalactivities.

ii. High Debt Burden; The facility carries a substantial debt burden totalling Ksh453.5million,inheritedfromNHIFand accumulatedunderSHA.Thelack ofastructuredfollow-upmechanismonoutstandingreimbursementshas furtherworsenedthesituation.
iii. Inadequate Service Coverage; Outpatient services are not covered at Level 5 hospitals under SHIF. Additionally, the withdrawal of the Linda Mama program has negatively impacted maternal and neonatal care services, particularly within the Neonatal Intensive Care Unit (NICU).
iv. WeakReferralSystem;Patients face challengesin accessing referred services due to their inability to afford SHA premiums.Thisundermines the efficiency of thereferral system and limits access tohigher-level carewithin the health network.

11. System Downtime and Capacity Building Challenges;SHA's digital systems experience frequent downtimes,which disrupt claim submissions and processing. In addition, online training related to empanelment and system usage are poorly structured, reducing staff efficiency and increasing the risk of rejected claims. 12. Vi. Service Delivery;Outpatient services are not covered at Level 5hospitals. Withdrawal of Linda Mama has negatively affected maternal and neonatal care, especiallyin theNICU.

vii. Referral System; Patients experience difficulties due to their inability to pay SHA premiums, limiting seamless transfers across facilities.
viii. Infrastructure & Projects; Several projects have stalled, including the Dental Unit, Critical Care Unit, and expansion of the Renal Unit.
ix. Supply Chain; KEMSA supplies are inadequate, with only a 30% fill rate on essential commodities. The hospital supplements supply through private vendors. Suppliers are also not honoring LPOs due to non-payment of their invoices.

| Debt | Amount (Ksh) | |---------------------|----------------| | NHIFOutstandingDebt | 279,576,802.00 | | SHAOutstandingDebt | 188,920,946.50 | | Total DebtBurden | 468,497,748.50 |

d)RequestbyHospital totheCommittee

31. The hospital respectfully submits the following requests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps: 1. Streamline SHA reimbursement processes to ensure timely and adequate disbursements.

ii. Facilitate the clearance of outstanding debts through structured negotiations involving SHA, NHIF, and the hospital.
ili. Reintroduce or establisha replacement for the LindaMamaprogram to support maternal and neonatal care services, particularly in the NICU.
iv. Fast-track the completion of stalled infrastructure projects, including the Dental Unit, Critical Care Unit, and Renal Unit expansion to improve service capacity.

6. Strengthen the referral system by subsidizing patient transfers and ensuring V fullfunctionality oflower-level facilities within thereferral network.

Vi. Improve the efficiency of theKEMSA supply chain,with a focus on increasing thefillrateforessentialmedicalcommodities.
vii. Upgrade SHA digital systems and provide well-structured, in-person training to improve staff capacity and reduce claim rejections.

3.3STELIZABETHSWINDON

a)FacilityOverview

32.St Elizabeth Swindon is a faith-based hospital founded by missionaries with the primarymissionofprovidingaffordableprivatehealthcareforvulnerable populations,especially those affectedbyHIV/AIDS.

33. The hospital partnered with government and development agencies to expand services and infrastructure, growing to a 34-bed facility. Initially accredited as a Level 3 facility by NHIF, the hospital has undergone several inspections and capacity reviews. 34. However, the hospital currently faces a critical operational challenge following systemic changes within the healthcare regulatory framework. The KMPDC system suddenlyreduced all Level3Bfacilities,including St ElizabethSwindon,to zerobeds without prior notice or inspection, despite the facility maintaining its physical 34bed license and infrastructure.As a result, the Social Health Authority (SHA) will notpayforadmissions. 35. The hospital can only admit cash-paying patients, excluding the vulnerable population it was designed to serve. Patients requiring admission are being redirected toLevel 4 facilities such asEvansHealthcare and Matata,leading to increased strain on thosehospitals andhardshipforpatients.

b)FundingandReimbursements

i. Claims

| | Amount (Ksh) | Percentage (%) | |-----------------------|----------------|------------------| | Total ClaimsSubmitted | 6,992,903.50 | 100% | | TotalClaimsReceived | 4,604,304.00 | 65% | | Outstanding Claims | 1,228,439.25 | 35% |

36. Since SHA's inception, St. Elizabeth Swindon has submitted claims totalling Ksh 6,992,903.50 and received Ksh 4,604,304.00 in reimbursements, representing 65% of total claims submitted.Outstanding claims totalKsh 1,228,439.25,representing 18% of submitted claims.Rejected claims amount to Ksh 1,160,160.25.The facility experiences payment delays that affect its ability to maintain consistent service delivery and meet operational obligations.

ii. Debt Position:

| Debt | Amount (Ksh) | |-----------------------|----------------| | NHIF Outstanding Debt | 2,600,000.00 | | SHA OutstandingDebt | 2,388,599.25 | | TotalDebtBurden | 4,988,599.25 |

37. The facility faces a total debt burden of Ksh 4,988,599.25, comprising SHA outstanding debt (Ksh 2,388,599.25) and inherited NH1F debt (Ksh 2,600,000.00).

c)Key Findings

38. The following key findings were identified: 1. Systemic Contradictions; There is poor coordinationbetween KMPDC, SHA, and DHA, with facilities receiving conflicting directives and no clear written communication. This lack ofalignment creates confusion at the facilitylevel and hinders smooth service delivery.

ii. Bed Capacity Conflict: The facility is licensed for 34 beds, yet the SHA portal reflects zero beds, effectively locking out patients dependent on SHA from accessing inpatient care. This discrepancy denies services to vulnerable populations.

4. ili Payment Model Barriers: The shift from NHIF's monthly or quarterly contributions to SHA's annual lump-sum payments has excluded many poor households that cannot afford upfront payments. This change has already reducedpatientaccess toessentialhealth services. 5. iV. Inspection Gaps; though recent joint inspections confirmed compliance, facilities were not issued written reports. Regional inspection officers also cite directives from the Cabinet Secretary halting inspections, leaving facilities withoutguidanceoncomplianceorimprovement. 6. Impact on Patients; Patients are increasingly denied inpatient care, with many resortingto self-medication,alternativetreatments,or travelinglong distances to higher-level facilities. As a result, the hospital is unable to fulfil its founding mission ofservingvulnerablepopulations.

d)RequestbyHospitaltotheCommittee

39. The hospital respectfully submitted the following requests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps: 2. SHA Insuranceshould be abletoeffectivelyaddress theissue ofbed capacity at the point of empanelment since all the required licenses and documents from relevant bodies areusually submitted at that stagebefore contracting the facility. The different levels should operate as licensed by KMPDC to ease congestion of patients in few facilities.

ii. SHAmustbe able tocommunicate effectivelywith allstakeholders and governing bodies to quickly address raised concerns aimed at improving services.
ii. SHA should streamline their communication and supportsystemfor seamless operations.
iv. SHA should sensitize thepublic about PHC tariffs to mitigate conflicts at billing stage.
V. SHA should explain to the facilities how the Global Budget Allocation operates to allowfacilities plan on service delivery according to contractual terms.

Vi. SHAshouldsendbackclaimsand allowfacilitiestoaddressmedicalreview concerns beforerejecting claims,the resubmission tabfor rejected claims should be addedinthedashboard.
vii. The dashboard should display all SHA payments: SHIF, PHC and Outpatient (Public Officers Medical Scheme)to allow easy reconciliation for the facilities.

3.4MATATANURSINGHOME

a)FacilityOverview

40.Matata Nursing Home is a faith-based healthcare facility operating as a Level 4 hospital mandated to offer both primary health care services and inpatient care. The facility has a bed capacity of 150 beds, which is generally adequate to meet patient demand except during health crises or disease outbreaks such as malaria epidemics.

41. The hospital was previously accredited under NHIF and transitioned to SHA when the Social Health Authority was established. The facility underwent both manual contracting initially andlater adopted thee-contractingsystem developed bySHA. The hospital is currently fully accredited and continues to serve patients despite facing significant operational and financial challenges under the newsystem. 42. As a faith-based organization, Matata Nursing Home plays a crucial role in sustaining healthcare provision to patients, particularly vulnerable populations who depend on affordable healthcare services in the region.

b)FundingandReimbursements
i. Claims

3Hon.JoshuaOron(left) is shown aroundMatataHospital when theCommitteevisited thefacility.

| | Amount(Ksh) | Percentage (%) | |----------------------|---------------|------------------| | TotalClaimsSubmitted | 118,277,076 | 100% | | Total ClaimsReceived | 63,801,537 | 54% | | Outstanding Claims | 54,475,539 | 46% |

Sunnary of SHA Funding and Reimbursements Disbursed to Matata Nursing Hone since its inception.

43. Since SHA's inception, Matata Nursing Home has submitted claims totalling Ksh total claims submitted. The amount received comprises Primary Health Care Fund payments of Ksh 12,140,098 and Social Health Insurance Fund payments of Ksh 51,661,439. Outstanding claims total Ksh 54,475,539, consisting of unpaid SHIF claims worth Ksh 50,675,539 and unpaid PHC claims worth Ksh 3,800,000. Only delays. The facility's payments have been on hold since June 2025, and letters of inquirytoSHAremainunanswered.

ili. Debt Position:

| Debt | Amount (Ksh) | |----------------------|----------------| | NHIF OutstandingDebt | 53,000,000 | | SHA OutstandingDebt | 54,475,539 | | TotalDebtBurden | 107,475,439 |

44. The facility faces a total debt burden of Ksh 107,475,539, comprising unpaid SHIIF claims (Ksh 50,675,539), unpaid PHC claims (Ksh 3,800,000), and inherited NH1F debt (Ksh 53,000,000).

ii. Key Findings

45. The following key findings were identified:

i. Delayed and Withheld Payments;TheFacility continues to face delays in receiving reimbursements, with some payments being withheld without clear explanations.Despiteverificationofdetails,fundsremainblocked due toissues such as mismatched facility codes, where wrong facility numbers are linked to claims, creatingunnecessaryfinancial strain onhospitals.
ii. Claims Rejections; There is a persistently high rate of claim rejections even when proper documentation including patient IDs, discharge summaries, and passports fraudulent, while some rejections are communicated months later, far beyond the legally stipulated 9o-day period, leaving facilities unable to resubmit claims in time.

3. iii SystemicIssueswithSHA;SHA'sheavyreliance on automationwithout adequate human oversight results in frequent errors. System downtimes often trigger fraud flags when patients are admitted during outages. Pre-authorization processes are impractical, requiring all doctors to log in simultaneously. Network issues and geocoding affect authorizations, especially in emergencies. Some doctors cannot 4. approve surgeries, and reimbursement favors public over private facilities. Allocation methods under capitation and global budgets lack transparency.

IV. Empanelment and Authorization; the transition from manual to e-contracting improved the empanelment process, but significant challenges remain. Claims often take over six months to be reimbursed,with minimal communication on claim status. Many are eventually rejected without clear justification. Surgical claims in particular remain stuck at the review stage, delaying payments to consultants and affecting service delivery.

6. Contractual and Policy Limitations; Rigid package rates, such as Ksh 30,0o0 for V caesarean sections,fail to coverextended hospital stays or complications.There are noprovisionsfor additionalclaimswhennewborns ormothers developfurther conditions. Outpatient claims remain poorly structured and inconsistently handled. 7. Vi. Governance and Accountability Gaps; Local SHA offices lack adequate authority to resolve pressing facility-level issues,forcing facilities to escalate matters unnecessarily. Senior officials in Nairobi often dismiss or redirect complaints without offering solutions, while internal disorganization within SHA results in departments—finance, claims, and compliance—passing responsibility back and forth, leaving problems unresolved.

vii. Service Delivery Impact on Vulnerable Populations; Quality services to patients have been paralyzed due to inadequate drug stocking. Expecting mothers cannot access medical treatment or maternity services without SHA registration and most patients to access medical services.
viii. Operational and Financial Constraints; As a service delivery gap, the facility reported that the statutory remittances including HELB,PAYE,NSSF,·and Housing Levy cannot be made, leading to accumulating penalties. The facility cannot meet obligations to patients and creditors,and staff payments are consistently delayed.
ix. Referral SystemInefficiencies;Referrals arenot seamless because thefacility cannotclaim ambulancecosts at Level 4,and ambulance services arenot covered underSHAbenefitspackages.
X. UHCImplementationBarriers;Barriersinclude therequirement forannual premium payments, unclear contribution rates,lack of coverage for critical services (e.g., ambulance services), monthly claim reimbursement cycles, and perceived discriminationin disbursement across differentfacilities.

iii. Requestby theHospital tothe Committee

46. Thehospital respectfully submitted the followingrequeststo the Committee,with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps:

i. Human oversight should bereinstated alongside AI systems to reduce wrongful rejections,whilethe 90-day payment rule must be strictly enforced for all approved claims. Additionally,pre-authorization processes should be improved by allowing asynchronous approvals, eliminating the impractical requirement for simultaneous doctorlog-ins.
ii. Facility coding errors must be corrected to prevent misallocationof claims, and SHA should increase transparency in how capitation and global budgets are

4. calculated. Fixed package payments should also be reviewed to better reflect the actual costs ofextended care and medicalcomplications.

iii. Rigid package rates should be reviewed to reflect actual costs of care, including provisions for complications and extended stays. Comprehensive coverage for ambulance services and outpatient chronic illness care should beimplemented.

6. 1V LocalSHAoffices should be empoweredwiththe authority toresolve issues withoutconstant referrals toNairobi.Aclear escalation pathway must be established forunresolved paymentmatters,supported byimproved customer care and stronger accountability mechanisms atSHA headquarters. 7. The apparent favoritism toward public facilities over private and faith-based V facilitiesin allocation and disbursement should beeliminated.Transparentcriteria for fund allocation should be established and consistently applied. 8. Vi. Contracts inherited from NHIFshould be reviewed to ensurepayment structures align with actual service delivery costs.Flexibility must be introduced for claims involving maternal and newborn complications, while counties should be required to remit contributions on time to avoid disruptions in service delivery.

vii. The annual lump-sum premium payment model should be reviewed to include flexible monthly or quarterly options for low-income households to improve access tohealthcare services.

3.5RACHUONYOCOUNTYHOSPITAL

a)1 Facility Overview

47. Rachuonyo County Hospital operates as a public healthcare facility serving thelocal community. The hospital faces significant operational challenges due to bed capacity discrepancies in official records,with some facilities licensed for 1oo beds being incorrectly listed as 2OO beds in SHA and KMPDC systems. These data inconsistencieshaveled tomisreporting andunfairpaymentpatterns,with attempts to correct these errors at the national level having stalled. 48. The facility provides both inpatient and outpatient services, with additional operational costs including oxygen supply services costing approximately Ksh 1.1 million. The hospital continues to serve patients despite facing significant systemic challengeswithSHA operations and fundingmechanisms.

b)FundingandReimbursements

i. Claims

| | Amount (Ksh) | Percentage (%) | |----------------------|----------------|------------------| | TotalClaimsSubmitted | 121,967,597 | 100% | | Total ClaimsReceived | 90,363,892.95 | 74% | | OutstandingClaims | 31,603,704.05 | 26% |

49. Since SHA's inception, Rachuonyo County Hospital has submitted claims totaling Ksh 121,967,597 and received Ksh 90,363,892.95 in reimbursements,representing 74% of total claims submitted.Outstanding claims total Ksh 31,603,704.05, representing 26% of submitted claims. The facility has also experienced rejected

claims amounting to Ksh 21,583,998. The facility experiences delayed disbursements that force the hospital into debt with suppliers for food, drugs, and consumables.Additional operational expenses include oxygen supply (approximately Ksh 1.1 million) and other costs for inpatient and outpatient services.

4Health Committee Chairman (Centre) Hon.(Dr) James Nyikal, chairing a meeting at Rachuonyo County Hospital.

ii. Debt Position:

| Debt | Amount (Ksh) | |----------------------|----------------| | NHIF OutstandingDebt | 22,430,880 | | SHA Outstanding Debt | 25,862,558 | | Total DebtBurden | 48,293,438 |

Key Findings

50. The following key findings were identified: 2. System Downtime; Frequent SHA system outages delay patient admissions and 1 claims processing. Patients are often admitted physically but entered the system later, creating audit and compliance issues. 11. Claims and Compliance; Facilities face slow authorisation procedures and cumbersome compliance requirements. Local SHA officers lack system access to 4. resolve disputes,while claims surveillance for verifying admitted patientsis nolonger functional.

ili. Primary Health Care (PHC) Funding; Although PHC is meant to be free for all registered members, facilities lack clarity on the per-patient reimbursement rate and how allocations are calculated. Payments are pooled globally and disbursed without transparentcommunication.

6. 1V Bed Capacity Discrepancies; Official SHA and KMPDC records often misstate bed capacities, with some facilities licensed for 100 beds being listed as 200. Attempts to correct these errors at the national level have stalled, leading to misreporting and unfairpaymentpatterns.

V. Delayed Disbursements;Latefund releasesforcehospitalsinto debtwith suppliers for food, drugs, and consumables, while stalling development projects such as toilets, generators, and equipment upgrades.

8. Vi. Tariff Misalignment; Contradictions exist between county service tariffs and SHA reimbursements—for example,county rates for deliveries are far below SHA packages. This creates inconsistencies between SHA guidelines, county finance bills, andthetruecostofcare.

vii. Access to Care;Patients not registered with SHA must pay cash, and many poor households still struggle to afford services despite PHC being nominally free.

d)RequestbytheHospital to theCommittee

51. The hospital respectfully submitted the following requests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) onidentified operationaland systemicgaps: 2. Improve System Reliability by investing in ICT to reduce downtime and ensure realtime patient admissions.

ii. Increase Transparency in PHC Funding by disclosing per-patient reimbursement ratesandallocationformulas
ili. Correct Bed Capacity Records through urgent alignment of digital records with physical verification by KMPDC and SHA.
iv. Streamline Claims and Compliance by restoring localverification capacity, granting regional officers' system access, and ensuring written feedback on compliance issues.
V. AddressTariff Discrepanciesby y aligning SHA reimbursement rates with county finance bills and regularly reviewing tariffs against inflation and actual costs.
vi. Ensure TimelyDisbursementswithpredictablefund release schedules toprevent service disruptions and supplier debts.
vii. infrastructure and equipment upgrades.
vili. Strengthen Data and Research by requiring facilities to track service disruptions, patient outcomes, and maternal health indicators during funding delays.

3.6NYANDIWALEVEL4HOSPITAL

a)FacilityOverview

52. Nyandiwa Level 4 Hospital is a public healthcare facility operating as a Level 4 hospital mandated to offer both primary health care services and inpatient care. The facility has a bed capacity of 60 beds according to SHA records, though only 46 beds are currentlyinusedue toward spacelimitations,withfourteen additionalbeds remaining in storage. The average daily occupancy is about 80%. 53. SHA reimbursements have financed construction,procurement of equipment, a modern kitchen, a septic tank, and other infrastructure.

b)Funding and Reimbursements

i. Claims

| | Amount (Ksh) | Percentage | |----------------------|----------------|--------------| | TotalClaimsSubmitted | 98,879,873.00 | 100% | | TotalClaimsReceived | 81,996,706.00 | 83% | | Outstanding Claims | 16,869,067.00 | 17.% | | Rejected Claims | 14,100.00 | 0.0143% |

Summary ofSHAFunding andReimbursements Disbursed toNyandivwaLevel 4 County Hospital since its inception - 31/08/2025.

54. Since SHA's inception, Nyandiwa Level 4 Hospital has submitted claims totaling Ksh 98,879,873 and received Ksh 81,996,706 in reimbursements, representing 83% of total claims submitted. Outstanding claims total Ksh 16,869,067, representing 17% of submitted claims. Rejected claims are minimal at Ksh 14,100, representing only 0.0143% of total submissions.SHApayments havebeenreceived, though delays were noted between April and June before clearance in August.Claims for outpatient services often reimburse less than the actual cost of drugs, lab work, and imaging. Preventive health allocations under PHC are unclear,with most funds going to curativeservices

5MembersoftheDepartmentalCommitteeonHealthinameetingwithhealthcarestaffatNyandirea Level 4Hospital

ii. DebtPosition:

| Debt | Amount (Ksh) | |----------------------|----------------| | NHIF OutstandingDebt | 5,653,500.00 | | SHAOutstandingDebt | 16,869,067.00 | | TotalDebtBurden | 22,522,567.00 |

55. The facility faces a total debt burden of Ksh 22,522,567, comprising SHA outstanding debt (Ksh 16,869,067) and inherited NHIF debt (Ksh 5,653,500). The outstanding SHA debt represents approved but unpaid claims that create operational challenges for the facility.

c) Key Findings;

56. The following key findings were identified: 2. 1 Governance and Financial Management Challenges;All SHA and FIF funds are remitted to the county,which returns 8o% to the facility.However,delays occur, and policies differacross counties,creating inconsistency.80/20 split varies by county,leading todelays and inefficiencies.TheHealth Management Team (HMT) and theBoard reviewbudgetsbefore approval and expenditure.KEMSA supplies some commodities,butfacilitiesmust supplementfrom other suppliers using FIF. The adequacy of KEMSA allocations remains a concern.

ii. Mismatch inBed CapacityRecords;SHA lists 6Obeds,but only 46 arein use, creating arisk of accusations of overbillingorfraud despite thefacility operating within its actual physical constraints.
ili. Weak Branch Support; The SHA branch offices lack adequate capacity and often refer cases to Nairobi headquarters, creating delays in dispute resolution and limiting local problem-solving capabilities.
iv. Teenage Mothers and Unique Identifiers; The current system for registering underage mothers is not functioning effectively,limiting their access to essential maternalhealth servicesandcreating bureaucraticbarriersforvulnerable populations.

6. Preventive Care Gap;PHCfunds are not clearly directed topreventiveservices likehealth education and community health workers,with most allocations going tocurativerather than preventive careinitiatives. 7. Vi. Delayed or inadequate reimbursements; especially for outpatient services and preventive care.The facility experiencesparticular challenges with outpatient services andpreventive care reimbursements,which often fail to cover actual servicedelivery costs.

d)RequestbyHospital totheCommittee

The hospital respectfully submits the following requests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps:

Improvement ofclaims and payment process through strict enforcement ofthe 9o-day payment rule to ensure all claims are settled within stipulated timelines. Transparency in PHC fund allocation should be enhanced by clearly distinguishing between preventive and curative components, while outpatientreimbursementrates should be reviewed and adjusted to reflect actual care costs.

ii. Facilitycapacitydata tobe corrected bySHAtoalign withactualphysical infrastructure on the ground. Bed capacity records should accurately reflect the 46 bedscurrentlyinuserather than thelisted6obedstopreventfraud allegations and improve planning accuracy.
iii. Governanceandfinancial management should be strengthened through harmonization of Facility Improvement Fund policies across counties to eliminate inconsistencies. County governments should streamline remittances to health facilities, while hospital boards and Health Management Teams should be empowered with greaterbudget autonomy.
iv. Specialpopulation accessshouldbeimproved throughestablishmentofafunctional and decentralized system for registering teenage mothers using unique identifiers at facility level,rather than limiting registration to branch or national offices,to improve healthcare access for vulnerable groups.

4. Request for branch office to provide adequate local support and reduce dependency on Nairobi headquarters for routine operational issues. Regional offices should be empowered withdecision-making authoritytoresolve facility-levelchallenges promptly.

3.7NYANDIWAHEALTHCENTRE

a) Facility Overview

57. The Health Centre,located in Kasipul constituency, Homa Bay County, is currently non-operational. It has not been registered under the Social Health'Authority(SHA) and,consequently,does not receive any payments or reimbursements from the scheme.

3.8STMARY'SHOSPITALMUMIAS

a)FacilityOverview

58.St.Mary's Mission Hospital Mumias is a Level 4 faith-based healthcare facility located in Kakamega County,Mumias West Sub-County,along the BungomaKakamega Road.The hospital has a bed capacity of 255beds and serves as a critical referral centre for maternity services, including care for underage mothers and vulnerable populations in the region.

59. The facility was previously accredited under NHIF and transitioned to SHA when the Social Health Authority was established inOctober 2024.The hospital underwent empanelment through SHA's e-contracting online platform, though initially faced challenges with incorrect facility allocation that waslater corrected. 60. St. Mary's operations were severely disrupted and suspended after June 2025 due to staff walkouts caused by non-payment of salaries, with staff arrears exceeding 3 months. The hospital currently operates at only 40% bed occupancy despite its 255bed capacity, with monthly operating costs of approximately Ksh 17 million, including Ksh 6.2 million for salaries, Ksh 1 million for consultants,and Ksh 233,800 for cleaning services.

6MembersoftheDepartmental CommitteeonHealthatSt.Mary's MissionHospitalinMunias, which closed recently due to alleged unpaid dues from the Social Health Authority (SHA).

b)FundingandReimbursements

i. Claims

SummaryofSHAFundingandReimbursementsDisbursed toSt.Mary'sHospital Mumias since itsinception.

| | Amount (Ksh) | Percentage (%) | |----------------------|----------------|------------------| | TotalClaimsSubmitted | 128,542,541 | 100% | | Total ClaimsReceived | 98,671,567 | 77% | | OutstandingClaims | 29,870,974 | 23% |

61. Since SHA's inception, St. Mary's Mission Hospital has submitted claims totaling Ksh 128,542,541 and received Ksh 98,671,567 in reimbursements, representing 76.7% of total claims submitted.The amount received comprises Primary Health Care Fund payments of Ksh 5,687,425 and Social Health Insurance Fund payments of Ksh 92,984,142.However, significant delays in payments began from May 2025, with reimbursements falling farbelow monthly claims submitted,creating severe cash flow challenges.

ii. Debt Position:

| Debt | Amount (Ksh) | |----------------------|----------------| | NHIFOutstandingDebt | 143,021,036 | | SHA Outstanding Debt | 35,558,400 | | TotalDebtBurden | 178,579,436 |

62. The facility faces a substantial total debt burden of Ksh 178,579,436, comprising inherited NHIF debt of Ksh 143,021,036 and SHA outstanding debt of Ksh 35,558,400 as at September 1, 2025.

c)Key Findings

The following key findings were identified:

i. Financial Crisis and Operational Suspension; the hospital suspended operations after June 2025 due to staff walkouts caused by non-payment of salaries for over 3 months.SHAbeganreimbursementslate(Decemberinstead of October 2024), creating animmediatefinancial gap that has persisted.
ii. Maternity andNeonatal Care;St.Mary'sis a keyreferral centrefor maternity services, including underage mothers. The lack of newborn ICU and equipment underminesthe qualityofcare.There arecurrentlyissueswithregisteringteenage mothers due to a lack of IDs. Temporary ID system in place, but inconsistent.
iii. Debt Burden: NHIF debt (Ksh143m+), irregular SHA reimbursements, rejected claims, and low income from private insurance.
iv. Staffing: Strikes due to delayed salaries; need for Ksh19.2m to settle arrears. Reliance oninterns andvolunteers.

5. System Reliability Issues; SHA's digital platform experiences downtime approximately 4 times per month, disrupting admissions, discharges, and claims processing. System glitches create biometric access barriers for patients, particularly those with faint fingerprints.

vi. Service Delivery and Infrastructure Gaps; Lack of NICU, shortages of drugs and oxygen duringfunding delays,reduced patient flow due to upfront payments.
vii. Referrals and Equity; The referral system faces discrimination against faithbased facilities, with services like Red Cross ambulances refusing to transport patients from mission hospitals,undermining equitablehealthcare access.
vii. Community Health Integration Gaps; the hospital struggles to effectively link itscommunityhealthworkerswithgovernment-funded communityhealth promoters, leading to potential underutilization of Primary Healthcare Fund resources.
ix. Teenage Mothers; Difficulty in registering patients without IDs, delays in serviceaccess.

d)Requestby theHospital totheCommittee

63.The hospital respectfully submits the followingrequests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps:

1. The National Treasury urgently settle the outstanding NHIF debts or, alternatively, establish a clear repayment framework to ease the financial burden on hospitals. SHA should enhance its reimbursement mechanisms by improving efficiency, transparency, and timelines to reduce delays and cash-flow challenges. In addition,hospitals should be supported to review and strengthen their business

models, with a focus on diversifying income streams, cutting operational costs, and exploring public-private partnerships to enhance financial sustainability.
ii. To stabilize operations and restore staff morale, the release of Ksh19.2 million in outstanding staff arrears.Further,a sustainable framework for salaries and consultant payments should be developed to prevent recurrent wage crises and ensurehospitals can retainqualifiedpersonnel.
iii. Strengthen SHA'sICT platforms to enhance reliability and user-friendliness. Adequate digital support should be provided to health facilities, or alternatively, regional SHA offices should be reintroduced to handle claims-related issues. Rejectedclaimsshouldbereopenedforresubmissionwith clearfeedbackprovided to facilities on the reasons for rejection.Additionally, SHA should establish fallback protocols to ensure system continuity during downtime, thereby preventing disruptionofservices.
iv. Establishment of a newborn intensive care unit (NICU)and the overall strengtheningofmaternityandneonatal services.Ambulance andreferralsystems should be standardized nationally to prevent discrimination against faith-based andmissionhospitals.Furthermore,hospitalsshouldenhance diseaseprevention efforts by strengthening collaboration between hospital-based community health workersand government health promoters,ensuring broaderreach and better health outcomes at the community level.
Claims with issues should be flagged and returned at the early stages of processing,not after approval for payment.Rejected claims should be reopened promptly to allow correction and resubmission.
Vi. All system updates should be communicated in advance, with clear information on what changes are being implemented and how they affect facility operations.
vii. Level 4 faith-based hospitals should be allowed to offer Emergency, Critical, and Chronic (ECC) illness services and benefit from the associated fund. Additional guidance is requested on the cost structuring for newborns in NBU requiring continuous oxygen or CPAP support.
viii. Facilities should be permitted to treat teenage mothers once issuedwith aUnique IdentifierNumber.Incaseswheredocumentationisunavailable,awaiverprocess should be clearlyoutlined inlinewithSHAprovisions.Sample cases are attached.
ix. The maternity reimbursement package should bereviewed and increased to reflect the actualcost of carefor both normal and caesarean deliveries.A breakdown of average facility expenditures is attached.
X. Referral policies should be revised to allow patients to be referred beyond publicto-public facilities.Patients should be able to choose a referral destination based onneed andpreference.
Xi. Reviewof existinglaws and policies to align SHA processes with practicalrealities at the facility level,eliminating bureaucraticinefficiencies.Special emphasis should beplacedonensuring g that teenagemothershaveequitableaccesstohealth services without discrimination or unnecessary barriers, in line with national commitments to universal health coverage and equity

3.9NYERICOUNTYREFERRALHOSPITAL

a)Facility Overview

64.Nyeri County Referral Hospital is a Level 5 public healthcare facility serving as a major referral center providing specialized services to the region.The hospital has a comprehensive bed capacity of335beds,comprising 294normalwardbeds,6ICU beds,3HDU beds,and 32baby cots.However,the facility reports that this capacity is inadequate as the hospital frequentlyruns out of beds due to high patient demand.

65. The hospital underwent empanelment under SHA through a structured process involving declaration of care levels and services offered, obtaining KMPDC licensing, and signing both hard copy and soft copy contracts. Initially, the facility faced limitations in offering emergency services due to restricted SHA portal access, though full access was granted recently. 66. Thefacility operates under theoversight of theNyeri HealthServicesFundBoard, established under the Nyeri Health Services Fund Act,which manages the Facility Improvement Fund (FIF) with transparency and accountability measures including annual audits by the Auditor General.

b)FundingandReimbursements

i. Claims

| | Amount (Ksh) | Percentage (%) | |----------------------|----------------|------------------| | TotalClaimsSubmitted | 339,649,692 | 100% | | TotalClaimsReceived | 197,112,640 | 58% | | Outstanding Claims | 142,537,052 | 42% |

67. Since SHA's inception Nyeri County Referral Hospital has submitted claims totaling Ksh 339,649,692 and received Ksh 197,112,640 in reimbursements from February 2025,representing only58%of total claims submitted.The facility experiences significant delaysinreimbursements,withpaymentsnotmade on timeasstipulated in contracts. 68. Thefacility reports thatbetween the months of February 2025 andMay 2025 an amount of Ksh56,121,150waserroneously paidtoanotherfacilitywhich luckilywaswithinNyeri County.ThefacilityhadalreadyspentKsh hospital. 69. In addition, as at 24th August 2025, the total number of claims that reflected in s of the following day 25th August 2025 that figure had risen to Ksh 34,838,720. The reasons that were given for rejection were failure to attachdocumentssuchasinvoicesandd discharge summaries.However, these documents are duly attached to the claims.

7Hon.Duncan Mathenge (left) interacts vvith patients at Nyeri County Referral Hospital.

ii. Debt Position:

| Debt | Amount (Ksh) | |----------------------------------------------------|----------------| | NHIFOutstandingDebt | 156,615,121 | | SHAOutstandingDebt | 142,537,052 | | BritamOutstandingDebt | 950,055 | | Medical AdministratorsKenya (MAKL) OutstandingDebt | 2,601,569 | | TotalDebtBurden | 302,703,797 |

70. Thefacility faces a massive total debtburden ofKsh302,703,797,with thelargest portion being inherited NHIF debt (51.7%) and SHA outstanding claims (47.1%). With additional smaller debts to intermediaries (e.g., MAK Ltd - Ksh3.2 million).

Medical Administrators Kenya Limited (MAKL) Context

71. Medical Administrators Kenya Limited (MAKL) is a private health insurance administrator in Kenya that manages medical schemes for specific groups, particularly government-employed groups such as teachers, police officers, and prison wardens. MAKL has historically been contracted to oversee and disburse medical benefitsfor these groups through a health scheme management. 72. While not a primary insurer itself, MAKL operates as a third-party administrator (TPA), liaising between healthcare providers and funding institutions to process claims,authorize treatment,andfacilitatereimbursements.

73. PCEA Tumutumu has reported delays and non-payment of claims by MAKL, resultingin significant debt accumulation.These challenges have affected service continuityandstrainedrelationsbetweenprovidersandtheadministration.

c)Key Findings

74.The following key findings were identified:

1. Delayed Reimbursements:Thehospital hassubmitted claimsworthKsh339.6 million,but only 58% (Ksh197.1 million) has been reimbursed. Pending claims (approx.Ksh142.5 million) have affected service delivery,equipment maintenance,and supplier payments. The now-defunct NHIF also owes the hospital Sh156 million, exacerbatingcashflowchallenges.

ii. Rejected ClaimsDue to Technicalities;Facility reported instanceswhere claims were rejected due to minor errors, such as mismatched identification numbers, missing attachments,or datainconsistencies.While theseerrors are often clerical,theirimpact is significant:rejected claims translate intolost revenue forfacilities and delays in care for patients. The rejection system is also seen as rigid, with limited avenues for quick correctionandresubmission.
ili. Erroneous Payments by SHA;Nyeri County Referral Hospital lost over Sh16 million to a neighbouring private hospital due to SHA's payment processing errors. The affectedhospital hasbeenunable torecover thefunds despiteefforts.
iv. Limited Benefits Package; Oncology patients were highlighted as being particularly disadvantaged under the SHA.Certain essential diagnostic andfollow-uptests are not covered, forcing patients to shoulder high out-of-pocket costs. Considering the longdiscontinuation, poor outcomes, and inequity in access. Laboratory tests are limited to 5 tests for outpatients. ICU 12-day package limits are impractical for longer stays.
Ambulance Services Unfunded despite Legal Provisions; The SHA Act provides V. for ambulance services reimbursement,yetfacilities reported they are not receiving funds for these services. Patients often complain about the high cost of ambulance transfers,particularly whenbeingreferred from lower-level tohigher-level facilities for specialized treatment. Lack of ambulance funding undermines the referral system, a critical pillar of healthcare delivery.
vi. SystemInefficiencies inDigital HealthPlatforms; thebiometric and digital claim authorization systems, though innovative, have experienced frequent downtime and errors. Examples include: Doctors physically present in a facility being marked as"out of station" by the system. Internet downtime halts biometric verification, delaying admissions or surgical interventions. The new Practice 360 app is causing authorization backlogs. These inefficiencies result in delayed care for patients and frustration among providers.
vii. Inadequate Coverage for Prisoners andVulnerable Groups; Correctional facilities have not fully aligned their budgets with SHA requirements,leaving prisoners unable to access services consistently.Similarly,other vulnerable populations often lack the financial means to cover gaps left by SHA, pushing them into healthcare exclusion.
viii. Limited Access for Infants of Underage Mothers;Infants born tounderage mothers are unable to access health services as they are not covered under their mothers'temporary benefits.

ix. EmergencyServices;Thefacility wasunable tooffer emergency services until May 2025 due to limited access to the SHA portal, which was only recently granted.
X. Unrealistic ICU Package Limits; The current 12-day packagelimit for ICU care is impractical, as many critically ill patients require extended stays.
xi. ServiceDenialforPublicServantsDueto Delayed Premium Remittances;Public servants are unable to access services when their premiums are not remitted toSHIA by the 9th of every month, forcing them to pay out of pocket and causing widespread outcry.
xii. Non-Functional Referral System; the referral portal is unavailable,preventing patients from being traced through the system as referral casesfrom primaryfacilities, underminingthecontinuum ofcare.
xiii. Transparency and Accountability in FIF (Facility Improvement Fund); at the facility level, there has been notable transparency and accountabilityin the use of FIF. Thereisanestablishedhealthservicesfundsboardwhichoversees themanagement of the FIF as per the Nyeri Health Services Fund Act. Decision-making follows structured governance channels: Health Management Team (HMT), Finance subcommittee, and Hospital Board oversight.
xiv. Expansion in Membership Coverage; The implementation of SHA has led to a substantial increase in registered beneficiaries within Nyeri County, with membership growing from approximately 4,000 to over 38,000. This reflects improved access to health coverage and increased population enrollment under the new health financing model.

7. xV. Supply Chain and Commodity Availability; until two months ago, essential drugs and supplies for ICU, renal, and theatre services were not stocked by KEMSA, posing challenges to uninterrupted service delivery. However, the situation has since improvedinthe currentfinancialyear.

c)RequestbytheHospitaltotheCommittee

75. The hospital respectfully submitted the following requests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) onidentified operationalandsystemicgaps:

i. Conduct an independent forensic audit ofSHA payment systems to identify loopholes leading to errors and introducepre-payment verification protocols toprevent wrongful disbursement ofclaims.
ii. Enforce strict timelines for claim settlement (e.g., 30-45 days), with penalties for noncompliance by SHA. Establish a real-time claim tracking system accessible to hospitals for transparency.
ili. Activationofthereferralportal toenable seamlesspatient transitions andreview policiesto allowLevel5facilitiestoprovideSHA-coveredoutpatientservices.
iv. Develop a structured repayment plan for outstanding NHIF debts, ensuring facilities are progressively cleared of arrears.

6. Policies enabling access for patients without national IDs, infants from underage V. mothers, indigents, prisoners, and other vulnerable groups to ensure equity in healthcare access. 7. Vi. Civic education programs about SHA operations, fund functions, and referral systems to improve public understanding and appropriate service utilization.

vii. Expansion of benefits package to meet medical requirements, laboratory test limits beyond 5 tests for outpatients, activation of the ECCIF fund for oncology and critical care, and review of impractical package limitations like 12-day ICU limits.
viii. Resolution of SHA system downtimes and Practice 360 App authorization conflicts that delay patient care. Ensure robust IT infrastructure supporting continuous service delivery.

3. ix aids,wheelchairs, crutches)in SHA portal to prevent out-of-pocket payments.

X. Train hospital finance officers and SHA staff on claims processing standards, documentation,anderrorprevention.
xi. Institutionalize regular consultative forums between SHA,hospitals, and county health departments to address emerging challenges and review performance.
xii. SHAshouldestablish analternativeverificationmechanismtoguaranteeservice continuityforpublicservants,evenwhenremittances aredelayed,withsubsequent reconciliationoncefundsarereceived.

3.10SIPILIMATERNITYANDNURSINGHOMELTD

a)FacilityOverview

76. Thehospitalis aprivatefacility empanelled under theSocial HealthAuthority(SHA) following a smooth transition from the defunct NHIF. It has a bed capacity of46 and provides both outpatient and inpatient services, including consultations,diagnostics, immunizations, procedures, maternity care, emergency services, and admissions. The facility emphasizes quality, timely, and affordable healthcare and operates on a 24/7 basis. 77. Since SHA's rollout, the hospital has maintained stable operations with uninterrupted service delivery,supported by financial management strategies includingbankloans andoverdraftsduringanyreimbursementdelaystoensurethat servicequalityremainsatoptimallevels.

b)FundingandReimbursement

i. Claims

| | Amount (Ksh) | Percentage (%) | |----------------------|----------------|------------------| | TotalClaimsSubmitted | 25,617,075 | 100% | | Total ClaimsReceived | 18,966,580 | 74% | | Outstanding Claims | 6,650,495 | 26% |

78.Since the rolloutofSHA,the hospital has received Ksh18,966,580,representing 74% of submitted claims (Ksh25,617,075). The facility reported that the SHA reimbursements are now more predictable and timelier,largely due to reforms introduced by the Ministry of Health that ensure payments are disbursed on the 14th ofevery month,with occasional additional disbursements on the 2ist. The referral system for patients is functional, especially for outbound referrals to higher-level facilities.Thefacility's operationsremain stable,withuninterrupted servicedelivery supported by financial adjustments such as bank loans during delays.

8Hon.PaulineLenguris interacts with patients at Sipili Maternity and NursingHome

ii. DebtPosition:

| Debt | Amount (Ksh) | |----------------------|----------------| | NHIF OutstandingDebt | 9,078,310 | | SHAOutstandingDebt | 6,650,495 | | TotalDebtBurden | 15,728,805 |

79. The facility carries a total debt burden of Ksh 15,728,805, comprising inherited NHIF debt of Ksh 9,078,310 which the facility expressed that they are hoping will be paid soon to enable them clear our supplier and doctors' debts.

Key Findings

80. The following key findings were identified:

i. Financing and Debt; the facility still carries a debt burden of Ksh6.65M under SHA and Ksh9.07M inherited from NHIF, affecting suppliers and doctors.
ii. System Limitations: The hospital faces system challenges in accessing remittances for amounts paid by SHA. This ICT limitation has been reported to SHA's ICT department,though resolution timelines remain unclear,affecting financialreconciliationprocesses.
iii. ReferralInefficiencies;whileoutboundreferrals tohigher-level facilities work effectively, the hospital experiences challenges with inbound referrals from peripheral facilities (Levels 2 and 3) that are unable to effectively utilize the SHA referral system, limiting patient flow optimization.

iv. Public Awareness; the facility identifies significant gaps in civic education about UHC benefits, particularly in rural communities, which affects patient enrollment andserviceutilizationrates.
V. Human Resource Gaps; There is a shortage of specialists in county and subcounty hospitals, limiting access to specialized care.

3. Vi. Empanelment & Training; The hospital experienced challenges during SHA's s n sn s n hm credentials,and system downtimes that affected early operations.

vii. Standardization of Payment Systems and Transparency; Ensure consistent payment mechanisms across all facility types while maintaining transparency in payment schedules and amounts to build confidence in the SHA system among healthcare providers.
viii. Continuous Capacity Building and Training Support; Facilitate provision of ongoing system training and mentorship programs for health workers in empaneled facilities to improve system utilization and operational efficiency.
ix. Patient Premium Burden; Clients have raised concerns about high annual premium payments and issues with the means testing questionnaire producing unaffordable premium amounts for some beneficiaries.

d)Request byHospital to the Committee

81. Thehospitalrespectfully submitted thefollowingrequests tothe Committee,with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps: 1. .Advocate for SHA to expedite ICT system upgrades' to allow facilities seamless operations and financial reconciliation processes.

ii. Support county-level initiatives to provide comprehensive training to lower-level facilities (Levels 2 and 3) on SHA referral protocols to ensure smoother patient flow and optimize the referral network efficiency.
iii. Strengthen UHC civic education campaigns, particularly targeting rural communities, to improve public understanding of benefits,boost enrollmentrates, and increase appropriate service utilization.
iv. Advocate for the Ministry of Health to deploy more specialists to county and subcounty hospitals to bridge critical staffing gaps and improve access to specialized healthcare services.

6. Support SHA's review of the means testing tool to ensure fairer and more V. affordable premium assessments and consider implementing flexible payment schedules beyond the current annual contribution requirement. 7. Vi. Facilitate provision of ongoing system training and mentorship programs for health workers in empanelled facilities to improve system utilization and operational efficiency.

vii. Ensure consistent payment mechanisms across all facility types while maintaining transparency inpayment schedules and amountstobuildconfidencein the SHA system among healthcare providers.

3.10PCEATUMUTUMUHOSPITAL

a)Facility Overview

82. PCEA Tumutumu Hospital is a faith-based Level 5 healthcare facility serving as a major referral hospital. The hospital has a comprehensive bed capacity of 209 beds, comprising 6 ICU beds, 8 HDU beds, 28 pediatric beds, and 167 adult beds. The facility provides specialized services including intensive care, high dependency care, surgical services, imaging, laboratory services, and comprehensive inpatient and outpatient care. 83. The hospital was empaneled under the Social Health Authority (SHA) through a reasonable process with no extraordinary challenges encountered during the transitionfromNHIF.Thefacility provides various SHA benefit packages including ICU/HDU services, surgical procedures, and rebates, imaging services, and selected laboratory services, though reimbursements for some services have been problematic. 84. The hospital faces significant operational challenges due to inconsistent SHA reimbursements, with payment proportions oscillating between 15% and 40% of submitted claims,creatingsevere cash flowconstraints and affectingservicedelivery capacity.

b)FundingandReimbursement

i. Claims

| | Amount (Ksh) | Percentage (%) | |----------------------|----------------|------------------| | TotalClaimsSubmitted | 273,190,142 | 100% | | TotalClaimsReceived | 144,816,550 | 53% | | Outstanding Claims | 128,373,592 | 47% |

85.Since SHA's inception in October 2024,PCEA TumutumuHospital has submitted claims totaling Ksh 273.19 million, of which only Ksh 144.8 million (53%) has been reimbursed. The facility notes that monthly disbursement rates fluctuate between 15%and 4o%,and delays arepersistent and disruptive to operations.

ii. Debt Position:

| Debt | Amount (Ksh) | |-----------------------|----------------| | NHIF Outstanding Debt | 89,825,672 | | SHA Outstanding Debt | 128,373,592 | | MAKLOutstandingDebt | 27,000,000 | | TotalDebtBurden | 245,199,264 |

86. The total outstanding debt is estimated at Ksh 245 million, attributed to pending reimbursements from NHIF,SHA,and MAKL(serving teachers and police). These unpaid amounts havestrained the hospital's abilitytomaintain essential services and meet supplier and payroll obligations.

9MembersoftheHealthCommitteewiththestaffatTumutunuHospital,whentheyvisitedthefacility

c) Key Findings

87.The following key findings were identified:

i. Reimbursement Delays; The hospital receives only 15-40% of submitted claims, with payment delays being persistent and severe. This inconsistency creates unpredictablecashflows and threatens operationalsustainability.
ii. DebtAccumulation;Thefacility carries a total debtburden exceedingKsh245 million,including Ksh 89.8 million inherited from defunct NHIF,Ksh 128.4 millionunderSHA,andoverKsh27millioninMAKLdebtsforteachers andpolice personnel.
iii. PatientAccessBarriers;Patients cannotaccess OPDservices atlevel5facilities without direct payment, effectively undermining universal healthcare principles. Nuclear clients,including staff and students are also excluded from services without cash payment.
iv. Supply Chain Gaps; the facility has faced persistent stockouts of essential drugs and commodities from the Kenya Medical Supplies Authority.As a result, the facility has resorted to sourcing from the Mission for Essential Drugs and Supplies,which has since suspended further supplies.Additional suppliers have already withdrawn their services, compounding the situation. Orders through KEMSA are nolonger relevant as the facility nolonger relies on this supply line. In response to these challenges, the facility has resorted to borrowing from financialinstitutions,negotiating gwithbanksforinvoice discounting arrangements,requesting extended credit periods, and has recently approved copaymentstosupportcontinuedserviceprovision

5. V ImpactonPatients;Patients areincreasinglydeniedinpatientcare,withmany resorting to self-medication,alternative treatments,or traveling long distances to higher-levelfacilities.The opportunity cost of failedreimbursements translates directly into adverse patient outcomes, including preventable deaths. Stock shortages force patients to purchase medications directly,compromising treatment adherence and increasing financial burden.As a result, the hospital is unable tofulfilits founding mission of servingvulnerablepopulations. 6. V1 Punitive ClaimsManagementSystem; Thefacility reportsgroundlessrejection of claims and punitive rejection processes. Claims remain unprocessed for unreasonablylong periods,with some remainingunder surveillance without clear justification or timelines.

vii. Staff Retention and Morale Crisis; SHA funding has not improved staffing levels. Instead, resignations have increased as staff cite uncertain salary payments. This creates a negative cycle affecting service quality and institutional stability.

8. Viii. Unsustainable Operational Model; The hospital faces an uneven playing field with the same benefit packages applying to government and faith-based facilities despite different operationalrealities.Thereimbursementmodelis unsustainable forspecializedLevel5services.

ix. adequately incorporated during stakeholder engagement processes, limiting their ability to influencepolicy decisions that affect their operations.

d)Requestsby theHospital to the Committee

88. The hospital respectfully submits the followingrequests.to the Committee,with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps:

i. AdvocateforSHA to establishsustainableandconsistentreimbursementrates that reflect the true costof specialized Level 5 services,moving beyond the current 15-40% payment range to ensure operational viability.
ii. KMPDC, SHA, and DHA should establish a joint coordination framework with a designated county or regional contact person to streamline communication and avoid contradictory directives.
ii. Flexible monthly or quarterly contributions should be reinstated for low-income households to prevent exclusion and improve patient access.
iv. Resolution of the Ksh 245 million debt burden across NHIF,SHA,and MAKL schemes through structured negotiation and payment plans that prevent further operationaldeterioration.

6. Elimination of punitive claims, rejection practices and establishment of clear timelines for claims processing. Claims should not remain under surveillance for unreasonableperiodswithoutclearjustification andresolutionpathways. 7. Vi. Policy changes to ensure Level 5 facilities can provide SHA-covered outpatient services,eliminating the current restriction that forces patients to pay directly and contradictsuniversalhealth coverageprinciples.

vii. Interventions to restore supplier confidence through guaranteed payment mechanisms and exploreinvoice discounting arrangements to maintain essential medical supplies and equipment.

viii. Development of differentiated benefit packages that recognize the higher operational costs and specialized servicesprovidedby Level 5 facilities compared to lower-level government facilities.
ix. Meaningful participation of faith-based and specialized facilities in policy development processes, particularly regarding benefit package reviews and operational policy changes.
X. Immediate emergency funding or guaranteed credit facilities to prevent complete operational collapse while longer-term systematic reforms are implemented.

3.11NYAHURURU COUNTY REFERRALHOSPITAL

a)FacilityOverview

89. Nyahururu County Referral Hospital NCRHis a Laikipia County Government's hospital located in LaikipiaWest,Nyahururu town.Initially accredited as a Level 4 facilitybyNHIFand hastransitioned toSHAfunding mechanisms while maintainingitsroleas akeyreferral center. 90. The facility has a capacity of 243 authorized beds and 26 authorized cots, maintaining an average bed occupancy rate of approximately 90%.

b)Funding and Reimbursement

i. Claims

| | Amount (Ksh) | Percentage (%) | |----------------------|----------------|------------------| | TotalClaimsSubmitted | 238,375,728 | 100% | | Total ClaimsReceived | 176,929,678.85 | 74% | | Outstanding Claims | 128,373,592 | 26% |

SummaryofSHAFundingandReimbursements'Disbursed toNyahururuCountyReferral Hospital since its inception.

91. Since the inception of the Social Health Authority (SHA) in October 2024, Nyahururu County Referral Hospital has submitted claims amounting to Ksh 238,375,728. Of this total, the hospital has received Ksh 176,929,678.85, representing 74% ofall claims submitted. The remaining Ksh 61,446,049.15,or 26%, remains outstanding as of August 2025.The hospital management reports that planning. In particular, surgical claims are subjected to medical reviews, contributing tofurtherreimbursementdelays. 92. The hospital receives SHA funding from two key sources: the Primary Health Care Fund,from which it has received Ksh 6.569,574.35 million,and the Social Health Insurance Fund,with Ksh 170.360,104.50 million disbursed to date.Notably,the Emergency, Chronic and Critical Ilness Fund (ECCIF) remains completely nonoperational,with zero disbursements made to thehospital under this stream.This lack of ECCIF funding significantly undermines the hospital's ability to provide

ii. DebtPosition:

| Debt | Amount (Ksh) | |---------------------|----------------| | NHIFOutstandingDebt | 36,753,246 | | SHAOutstandingDebt | 61,446,049.15 | | Total DebtBurden | 98,199,295.15 |

c) Key Issues Identified

93.The following key findings were identified:
i. Incomplete Fund Operationalization; The Emergency, Chronic and Critical Illness Fund remains completely non-operational with zero disbursements, creating significant gaps in coverage for critical health services and emergency care.
ii. Contractual ClarityIssues;PrimaryHealth Care contractsfor Level 4facilities lack clarity, particularly regarding the modified capitation rate of Ksh 225 per quarter, with hospitals receiving no detailed information about capitated beneficiaries.
i1i. Vulnerable Population Exclusions; Teenage mothers without identification documents cannot enroll withSHA,effectively excludingvulnerablepopulations from essential maternalhealth services and contradicting equity principles.
iv. System Abuse and Administrative Burden; The means testing instrument is subject to widespread abuse by citizens seeking minimum premium payments, while biometric registration delays exceed 16 minutes, creating operational inefficiencies.
Emergency Services Gaps; Ambulance referral services continue requiring cash payments as they are not covered under SHA benefits, creating barriers to emergency care access and undermining comprehensive coverage.

10Health Committee Members at the SHA registration desk at Nyalururu CountyHospital.

d)RequestbytheHospital to theCommittee

94. The hospital respectfully submits the following requests to the Committee, with the aim of guiding policy interventions and engaging the Social Health Authority (SHA) on identified operational and systemic gaps:

i. SHA should ensure the activation of the Emergency, Chronic and Critical Illness Fund to provide comprehensive coverage for critical health services and eliminate existing coverage gaps.
ii. Provide clear guidance on Primary Health Care contracts for Level 4 facilities, including detailed capitation arrangements and beneficiary information to improve operational clarity.
iili. Include ambulance and emergency transport services within SHA benefit packages to ensure comprehensive emergency care coverage without cash payment barriers.
iv. Flexible monthly or quarterly contributions should be reinstated for low-income households to prevent exclusion and improve patient access.

6. Facilities should collect data on referred patients,including abandonment and selfmedication, to better assess the real impact of current policies on vulnerable populations.

CHAPTERFOUR 4.0COMMITTEEOBSERVATIONS

95. The Committee's assessment of the ten (1o) health facilities reveals a series of fundamental operational and policy gaps within the implementation ofthe functions of the Social Health Authority (SHA). The Committee made the following observations:

1)FinancialManagementandPayments

i. Delayed and Withheld Payments; The Committee observed that reimbursements to health facilities under the Social Health Authority (SHA) have been inconsistent, with some months recording no disbursements at all. A substantial backlog of arrears inherited from the defunct National Health Insurance Fund(NHIF)remains unresolved.Approved but unpaid claims continue to accumulate acrossfacilities,further straining thefinancial stability of hospitals. The Committee also noted a lack of transparency in SHA's payment systems as reimbursements are often issued as lump sums without clear disaggregation based on the type of F unds.
ii. Erroneous Payments bySHA;TheCommittee noted that erroneous payments by SHA have occasioned significant financial strain on health facilities asnoted inNyeri CountyReferral Hospitalwhich lost over KSh16 million to a neighbouring private hospital due to payment processing errors, with recovery efforts proving unsuccessful.
ili. Rejected andUnclear Claims and LackofFrameworkforResolution of Complaints; The Committee observed that there is a high*rate of claim rejections even in cases where health facilities had provided adequate supporting documentation.Hospitalsreported the absence of a clear and transparent mechanism for claim resubmission,with feedback on rejected claims often delayed well beyond the 90-day statutory period. Furthermore, the increasing reliance on AI-driven claim processing and approvals without sufficient human oversight has led to unjust denials,causing significant financialstrain onfacilities.TheCommitteefurthernoted the absenceofan effective framework for resolving disputes and complaints related to claim rejections,leaving facilities without a clear avenue for redress or appeal.
iv. Medical Administrators Kenya Limited (MAKL); other challenges observed by the Committee during its visit included persistent delays and non-payment of claims by Medical Administrators Kenya Limited (MAKL) to hospitals such as PCEA Tumutumu Hospital and Nyeri County Referral Hospital. These delays have led to a significant accumulation of debt, disrupted service delivery, strained cash flow, and limited the hospitals' operational capacity.

2)Systemic and Operational Challenges

i. System and ICT Failures; The Committee noted frequent SHA system downtimes occurring up to four times a month,which disrupt hospital operations and delay service delivery. Biometric verification challenges were also highlighted, particularly for patients without national IDs or

those with faint fingerprints. Further, there were discrepancies between SHA and KMPDC records including mismatched bed capacities and facility codesleading to administrativebottlenecks.

ii. Lack of Clarity on theEstablishment and Operationalisation of the Claims Management Office; The Committee observed that the Social HealthAuthority(SHA)hasnotclearlyestablished oroperationalizedthe ClaimsManagementOfficeasrequiredundersection35(i)oftheSocial Health Insurance Act, No.16 of 2023.This gap has led to inconsistencies in the utilization of primary healthcarefundsdisbursedbySHA, inefficiencies in the processing gand management of claims,limited accountability,and irregular communication with healthfacilities.

3)Governanceand Coordination

i. Governance and Coordination Gaps;The Committee noted significant governance and coordination gaps among key regulatory and oversight bodies, including the Kenya Medical Practitioners and Dentists Council (DHA), and county governments. There is weak coordination between SHA, KMPDC, DHA and county governments which produces contradictory directives. There is also absence of written compliance guidelines and fragmented regulation.
ii. FacilityImprovement Fund(FIF);The Committee observed thatFacility Improvement Fund (FIF)policies vary significantly across counties, resulting in inconsistencies in governance, financial management and accountabilityframeworks.Forexample,inHomabay County,these variationshavecreated confusioninthecollection,retention andutilization offacility-generatedrevenuesthereby hindering theuniform implementationofhealthfinancingreforms.
iii. Failure to Operationalise theDisputeResolution Tribunal;Despite the legal provisions under the Social Health Insurance Act, No. 16 of 2023, the DisputeResolutionTribunalhasnotbeenestablishedoroperationalised, leaving healthcare providers and beneficiaries without a structured mechanism to address grievances and resolve disputes.

4)ServiceCoverage and Equity

i. Exclusion of VulnerablePopulations;TheCommittee observed that several vulnerable groups remain marginalized in accessing SHA benefits. Teenage mothers without national identification cards face registration barriers that deny them and their infants access to essential maternal and child health services.Similarly,prisoners,indigent persons and individuals living with chronic conditions experience inconsistent coverage across facilities. The requirement for lump-sum annual premium payments has further excluded many poor households, undermining the principles of equity and Universal Health Coverage(UHC). The Committee also noted the absence of a clear national framework for identifying and enrolling vulnerable populations, particularly teenage mothers and their infants, resultingintheircontinued exclusionfrom critical healthservices.
ii. Primary Health Care (PHC) and Preventive Services; The Committee noted that allocationsforPHC remain unclear,withfunding skewed heavily

3. towards curative services at the expense of preventive care.Weak linkages were also evident between hospital-based community health workers and government-funded community health promoters,undermining the outcomesof preventivehealth strategies.

5)ServiceDelivery andAccess

i. Service Delivery Gaps; The Committee noted that some hospitals have been forced to suspend admissions due to theSHA system misclassifications,as in the case of St.Elizabeth Swindon Hospital,which was listed ashaving"zero beds." Critical service gaps were also noted including the absence of Neonatal Intensive Care Units (NICUs) in level 5 hospitals,coupled with shortages of oxygen, essential drugs and utilities during periods of delayed reimbursements.
ii. Referral and AmbulanceBarriers;The Committee noted that thereis no clear national policy governing the provision of accident and emergency services, including ambulance operations. Although the Social Health Insurance Act, No. 16 of 2023 provides for reimbursement of ambulance services, many health facilities reported that they have not received any funds for such services. The absence of adequate ambulance funding undermines the effectiveness ofthe referral system, which is a critical component of healthcare delivery. Additionally,reported discrimination in patient transfers for instance refusal by theKenya Red Crossto transport patientsfrom missionhospitals, underminesthereferralcontinuum.
ili. Tariff Misalignments and Benefit Package Gaps;The Committee noted contradictionsbetween the actual cost of care and SHA reimbursementrates, with some packages failing to meet the true cost of care (e.g., Ksh 30,000 for caesarean deliveries,12-dayICU limits,laboratorytests arelimited to five(5) tests for outpatients, and restricted outpatient benefits at Level 5 facilities). These benefit packages and tariffs undermine comprehensive and quality service delivery, discouraging providers from offering specialized care. Oncology patients, in 0particular,aredisadvantaged as some essential diagnostic and follow-up tests are not covered, forcing patients to incur high out-of-pocketcosts.

6) Workforce and Capacity Building

1. Financial Strain and Staffing: Due to delayed and withheld payments, many hospitals have been unable to pay staff salaries for several months. This has triggered strikes,reduced morale and over-reliance on volunteer workers to sustain essential services.

ii. Capacity Building: The Committee observed that inadequate training on SHA systems for the health facility staff has contributed toinefficiencies in claims processing and service delivery.

7)Supply Chain Management

1. Supplier and Commodity Shortages: The Committee noted that the Kenya Medical Supplies Authority (KEMSA) continues to provide inadequate and delayed supplies, with fill rates as low as 30% in some facilities. This has resulted in stockouts ofcritical drugs, oxygen and consumables, compromising patient care and contributing topreventable deaths.

CHAPTERFIVE 5.0COMMITTEERECOMMENDATIONS

96. Based on the Committee's findings and observations, the following are recommended to strengthen the functioning of the Social Health Authority (SHA), advance service delivery, and improve patient outcomes. Following the adoption of this Report by the National Assembly, the Cabinet Secretary for Health shall submit to the House a detailed implementation status report within six(6) months.

1)Claims and Payment;

i.NHIF Arrears Settlement
a. The Principal Secretary for the National Treasury,together with the Principal Secretary for the State Department for Medical Services, should urgentlysettle allverifiedNHIFarrears or developa clear,time-bound repayment framework within three (3) months to ease the financial strain on hospitals.TheNational Treasury should invoke Article223of the Constitution tofacilitate the settlementofoutstandingNHIFdebtsofup toKsh.1obillion,thereby ensuring thefinancial stability ofhealthfacilities and restoring confidence in the transition to the Social Health Authority (SHA).
ii. Enforcementofthe9o-DayClaimsPaymentRule
a.The Chief Executive Officer (CEO) SHA shall enforce the 9O-day claims settlement rule and issue standardized remittance advice detailing paid, pending,and rejected claims with documented reasons.Rejected claims shallincludeclearjustificationand allowforresubmissionthrough the digital portal. The CEO to submit a compliance and implementation report including a comprehensive financial statement of all SHA Revenues and Expenditures within three (3)months.
iii. Disbursement of Pending SHA Bills
a.AsverificationofthedefunctNHIFdebtcontinues,theChiefExecutive Officer(CEO)SHA should immediatelydisburse allpending SHA reimbursements toprevent service disruptions.
The Chief Executive Officer (CEO) SHA should submit a report detailing the status of paid and outstanding SHA claims to the Committee within three (3) months.
iv. FulloperationalizationofPHCFandECCIF
a. The Principal Secretary for the State Department for Medical Services and the Chief Executive Officer (CEO) of the Social Health Authority (SHA), should fast-track thedisbursement ofPHCFand ECCIFfunds and fully operationalize the PHCF and ECCIF benefit packages within sixty (60) days,ensuring that these Funds become functional in all facilities where they are currently non-operational.
V. To improve efficiency and fairness in claims processing, the CEO, SHA should reinstatemandatoryhumanverificationforAI-flagged claimswithin forty-five (45) days,toreduce allegations ofwrongfulrejections.
V1 Where fraud or non-compliance is detected, the CEO SHA should initiate investigations andensure that anyidentifiedfraudisprosecuted atindividual level while ensuringthatnohealth facilityis closedunlesspatient care continuity is guaranteed.
vii. The Cabinet Secretary,Ministry of Health,within 9o days,should engage the Medical Administrators Kenya Limited (MAKL) to resolve and settle all verified debts owed totheir accredited healthfacilities.

2)Registration andPremiumPayment;

(i)Full Operationalization of Benefits Package for the three SHA Funds
a.The Cabinet Secretary, Ministry of Health should operationalize full benefit access forSHIIF, PHCF and ECCIF in all Level 2-5 facilities, within ninety(9o) days.
(i) Standardization of Proxy Means Testing:
a. The Cabinet Secretary, Ministry of Health should standardize the proxy meanstestingframeworkfortheinformalsectorandestablishastandard premium amount for indigents and publish the standardized framework and standard rateforindigents within sixty(6o) days.
(ii) Public Communication on Premium Financing
a. The CEO, SHA should implement a national communication campaign within forty-five (45) days to clarify the premium financing obligations including thefour-month initial paymentrule and SHA LipaPole.Pole scheme terms.

3)Empanelment and Bed Capacity;

i. Correction of Digital Record Errors

2. a.The CEO,SHA,in collaboration with the Kenya Medical Practitioners and Dentists Council (KMPDC), should audit and correct all errors in digital records including bed capacity and facility names,within sixty (6o) days to prevent wrongful claim rejections and misdirected payments.

b. The CEO,SHA should ensure the establishment of the Unique Facility Identifier System within six (6) months to avoid confusion during reimbursementtofacilities.
ii. Investigation of Unilateral Bed Removal

5. a.The CEO, SHA should complete investigations on the removal of beds from the databaseofsomefacilities and implementcorrective actionwithin sixty (60) days.

4)Pre-Authorization forAdmissionsand Procedures;

ImproveReliability of Approval Systems
a. Within ninety (9o) days, the CEO,DHA and CEO, SHA should upgrade approval systems to reduce downtime delays and ensure reliability of approval systems for both admission and other medical procedures by addressing frequent downtimes and delays.
ii. Harmonization of Procedure Approval Processes

a.The CEO,DHA and CEO, SHA should review and harmonize approval workflows within sixty(6o) days to allow for timely revision of diagnoses and authorizations when a patient's clinical condition changes or a new diagnosis is made during admission.
b. The CEO, DHA and CEO, SHA should within sixty (6O) days simplify preauthorizationprotocolstoremoveunnecessarybarrierstourgent admissions andsurgicalinterventions,suchasin casesinvolvingmultiplefractures
ii. Removal of GeofencingRestrictionforpre-authorizations
a.The CEO,DHA and CEO,SHA should remove the one-kilometre radius for a One-Time Password (OTP) for pre-authorizations for admission and proceduresofpatients.

5)Indigent Identification and Inclusion of Vulnerable Populations;

i. NationalIndigentIdentificationFramework

2. a.The Cabinet Secretary, Ministry of Health should within six (6) months, develop a clear nationalframework fortheidentificationofindigents and vulnerable populations, ensuring their automatic registration and guaranteed coverage to prevent exclusion from essential health services.

ii. Registration of Teenage Mothers and Infants

4. a.The Cabinet Secretary, Ministry of Health should, within ninety (90) days, implement a unique identifier-based registration system for registering teenagemothers and theirinfantsforuninterrupted access tomaternal and child health services.

6) IT Support Systems;

i:Data-Sharing Framework across Regulatory Bodies
a. The Cabinet Secretary, Ministry of Health should establish a data-sharing framework and theintegrationofICT systemsbetween theKenyaMedical Practitioners and Dentists Council (KMPDC), the Digital Health Agency (DHA),and the Social Health Authority(SHA)within three(3) Months so as to improve interoperability, streamline regulatory processes and improveverificationprocedures toprovideefficient service delivery.
ii. Establishment of Regional SHA Offices
a.The Board of the Social Health Agency should establish fully functional SHA regionaloffices within nine (9) months to provide real-time technical supportforallSHAfunctionsincluding genrolment,beneficiary identification, claims processing, payments and pre-authorizations, so as to reduce over-reliance on the Nairobi headquarters office.
ii. Strengthening ICT Platforms
S) s should reduce biometric/OTPerrors and enhance system stability.
7) Capacity Building;
i. The Cabinet Secretary,Ministry of Health should support the Social Health Authority in rolling out national training programs for all public, private, and faith-based facilities on the digital systems, claims, pre-authorizations, and the benefit package within four (4) months.
8)Dispute Resolution;
a.The Board ofthe Social HealthAuthority should,within three(3) months, establishan administrativemechanismin theinterim tohandle complaints, and disputes including on claim rejections,billing disagreements and facilityclosure.

i. Adoption of SHI Dispute Resolution Mechanism

ii. Establishmentof theSHA ClaimsManagementOffice

a.The Board of the Social Health Authority within three (3) Months should establishand fullyoperationalisetheClaimsManagement Officewithin the Social Health Authority (SHA),in accordance with Section 35(1) of the SocialHealthInsuranceAct,No.16 of2023.
b. The Board of the Social Health Authority within the next six (6) months shouldensurethattheClaimsManagement Officedevelops clear guidelines, standard operating procedures and digital systems to ensure transparent, efficient and timely processing of claims.

9)Facility Improvement Fund (FIF)Harmonization;

i. Within six (6) months, the Cabinet Secretary, Ministry of Health should engage with the Council of Governors (COG)on the harmonization of the national and countyFIFlaws toeliminateinconsistencies particularlyon remittance requirements to county accounts, and to ensure uniform accountability frameworks.

10)Ambulanceand Referral Services;

i. ReimbursementforAmbulanceServices

2. a.Within three (3)months,the CEO,SHA should operationalize the reimbursement for ambulance and referral services as provided under the Social Health Insurance Act, No.16 of 2023, ensuring that all facilities includingfaith-based andprivatefacilities aretreatedequitably

ii. Standardized Referral Protocol and Expand Ambulance Coverage
a. Within six (6)months,the Cabinet Secretary,Ministry of Health should standardizereferralprotocolstoeliminatediscriminationagainstcertain facilities andguaranteethetimelytransfersofpatientsduringemergencies.
b. Within six (6) months, the Cabinet Secretary,Ministry of Health in collaboration with the county governments, should expand ambulance coverage to rural and underserved areas so as to reduce preventable deaths and improve overall health outcomes.

11)Civic Education and Public Trust;

i. National Civic Education Programme and Community-Level Engagement
a. Within three(3)months,the CabinetSecretary,Ministry ofHealth and the CEO, SHA should undertake community engagement programmes through the CommunityHealthPromoters,media andlocalforums so as tobuildtrust andcountermisinformation.
b. The Cabinet Secretary, Ministry of Health should roll out continuous civic education programs to empower citizens with knowledge on their rights, responsibilities and benefits under SHA for informed participation and accountability.

12)Governance and Oversight;

i. Transparency of theSHABoard

a.The Board of the Social Health Authority within the next six (6) months should improve its visibility across the country and be accountable to stakeholders by undertaking routine public reporting on inflows of funds, claim processing and disbursements.
b. The Cabinet Secretary, Ministry of Health,should convene a national multi-stakeholder dialogue within six(6)months to address systemic weaknesses, audit the laws where necessary, and promote a collaborative approachtoimplementation.

13)Expand Coverage of Essential Health Services;

i. Review of Benefit Package and Tariffs

2. a.The Cabinet Secretary,Ministry of Health should engage theBenefits Packageand Tariffs AdvisoryPanel to conduct a comprehensive actuarial review of the current benefits package within six(6) months to align the tariffs with real treatment costs and expand coverage to diagnostics, dialysis, emergency, ambulance care, ICU/HDU/NICU and maternal and neonatalservices.

b. The Cabinet Secretary, Ministry of Health should engage the Benefits Package and TariffsAdvisoryPanel to remove the existing ICU daylimit, extend coverage to High Dependency Units (HDU) and Neonatal Intensive Care Units (NICU) and increase the reimbursementrate for ICU and HDU from Ksh. 28,000 to a minimum of Ksh. 44,000, subject to actuarial evaluation.
ii. National TransplantProgramme
a. The Cabinet Secretary, Ministry of Health should, within nine (9) months, establish a national transplant programme for kidney, bone marrow and other critical organ transplants.

14)StrengthenStakeholderCollaboration:

i.Strengthen Multi-Level Coordination and Promote Public Private Partnerships
a.The Cabinet Secretary, Ministry of Health should implement stronger collaboration between SHA, the Ministry of Health, county governments, and health facility management to improve policy alignment and optimize resourceutilization.
b. The Cabinet Secretary, Ministry of Health should encourage publicprivate partnerships to draw on innovation, expand infrastructure, and increaseaccesstospecializedhealthcareservices.

THENATIONALASSEMBLY 13THPARLIAMENT-FOURTHSESSION(2025) DIRECTORATEOFDEPARTMENTALCOMMITTEES DEPARTMENTALCOMMITTEEONHEALTH

REPORTONTHEASSESEMENTOFTHESOCIALHEALTHAUTHORITY(SHA) UTILIZATIONOFFUNDSDISBURSEDSINCEINCEPTIONANDCHALLENGES FACEDBYFACILITIES

We,the undersigned Members of the Departmental Committee onHealth do hereby append our signaturestoadoptthisReport

22 /(1/2025

Date:

VENUE..

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| NO | NAME | SIGNATURE | |------|--------------------------------------------------------|-------------| | 1. | The Hon.Dr.Nyikal James Wambura,M.P, CBS - Chairperson | | | 2. | TheHon.NtwigaPatrickMunene,M.P-Vice- Chairperson. | | | 3. | The Hon.Dr.Pukose Robert,CBS,M.P | | | 4. | The Hon.TitusKhamala,M.P | | | 5. | TheHon.SunkuliJuliusLekakenyOle,EGH,EBS,M.P. | | | 6. | The Hon.Prof. Jaldesa Guyo Waqo,M.P. | | | 7. | The Hon.Owino MartinPeters,M.P. | | | 8. | The Hon.Wanyonyi Martin Pepela, M.P | | | 9. | The Hon. Lenguris Pauline, M.P | | | 10. | TheHon.Mary Maingi,MP | | | 11. | The Hon. Muge Cynthia Jepkosgei, M.P | | | 12. | The Hon. Oron Joshua Odongo,M.P. | | | 13. | The Hon.Kibagendi Antony,M.P. | | | 14. | TheHon.MathengeDuncanMaina,M.P | | | 15. | The Hon.Kipngor Reuben Kiborek, M.P | |

MINUTESOFTHE82NDSITTINGOFTHEDEPARTMENTALCOMMITTEEON HEALTH HELD IN FOUR POINTS SHERATON HOTEL ON SATURDAY, 22ND NOVEMBER2025,AT9.00AM

PRESENT

| 1. | The.Hon.Dr.NyikalJamesWambura,MP | -Chairperson | |------|---------------------------------------------|----------------| | 2. | The Hon.Dr.Pukose Robert,MP | -Member | | 3. | The Hon. Prof. Jaldesa Guyo Waqo, MP | -Member | | 4. | The Hon. Lenguris Pauline, MP | -Member | | 5. | The Hon. Oron Joshua Odongo, MP | -Member | | 6. | The Hon. Titus Khamala, MP | -Member | | 7. | TheHon.SunkuliJuliusLekakeny Ole,EGH,EBS,MP | -Member | | 8. | The Hon. Kipngor Reuben Kiborek, MP | -Member |

ABSENTWITHAPOLOGY

| 1. | The Hon. Ntwiga Patrick Munene, MP | -Vice Chairperson | |------|--------------------------------------|---------------------| | 2. | The Hon Wanyonyi Martin Pepela, MP | -Member | | 3. | The Hon. Owino Martin Peters, MP | -Member | | 4. | The Hon. Cynthia Muge, MP | -Member | | 5. | The Hon. Mathenge Duncan Maina, MP | -Member | | 6. | The Hon. Mary Maingi, MP | -Member | | 7. | Hon Kibagendi Antoney, MP | -Member |

COMMITTEESECRETARIAT

| 1. | Mr.Hassan A.Arale | -Clerk Assistant I | |------|---------------------|-----------------------| | 2. | Ms.Gladys Kiprotich | -Clerk AssistantI | | 3. | Mr.TimothyKimathi | -Clerk AssistantI | | 4. | Mr.Faith Chepkemoi | - Legal Counsel II | | 5. | Ms.Angela Musau | - Legal Counsel II | | 6. | Ms.Abigael Muinde | -Research Officer III | | 7. | Ms.FatmaMohamed | -Intern |

INATTENDANCE-THELISTATTACHED

AGENDA

1. Prayers; 2. Preliminaries; 3. Adoption ofthe Agenda; 4. Confirmation ofPreviousMinutes; 5. Matters arising;

6.CONSIDERATIONANDADOPTIONOFREPORTS

7.Pending Business (enclosed)

8. Any Other Business;and 9. Adjournment

NO.NA/DC-H/2025/551:PRELIMINARIES/INTRODUCTION

The Chairperson called the meeting to order at twenty minutes past twelve o'clock, followed by thePrayerandself-introductions.

MIN.NO.NA/DC-H/2025/552:ADOPTIONOFAGENDA

The agenda of the meeting was adopted, having been proposed by the Hon. Pauline Lenguris, MP, and seconded by the Hon Prof. Guyo Jaldesa, MP.

ThisAgenda itemwas deferred to alater dateforconsideration.

MIN.NO.NA/DC-H/2025/554:MATTERSARISING

There were no matters arising.

MIN.NO.NA/DC-H/2025/555:CONSIDERATION ANDADOPTION OFTHE REPORT OF THE HEALTH (AMENDMENT) BILL (NATIONAL ASSEMBLY) BILL BY HON.JANENJERIMAINA,MP

Adoption of the report of the Health (Amendment)Bill (National Assembly)Bill by Hon.Jane Njeri, MP as the true reflection of the Committee deliberation which was proposed by Hon. Pauline Lenguris, MP, and seconded by Hon. Dr. Robert Pukose, CBS, MP as the true reflection oftheCommitteedeliberations.

MIN.NO.NA/DC-H/2025/556:CONSIDERATIONANDADOPTIONOFTHE REPORT ONTHE ASSESEMENTOF THE HEALTH AUTHORITY (SHA) UTILIZATIONOFFUNDSDISBURSEDSINCEINCEPTIONANDCHALLENGES FACEDBYFACILITIES

Adoption ofthereport on the assessment of the Social HealthAuthority(Sha)Utilization of Funds disbursed since inception and challenges faced by facilities which was proposed by Hon. Pauline Lenguris,MP,and seconded by Hon.Prof.Jaldesa GuyoWaqo,MP as the true reflection of the Committee deliberations.

MIN.NO.NA/DC-H/2025/557:ANYOTHERBUSINESS

There was no any other business.

MIN.NO.NA/DC-H/2025/558:ADJOURNMENT

There being no other business, the meeting was adjourned at 1.15 p.m. The next meeting will be heldonnotice.

221205

Sigr

Date.

HON.DR.NYIKALJAMES WAMBURA,CBS,MP CHAIRPERSON,DEPARTMENTALCOMMITTEEONHEALTH

Machine-extracted text (docling) from a scanned document — may contain recognition errors. Original PDF — parliament.go.ke.

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Report On The Assessment Of Utilization Of Funds By Social Health Authority And Challenges Faced By Medical Facilities

REPUBLICOFKENYA THENATIONALASSEMBLY

TABLEOFCONTENTS

LISTOFANNEXURES

CHAIRPERSON'SFOREWORD

HON.DR.NYIKALJAMESWAMBURA,CBS,MP. CHAIRPERSON,DEPARTMENTALCOMMITTEEONHEALTH

CHAPTERONE

1.0PREFACE

1.1EstablishmentandMandateoftheCommittee

1.2 Subjectsunder the Committee

1.3 Oversight

1.4 CommitteeMembership

Chairperson

ODM Party

Vice-Chairperson

UDA Party

UDA Party

Ford Kenya Party

UDA Party

UDA Party

UPIA Party

1.5CommitteeSecretariat

Mr.Hassan AbdullahiArale

ClerkAssistantI/HeadofSecretariat

CHAPTERTWO

2.0INTRODUCTIONANDBACKGROUND

2.1Background on theSocial HealthAuthority(SHA)

2.2TheDigitalHealthAct,2023

2.3ContextoftheFact-FindingVisits

2.4Methodology

CHAPTERTHREE

3.OTHEASSESSMENTOFSHAUTILIZATIONOFFUNDSINSELECTED HEALTHFACILITIES

3.1LADNANHOSPITAL,PANGANI

a)Facility Overview

b)FundingandReimbursements

i. Claims

ii. Debt Position:

Key Findings

d)RequestbyHospital totheCommittee

3.2 MBAGATHICOUNTYHOSPITAL

a Facility Overview

b)Funding and Reimbursements

i. Claims

d)RequestbyHospital totheCommittee

3.3STELIZABETHSWINDON

a)FacilityOverview

b)FundingandReimbursements

i. Claims

ii. Debt Position:

c)Key Findings

d)RequestbyHospitaltotheCommittee

3.4MATATANURSINGHOME

a)FacilityOverview

ili. Debt Position:

ii. Key Findings

45. The following key findings were identified:

iii. Requestby theHospital tothe Committee

3.5RACHUONYOCOUNTYHOSPITAL

a)1 Facility Overview

b)FundingandReimbursements

i. Claims

ii. Debt Position:

Key Findings

d)RequestbytheHospital to theCommittee

3.6NYANDIWALEVEL4HOSPITAL

a)FacilityOverview

b)Funding and Reimbursements

i. Claims

ii. DebtPosition:

c) Key Findings;

d)RequestbyHospital totheCommittee

3.7NYANDIWAHEALTHCENTRE

a) Facility Overview

3.8STMARY'SHOSPITALMUMIAS

a)FacilityOverview

b)FundingandReimbursements

i. Claims

ii. Debt Position:

c)Key Findings

d)Requestby theHospital totheCommittee