Kenya’s ambitious health financing reforms are facing fresh scrutiny after a new Social Health Assurance (SHA) report revealed that tens of thousands of medical claims are being rejected—largely due to missing paperwork and administrative lapses.
The report, presented at the 29th Ordinary Session of the Intergovernmental Budget and Economic Council (IBEC), paints a troubling picture of systemic bottlenecks even as the programme continues to expand its reach nationwide.
According to the latest SHA assessment covering October 2024 to January 2026, a staggering 123,000 claims were rejected across county health facilities.
The overwhelming culprit? Incomplete or missing documentation, which alone accounted for 91,935 rejected claims.
Officials say the failures stem from basic but costly administrative gaps, including:
Incomplete claim forms
Missing patient identification
Insufficient supporting medical documents
Health facilities have now been urged to tighten internal verification processes and enhance staff training to stem the losses.
Beyond paperwork errors, the report highlights other rejection triggers:
4,073 claims failed to meet SHA clinical or medical criteria
1,932 claims were rejected due to benefit package or coverage issues
2,066 claims were flagged as duplicate or multiple submissions
348 claims failed due to lack of pre-authorisation
While pre-authorisation rejections were relatively low, the report warns that delays in approvals continue to slow access to essential health services.
Another major red flag is compliance with timelines.
At least 23,000 claims were rejected simply because facilities failed to resubmit them within the required window—underscoring what analysts describe as a “process discipline problem” within parts of the health system.
Even with the rejection crisis, the numbers show the programme is growing:
29.4 million Kenyans registered under SHA
Sh142 billion collected in contributions
8,082,790 people accessing primary health care
3,238,082 beneficiaries covered under the Social Health Insurance Fund (SHIF)
The data suggests strong uptake, though experts warn administrative inefficiencies could undermine public confidence if not urgently addressed.
The latest SHIF payment analysis reveals how funds are flowing across the health sector:
Private providers: 2,543 facilities received Sh41.68 billion
County facilities: 2,323 providers received Sh19.21 billion (71% settlement rate)
Faith-based facilities: 362 providers received Sh15.2 billion
Ministry of Health facilities: 8 providers received Sh8.5 billion
In total, Sh84.5 billion has been paid out—highlighting the massive financial footprint of the new health financing model.
The report exposes a critical paradox: coverage is expanding, but administrative weaknesses are locking out thousands of legitimate claims.
If documentation discipline improves, analysts say Kenya could significantly reduce claim losses and speed up reimbursements—key steps toward making SHA deliver on its promise of universal health coverage.
For now, however, one message is clear: in Kenya’s new health insurance era, paperwork can make—or break—your claim.
