By Michelle Ndaga
The Ministry of Health has announced a new, streamlined and transparent framework for overseas medical treatment under the Social Health Insurance (SHI) scheme, marking a major milestone in Kenya’s quest to guarantee access to specialized healthcare for all citizens.
In a press release, Health Cabinet Secretary Aden Duale said the move reflects the government’s commitment to ensuring that no Kenyan is denied access to life-saving medical and surgical procedures not yet available locally.
The process is anchored in the Social Health Insurance Act, 2023, its attendant regulations, and the Public Procurement and Asset Disposal Act.
Under the new system, the Social Health Authority (SHA) can only make payments to empanelled and contracted healthcare providers. Beneficiaries will be eligible for treatment abroad only if the required service is unavailable locally, their SHI contributions are up-to-date, and the treatment is provided by an SHA-contracted facility.
The Benefits Package and Tariffs Advisory Panel (BPTAP) has already gazetted an initial list of 36 healthcare services eligible for overseas referral. This list will continue to expand based on comprehensive Health Technology Assessments (HTA).
All referrals will undergo a peer review process by the Claims Management Office to confirm medical necessity, and only proven and conventional treatments within the financial limits of the benefits package will be approved.
The maximum payable amount for overseas procedures has been capped at KSh 500,000, subject to review after rate negotiations with accredited providers abroad.
The Ministry has directed the SHA Board of Directors to proceed with empanelment and contracting of overseas facilities and to publish the list of approved providers to facilitate timely approvals.
CS Duale emphasized that the framework guarantees a transparent, evidence-based and accountable system, ensuring Kenyans receive value for money and continuous follow-up care upon returning home.
