The Social Health Authority (SHA) has issued a clarification on how its oncology pre-authorization system operates following growing public concern over alleged favouritism in cancer care approvals.
In a statement on Tuesday, January 20, the authority said approvals are governed strictly by existing legal and policy frameworks.
SHA explained that once a healthcare provider submits a request, decisions are generated automatically based on preset rules.
“All cancer-related pre-authorizations under SHA are processed through a fully automated digital system, in line with the benefit limits, access rules, and tariffs set out in Legal Notice No. 56 (LN 56).
“Once a request is submitted by a healthcare provider, approvals are generated by the system based on predefined rules. Individual staff members do not have the ability to arbitrarily adjust approvals,” the statement read.
Addressing concerns about why different patients may receive different approval outcomes despite having similar diagnoses, SHA explained that cancer treatment is individualized and depends on multiple clinical and administrative factors.
“While two patients may share a broad diagnosis such as ‘breast cancer,’ their clinical profiles, diagnostic needs, and treatment pathways are rarely identical.
“Cancer care is personalized and depends on several factors, including extent of prior benefit utilization, which determines the remaining available balance within the annual oncology package; stage of care, whether diagnostic work-up, active treatment, or follow-up; clinical complexity, including tumor characteristics and whether tests are required sequentially or concurrently; completeness and structure of the pre-authorization request submitted by the healthcare provider; and choice of healthcare provider, noting that beneficiaries are free to seek care at any SHA-contracted cancer facility,” the statement added.
SHA stressed that such variations should not be interpreted as favoritism, but rather as the consistent application of policy to different medical circumstances.
“As a result, differences in approvals do not imply preferential treatment, but reflect the application of uniform benefit rules to differing clinical circumstances,” the statement continued.
On the issue of oncology diagnostics and reimbursement, SHA noted that all claims are paid using standardized tariffs that apply equally across all categories of healthcare facilities.
“Claims reimbursement is undertaken using uniform, gazetted tariffs that apply equally across public, private, and faith-based facilities. These tariffs are publicly available on SHA Website http://www.sha.go.kenand are intended to ensure fairness, transparency, and sustainability of the health insurance pool,” the statement further read.
Responding to allegations of external influence and interference, the authority maintained that its systems are designed specifically to prevent such practices.
“SHA does not condone, permit, or tolerate preferential access to benefits based on personal influence or connections. The digital pre-authorization system includes real-time utilization tracking and audit trails designed to prevent duplication, inappropriate use of benefits, or unauthorized interference,” the statement read.
Looking ahead, SHA said it is implementing further reforms aimed at improving equity and patient experience in cancer care through better alignment with national standards.
“To further strengthen equity and sustainability in cancer care, SHA is embedding National Cancer Control Programme (NCCP)-aligned clinical pathways into the pre-authorization workflow. This will support more standardized diagnostic panels, clearer provider submissions, and improved patient experience,” the statement concluded.
Elsewhere, SHA has warned health facilities against charging patients for Primary Health Care (PHC) drugs, saying it has noted low drug dispensing rates in some facilities.
The authority pointed out that the low dispensation rates indicate that patients are being billed for medicines that are never issued.
“SHA has noted with great concern the low drug dispensing rates, indicating that some facilities may be billing without issuing medicines,” read the statement in part.
SHA said it will not pay for such claims and will deduct the drug component from payments where fraudulent or non-compliant billing is detected.
The authority noted that PHC services and medicines are fully covered by the authority, and patients should not be charged in health facilities.
“SHA will not pay such claims and will deduct the drug component where applicable. All PHC services and medicines are fully covered under SHA. Patients must not be charged,” the authority added.
Further, SHA urged members of the public to report any cases of illegal charging by calling the toll-free number 147 or emailing helpdesk@dha.go.ke.
