The Ministry of Health (MoH) has announced several measures for overseas medical treatment under the Social Health Insurance (SHA) scheme, introducing a maximum funding cap of KSh 500,000 per procedure.
In a statement released on Saturday, September 20, the Ministry through the Social Health Authority outlined new stringent measures designed to ensure transparency and accountability in the approval process for medical treatment abroad.
According to the press release signed by Health Cabinet Secretary Aden Duale, the new system follows what the ministry describes as ‘a rigorous, systematic, and evidence-based assessment’ conducted by the Benefits Package and Tariffs Advisory Panel.
The Social Health Insurance Act mandates that SHA can only make payments to healthcare providers who are empaneled and have a contract with the Authority.
Beneficiaries can only access treatment outside Kenya if the healthcare service is not available locally, and their contributions must be up-to-date.
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For overseas treatment, beneficiaries must show that local options have been exhausted. Overseas facilities must be accredited in their home country and officially recognized by Kenyan regulatory bodies. These providers must also be linked to a contracted health facility in Kenya for follow-up care.
The Benefits Package and Tariffs Advisory Panel has developed an initial list of 36 healthcare services not available in Kenya, which has been gazetted. The process of identifying additional interventions continues under a Health Technology Assessment framework.
Referrals for overseas treatment will be subject to peer review by the Claims Management Office to ensure medical necessity. Treatment must fall within the financial limits of the benefits package and cannot be unproven, experimental, or unconventional therapy.
The Ksh 500,000 maximum is subject to review upon completion of contracting and negotiations with accredited providers abroad.
The Ministry has directed the SHA Board of Directors to proceed with empaneling overseas facilities and notify the public of contracted facilities to facilitate approval of treatment requests.
The new framework follows previous concerns about system abuse, where patients were referred abroad for procedures available in Kenya. This led to a temporary suspension of overseas treatment approvals for system upgrades.
The ministry stated the new system ensures transparent, evidence-based, and accountable processes for Kenyans seeking treatment abroad, guaranteeing value for money and quality care.
These reforms follow a temporary suspension of overseas treatment approvals, which was implemented to allow for comprehensive system alignment and upgrades.
During this period, patients were encouraged to explore local treatment alternatives while authorities worked on establishing more robust oversight mechanisms.
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