The Ministry of Health has unveiled a new framework that allows Kenyans under the Social Health Insurance (SHI) scheme to access specialized medical care abroad.
This move ensures that no citizen is denied life-saving treatments and surgical procedures not yet available locally, while reinforcing the capacity of the national health system.
Cabinet Secretary for Health Aden Duale in Saturday said the initiative marks a new era for healthcare in the country.
“This milestone is a testament to the government’s commitment to ensuring that no Kenyan is denied access to life-saving, specialized medical and surgical procedures not yet available locally,” Duale said.
The announcement follows a rigorous assessment by the Benefits Package and Tariffs Advisory Panel (BPTAP) to determine which services qualify for overseas referral.
Unlike the old framework under the defunct National Health Insurance Fund, the new system is guided by the Social Health Insurance Act, 2023, its regulations, and the Public Procurement and Asset Disposal Act.
Under the new guidelines, only beneficiaries whose contributions are up to date and whose required services are unavailable locally can access treatment abroad.
Additionally, overseas treatment must be provided by health facilities contracted with the Social Health Authority (SHA).
These facilities must be accredited in their home country and recognized by Kenyan regulatory bodies, with links to local facilities for continuous follow-up care.
The BPTAP has identified an initial 36 healthcare services eligible for overseas treatment, with plans to expand the list based on continuous Health Technology Assessment.
Referrals will undergo peer review by the Claims Management Office to confirm medical necessity and ensure treatments fall within financial limits, avoiding experimental or unconventional therapies.
Financial coverage for overseas procedures is capped at Sh500,000, subject to review after contracting and rate negotiations with accredited providers abroad.
Duale emphasized that the system is designed to be transparent, accountable, and evidence-based, guaranteeing quality care and value for money.
“The Ministry of Health has directed the SHA Board of Directors to proceed with the Empanelment and Contracting of Overseas Facilities and to notify the Public of the List of Contracted Facilities,” Duale added.
This initiative is expected to streamline approvals for overseas treatment requests, ensuring patients receive timely and safe care while safeguarding public resources.
