Why SHA Fails Kenya's Sick — Lessons from German Health Cover

Health Policy

The Disease Was Not Depleted — Only the Money Was

A half-paralysed teacher begging for Sh65,000. A mother's chemotherapy suspended until August. This is what SHA means at the bedside.

By Dr. rer. nat. habil. Dr. Seronei Chelulei Cheison

Langwedel, Niedersachsen

The message reached me as an SOS. A relative — a teacher — had collapsed with a neurological failure and was now half-paralysed, one side of his body no longer answering. The treatment existed. The doctor said so plainly: go and buy the drugs yourselves, and I will administer them. What did not exist was the money. The Social Health Authority had looked at the case and returned one word — depleted. The allocation was depleted. Not the disease. The disease was very much alive, working its way through a man's nervous system while we spoke. It was the money that had run out. And so a teacher who gave his working life to other people's children was reduced to begging sixty-five thousand shillings from relatives and friends to stop his own body from shutting down.

Then, a few days later, a stranger.

He was teary — a grown man, undone in public. His mother has cancer. She has been on chemotherapy: the long, scheduled, unforgiving kind that works only if it is not interrupted. And in March this year he was told the thing that broke him. Her chemotherapy cannot continue until August, when the next allocation will be loaded. Five months. He has done everything a son can do — borrowed here, called a harambee there, poorly attended because everyone's pockets are as thin as his — all to bridge a gap that should never have opened, until an allocation reopens like a shop after lunch.

Five months without chemotherapy. I want someone in authority to say that sentence aloud and to hear it. Does cancer take a technical break? Is there a half-term with disease? Does a tumour consult the SHA calendar, agree to pause for the quarter, and resume politely in August where it left off?

Does cancer take a technical break? Is there a half-term with disease?

It does not. Cancer keeps its own schedule, and the schedule is not the Treasury's. A cover that suspends a woman's chemotherapy for the convenience of a disbursement cycle is not insuring her against illness. It is timetabling her illness around its cash flow.

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These two are not unlucky exceptions. They are the system working exactly as it was built. My relative is one of more than four hundred thousand teachers whom the Teachers Service Commission moved off the AON Minet scheme and onto SHA's Mwalimu Comprehensive Medical Cover on the first of December last year. Under the old cover, the most junior teacher carried a million shillings of inpatient protection; a senior principal, three million, with overseas treatment, dental and optical care. It worked. It is precisely because it worked that they now mourn it. What replaced it came with caps so tight that a union official observed: once a thousand shillings has gone to the consultation, the two hundred left cannot treat anyone.

And here is the sentence that should end every defence of this migration. Parliament's own education committee recorded that moving teachers to SHA "realised a saving of four billion shillings" — and described that switch, in its own words, as a claw-back on teachers' medical cover. Sit with both findings at once. The migration was sold to the Treasury because it was cheaper. And cheaper does not stay quietly in a ledger. Cheaper walks into the ward and becomes a depleted allocation, a suspended chemotherapy, a teacher with a tin cup. The four-billion saving and the half-paralysed man are the same fact seen from opposite ends. The saving is the symptom.

A Word That Keeps Its Promise

I write from Germany, where I have carried a sickness-fund card in my wallet for the better part of two decades. The German word for health insurance, Krankenversicherung, means — translated word for word — sickness insurance. And the system keeps the promise its name makes. You present the card; the fund pays the doctor directly; treatment runs until you are well, not until a counter reaches zero. The limits exist — no pool is bottomless — but they live upstream, at a budget table no patient ever sees, and they are never allowed to interrupt a course of care. Roughly ninety-six cents of every euro reaches treatment, and anyone may audit the figure. No German oncologist has ever told a patient to come back in August.

In Kenya the equivalent figure cannot even be calculated, and that is the indictment. Before a shilling reaches a sick person, a private operator skims two and a half per cent off contributions and five per cent off every claim. Between eleven and fifty billion shillings, on the Auditor-General's own accounting, has drained into phantom clinics billing for patients who never lived. And when a pool is looted, nobody enlarges it. They tighten it — shrink the allocation, lengthen the queue, demand another form. So the honest, dying contributor pays for the thief twice: once in the shillings stolen, and again in the cap raised to stop the next theft. My relative's sixty-five thousand shillings is that second payment. So is the August that mother is told to wait for.

The honest, dying contributor pays for the thief twice — once in the shillings stolen, and again in the cap raised to stop the next theft.

Let me be fair, because the argument is only worth making honestly. The idea behind SHA was right. A graduated levy is fairer than the flat fee it replaced. Free primary care at the dispensary matters, and where it reaches people it changes lives. The government says claims now clear within forty-eight hours and that the scheme is an improvement, and at the front end it may well be. But the test of a health insurer is not the queue at the dispensary for a child's immunisation. The test is the chemotherapy chair and the stroke ward — the catastrophe a citizen can never self-finance. That is the one place a health system is forbidden to fail. It is the precise place SHA is failing.

President Ruto promised that no Kenyan would ever again stand one illness away from poverty. These two are not one illness away. They are one illness in — half a body stilled, a chemotherapy frozen, two families passing the phone around asking who can spare what. The country's answer, when their turn came, was that the money set aside for them had run out while they were still sick.

The disease was not depleted. Only the money was. Cancer keeps no half-term, and a stroke files no leave. Until we cap the system and not the sufferer, publish the ratio and not the slogan, and own the rails and not merely the launch, our sickness insurance will remain what its German cousins were built never to become: an insurance that has itself fallen sick.

Dr. Seronei Chelulei Cheison writes on science, business and development policy at the intersection of Germany and East Africa, at cheison.com and sinonin.com.