Patients in need of surgical procedures are now facing prolonged delays as hospitals await crucial system upgrades before services can resume.
For about a week, the Social Health Authority (SHA) preauthorisation portal has been non-functional, leaving critical surgical procedures in limbo and patients suffering in silence.
The entity was envisioned as a transformative solution to streamline healthcare access and affordability. However, less than two months into its operations, the SHA is marred by inefficiencies, disorganisation, and growing dissatisfaction among patients, healthcare providers, and other stakeholders.
This financial uncertainty has led many hospitals to restrict or deny services to patients relying on SHA. Pre-authorisations for critical procedures are stalled, leaving patients in pain and hospitals in limbo.
One of the most glaring failures of SHA has been its preauthorisation portal. Designed to streamline approvals for surgeries and other medical procedures, the system has become a bottleneck. For the past week, the portal has been non-functional, causing widespread delays in elective and emergency surgeries.
At a hospital in Kitale, staff report more than 10 pending approvals dating back to late November. None has been cleared.
“We’ve had to send patients back home, promising to schedule their surgeries only once the approval comes through,” a hospital administrator told the Business Daily.
“This delay has devastating consequences. Some cases require immediate intervention, but we cannot shoulder the cost without approval.”
In emergencies, hospitals are now asking patients to pay cash upfront.
“We’re left with no choice,” said another administrator. “Performing procedures without approval means we risk not being reimbursed. For now, cash payments are the only way to proceed with urgent cases.”
Dr Brian Lishenga, the National Chairman of the Rural Urban Private Hospitals Association, highlighted the widespread issues stemming from recent updates to the SHA preauthorisation portal. The changes introduced new rules requiring all preauthorization requests to be verified by an auditor within the system.
"Previously, the preauthorisation process was seamless," Dr Lishenga explained.
"But it seems there was a flaw in the system when it was launched two months ago. Almost every procedure was being automatically approved. This led to a sharp surge in surgical bills, which have ballooned to nearly Sh5 billion in unpaid claims within less than a month. Concerns arose that this trend was financially unsustainable, prompting the adjustments."
The newly introduced layers of verification, requires that every update has to be verified by a person, however, this have significantly slowed down approvals, leaving both hospitals and patients in limbo.
“Last week, hospitals from across the country raised concerns during our meeting. Both elective and emergency procedures are being affected,” he explained.
Elective surgeries, which are typically scheduled in advance, have been indefinitely delayed. Emergency cases are no better off, as hospitals are reluctant to take on financial liabilities without assurance of reimbursement.
“Over the weekend, we received a referral of a patient who had a severe accident, required surgery for fractures. The procedure should have been done yesterday, but without approval, the patient is left in excruciating pain. Unless we act purely out of mercy, there is nothing we can do and patient will have to wait,” said the administrator.
“I currently have seven cases awaiting preauthorisation,” said a doctor who sought anonymity. If I perform them without approval, then I will be left with the bill to clear. I still have some National Health Insurance Fund claims that were not settled after we performed the procedure. “I learnt the hard way and will not repeat that mistake again,” Dr Lishenga said.
“Patients relying on private insurance face additional hurdles. Without SHA’s commitment to approve, their insurance cards remain inactive. “This further complicates things for patients who thought they had a financial safety net,” noted Dr Lishenga.
Dr Lishenga said that he had raised the issue with SHA Chairman, Dr Ali Muhammed. According to Dr Muhammed, doubts about the efficiency and accuracy of the preauthorization department have led to a complete system overhaul.
“They suspect that some approvals were being given unnecessarily, which has caused the current freeze. Dr Muhammed assured me that this week would be spent fixing the system,” said Dr Lishenga.
But for patients like those waiting in Kitale and across the country, each passing day without action translates to unbearable suffering, unending queues, and mounting despair.
The crisis has revealed the fragility of the healthcare system, with vulnerable Kenyans bearing the brunt of bureaucratic inefficiency. Efforts to reach SHA chairman, Dr Ali were futile as calls and messages went unanswered.
“At the onset of the SHA system, I encountered a significant challenge,” recounts Dr Ruto Cheregany.
“A patient came in with an ectopic pregnancy, a critical emergency. We rushed her straight to the theater because waiting wasn’t an option. After the procedure, we submitted a request for approval, but it was rejected. They demanded an ultrasound, which wasn’t feasible given the urgency of the situation.”
Dr Cheregany notes that such rigid requirements hinder emergency responses, leaving medical professionals in a difficult position.
“In cases like these, it becomes nearly impossible to prioritiae life-saving procedures without prior approval. The only alternative is to ask patients to pay in cash up front, which not all can afford,” he says, emphasizing the strain this places on both doctors and patients.
Healthcare experts are urging immediate action to salvage SHA and prevent the total collapse of the healthcare financing system.
“We need SHA to clear the backlog of claims, fixing the preauthorisation portal, and implementing transparent, efficient leadership,”Dr Lishenga said.
He adds: “While the authority’s vision was ambitious, its execution has left hospitals overburdened and patients abandoned in their greatest time of need. Unless drastic measures are taken, SHA risks becoming another symbol of unfulfilled promises in Kenya’s pursuit of equitable healthcare.”
