A technical team the Social Health Authority’s (SHA) transition committee set up to implement the digital shift to the new Social Health Insurance Fund (SHIF) has revealed gaps in the scheme’s claims management system (CMS) that may hamper a smooth shift from the old National Health Insurance Fund (NHIF) on October 1.
A CMS is software that helps insurance companies manage and evaluate claims from their customers.
The team said there were challenges with the CMS, despite earlier expectations that the digital platform, which acts as a database, would be ready by October 1.
A key stakeholder in the SHA’s digital health transition told the Business Daily that the team also flagged gaps in the Health Information Exchange, including inadequate human resources and infrastructure, as well as unstable Internet connectivity, which could lead to a delay in the implementation of the scheme.
“The team working on Enterprise Resource Planning and the claims management system for SHIF are the ones who are very much behind, they have not yet reached the stage where other components have reached, and have since embarked on preparing another portal to work with as they get ready.
“In a sense, as we look for October 1, we may just be ready, but it’s not 100 percent because we are waiting for the key components in claims management and operationalising SHIF,” said the official.
“We are moving towards Universal Health Coverage, which is enabled with SHIF and emergency, chronic, and critical illness funds, and primary healthcare funds. All these funds require some sort of system to work for you to be able to train and justify your requests. This is where the problem is because we are coming from NHIF towards a new way of working.”
SHA Chairman Timothy Olweny did not respond to calls and texts sent to his mobile phone when the Business Daily tried to reach him for comment.
According to Section 47 of the SHIF, digitisation, and processes should be carried out using appropriate, reliable, secure, interoperable, verifiable, and responsive technology through an information system.
The processes and services include member enrolment, member identification, contributions to the fund, contracts, notifications, pre-authorisation, claims management, and claims settlement. The Ministry of Health has revealed that the centralised ICT system required for the SHIF would cost at least Sh5 billion to set up.
The new development comes less than 40 days from the date set by the Ministry of Health for the start of deductions after a series of date changes.
The ministry announced the postponement of the SHIF rollout to 1 October 2024 following challenges identified during the pilot phase, which saw digital platform failures and a series of date changeovers.
As a result, the NHIF contract has been extended by three months to 30 September 2024 to ensure uninterrupted service delivery.
“To fully comply with the provisions of the SHIF Act, the Cabinet Secretary (Health) has directed that the payment and access to the new benefits package under the Authority be scheduled to begin from October 1 2024. Therefore, the existing NHIF contributions and benefits will continue until September 30, 2024, to ensure seamless service delivery,” the Ministry of Health announced on June 28.
