The Social Health Authority (SHA) has sought to allay public concern following a media report alleging favouritism in the approval of cancer treatment, which reportedly left some patients paying out of pocket despite making similar insurance contributions.
In a statement issued on Tuesday, January 20, SHA said it welcomes public scrutiny and maintained that oncology approvals are processed through a fully automated digital system governed by Legal Notice No. 56, leaving no room for manual interference by staff.
According to the authority, once a health facility submits a pre-authorisation request, approvals are generated automatically, and officers cannot alter or influence the outcome.
SHA acknowledged that some approvals may appear inconsistent but explained that cancer treatment is highly personalised.
As a result, patients with similar diagnoses may require different tests and treatment plans based on individual clinical needs.
The authority noted that approvals under the annual oncology cap are influenced by several factors, including a patient’s previous utilisation of benefits, the stage of treatment, the complexity of the case, and the manner in which hospitals submit claims.
The response follows a Daily Nation report alleging that personal phone calls to senior SHA officials could allegedly result in higher approvals for some patients.
The article cited the case of two breast cancer patients who paid the same Sh6,000 premium but received different approvals for diagnostic tests.
“I do not understand. We were scheduled for the same tests, but I have to pay extra because I do not know anyone. This is impunity,” one patient was quoted as saying.
SHA rejected claims of preferential treatment, insisting that standardised and gazetted tariffs are applied uniformly across public, private, and faith-based health facilities nationwide.
It said oncology reimbursements follow published tariffs available on its website and are designed to promote fairness, transparency, and sustainability of the insurance pool.
However, medical experts quoted in the report raised concerns about gaps in the approval process.
Consultant pathologist Dr Ahmed Kalebi said SHA often approves only a single diagnostic marker when multiple tests are required.
“For example, breast cancer requires three or four immunohistochemistry markers, but SHA approves only one. A patient with leukaemia may require up to 10 flow cytometry markers, but SHA approves only one,” Dr Kalebi said, adding that such limitations prevent patients from fully benefiting from the gazetted benefits package.
SHA maintained that its automated system was designed to eliminate human interference and stressed that variations in approvals do not amount to favouritism.
As public debate intensifies, the authority reiterated its commitment to equity and urged healthcare providers to submit complete and accurate requests as calls grow for reforms to align policy with practice.
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