The Social Health Authority (SHA) has pushed back against claims of favoritism in the approval of cancer treatment, insisting that decisions on oncology care are made through an automated system that leaves no room for human influence.
The clarification follows a Daily Nation report that accused SHA officials of selectively approving cancer care for some patients, allegedly based on personal connections, while others were left to cover costs out of pocket.
In a statement issued on Tuesday, January 20, SHA said it welcomes public scrutiny and defended its pre-authorisation process, noting that all oncology approvals are generated through a fully digital platform guided by Legal Notice No. 56.
According to the authority, once a hospital submits a request for pre-authorisation, the system processes it automatically. SHA staff, the statement said, have no ability to alter, adjust or influence the outcome of approvals.
“Approvals are system-generated and based strictly on the benefits package as gazetted,” SHA said, dismissing suggestions that phone calls to senior officials could result in preferential treatment.
However, SHA acknowledged that approvals may sometimes appear uneven, especially to patients with similar diagnoses. It explained that cancer care is highly individualised, meaning two patients with the same condition may require different tests and treatment plans depending on clinical complexity, stage of disease and prior use of benefits.
The authority added that approvals under the annual oncology cap are influenced by several factors, including a patient’s previous benefit utilisation, the phase of treatment, and how healthcare providers submit their claims.
The controversy was sparked by a Daily Nation story that highlighted two breast cancer patients who pay the same monthly premium of Sh6,000 but received different approvals for diagnostic tests. One of the patients was quoted expressing frustration, saying she was forced to pay extra simply because she did not “know anyone” within the system.
SHA firmly rejected the allegation, stressing that standardised, 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, aimed at ensuring fairness, transparency and sustainability of the insurance fund.
Still, concerns raised by medical professionals suggest the system may not be meeting patients’ needs fully. Consultant pathologist Dr Ahmed Kalebi, quoted in the Daily Nation, argued that SHA often approves fewer diagnostic markers than are clinically required.
“For breast cancer, three or four immunohistochemistry markers may be needed, but SHA approves only one. In leukaemia, a patient may need up to 10 flow cytometry markers, yet only one is approved,” Dr Kalebi said.
He warned that such limitations mean patients may not fully benefit from the insurance package as outlined in the gazetted benefits.
In response, SHA maintained that its systems were designed specifically to eliminate human interference and that differences in approvals should not be interpreted as evidence of favoritism.
As public debate around cancer care and insurance coverage intensifies, the authority says it remains committed to equity and transparency, while urging healthcare providers to submit complete and accurate requests to avoid delays or partial approvals.