Is outpatient care covered by my 2.75% SHIF deduction?

Outpatient care at Levels 2 and 3 (dispensaries and health centres) is covered under PHF, which is government-funded, not from your SHIF premium. Outpatient care at Level 4 and above sits under SHIF and is funded by your 2.75% deduction. In practice, day-to-day primary care visits are the PHF pathway; specialist consults and higher-level diagnostics are the SHIF pathway.

What does an outpatient visit cover under SHA?

Under PHF: consultations, laboratory tests, X-rays, ultrasounds, prescriptions, drug administration, treatment for non-communicable diseases, STIs, HIV, immunisations, and reproductive, maternal and child health services. Under SHIF outpatient: doctor consultations, diagnoses, lab tests, imaging, prescriptions, drug administration, and minor surgical procedures. Both are per SHA fund pages.

Can I visit any private clinic under SHA?

Only if the private clinic is contracted with SHA. Most standalone private primary-care clinics in Kenya are not contracted. Some faith-based primary-care clinics are contracted. Check the SHA contracted facilities list at sha.go.ke/contracted-facilities before assuming a private clinic will bill SHA.

What if my primary facility cannot handle my case?

That is the referral pathway. Level 2 or 3 refers up to a Level 4 hospital, which can refer to a Level 5 or 6 for more specialised care. Referrals matter for billing: an outpatient episode that starts as PHF and escalates to SHIF specialist care needs the referral chain documented for the claim to sit correctly against the two funds.

SHA outpatient benefits Kenya 2026: what visits cover

Two funds, one outpatient system

SHA runs three funds under the Social Health Insurance Act 2023. Two of them meet you at outpatient:

Primary Healthcare Fund (PHF). Government-funded. Covers outpatient care at Levels 2 and 3: dispensaries and health centres. Access is broad; PHF is not conditional on your 2.75% SHIF deduction reaching SHA.
Social Health Insurance Fund (SHIF). Funded by the 2.75% member premium. Includes an outpatient services package for Level 4 and above hospitals: doctor consultations, diagnoses, lab tests, imaging, prescriptions, drug administration, and minor surgical procedures. Requires active SHA status.

Full breakdown: what SHA actually covers.

What PHF outpatient covers

From SHA's PHF benefits page (26 August 2026 fetch), the PHF outpatient care package is described as covering:

Consultations
Diagnoses
Laboratory tests
X-rays and ultrasounds
Prescriptions and drug administration
Treatment for non-communicable diseases (hypertension, diabetes, asthma, and similar)
Treatment for STIs and HIV (alongside NASCOP-managed HIV programmes)
Immunisations (the Kenya EPI schedule for children, plus adult vaccinations available at the facility)
Reproductive, maternal and child health services

PHF also covers maternity, newborn and child health services (antenatal, postnatal, family planning, neonatal care, Anti-D serum), cancer screening (breast, cervical, prostate, colon), optical health (eye tests, prescription glasses), end-of-life services, and some inpatient services at Level 3 [Source 1]. See SHA for maternity for the maternity-specific pathway.

What SHIF outpatient adds

SHIF has its own outpatient services package for Level 4 and above hospitals. Per SHA's SHIF benefits page (26 August 2026 fetch):

Doctor consultations (including specialist consultations at appropriately-levelled facilities)
Diagnoses
Lab tests
Imaging
Prescriptions and drug administration
Minor surgical procedures

The SHIF pharmacy package covers medications for chronic illnesses (diabetes, hypertension, asthma, renal disease, mental health conditions). Specialised laboratory services cover advanced tests for chronic diseases. Medical imaging covers MRI, CT, angiography, fluoroscopy, mammography, ultrasound, ECHO, and EEG at contracted facilities [Source 2].

What SHA outpatient does not cover

A private clinic that is not on the SHA contracted list. If the facility does not appear at sha.go.ke/contracted-facilities, SHA will not pay the visit. Most standalone private primary-care clinics in Nairobi and other cities are not contracted; a portion of faith-based clinics are.
Specialist consultation without a referral, at some facilities. Some contracted hospitals require a lower-level facility referral before SHA will bill a specialist consultation, especially at Level 5 and 6.
Medications not on the Kenya Essential Medicines List or not on the SHA covered formulary. A doctor may still prescribe them; the patient pays.
Non-essential and cosmetic services at any level, whether at a public or private facility.
Fees over the SHA tariff at a private facility. Even where the service is covered, the facility's charge above the SHA tariff is a member co-pay. See SHA and private hospitals: what you may still owe.

The referral pathway

Kenya's public health system runs on a referral pyramid:

Level 1. Community units (community health promoters). Not usually a billing point.
Level 2. Dispensaries. Outpatient primary care under PHF.
Level 3. Health centres. Outpatient primary care under PHF, with some inpatient capacity.
Level 4. Sub-county and primary-referral hospitals. SHIF outpatient and inpatient.
Level 5. County referral hospitals. SHIF for the broader specialist services.
Level 6. National referral hospitals (Kenyatta National Hospital, Moi Teaching and Referral Hospital, Mathari National Teaching and Referral Hospital, Kenyatta University Teaching Referral and Research Hospital). SHIF and ECCIF for tertiary and quaternary care.

A referral from a lower-level facility documents the medical need to escalate and is often required for the higher-level facility to bill SHA at the specialist tariff. Keep referral letters. If you self-present at a Level 5 or 6 for a condition that could have started at Level 3, expect the possibility of being redirected back down or asked to pay if SHA declines the specialist billing on grounds of no referral.

Which private clinics are contracted

The pattern that holds without naming specific facilities:

Most standalone private primary-care clinics are not on the SHA contracted list.
Selected private hospital-affiliated outpatient departments are contracted at the same level as the hospital.
Selected faith-based primary-care clinics are contracted.
Selected national employer or scheme-linked clinics may have arrangements that overlap with SHA.

Check sha.go.ke/contracted-facilities before assuming a private clinic will bill SHA. See which hospitals accept SHA for the general lookup pathway.

Outpatient and chronic-condition refills

For patients on chronic medications (hypertension, diabetes, asthma, epilepsy, chronic mental health), the outpatient interaction with SHA matters every month. The medication may be covered under the SHIF pharmacy package for chronic illnesses, or under ECCIF chronic illness management for diabetes, cancer, and mental health. Practical guidance:

Get the prescription refilled at a facility that is on the SHA contracted list, at a level appropriate to your prescribed drug.
Ask what SHA covers of the specific drug (some brand names are excluded even where the generic is covered).
Attend regular clinic reviews so that the prescription is renewed and pre-authorisation, where applicable, stays in date.
Register on the facility's chronic care register; refills against a chronic care register are administratively simpler.

See SHA for chronic and emergency conditions for the umbrella ECCIF explanation.

Strategic tip: use PHF for primary care

For routine primary care (a cold, a rash, a routine check, a child's immunisation, a chronic-condition review, a family planning visit), the PHF pathway at a Level 2 or 3 facility is the intended use of the SHA architecture. It is government-funded, not conditional on your SHIF premium, and it does not consume anything from your SHIF cover. That preserves the SHIF cover for what SHIF is designed for: secondary and tertiary hospital care when you actually need it. Skipping past PHF for every ordinary visit is not always ideal because it exposes routine care to co-pays that PHF would have covered fully.

Practical guidance

Find your nearest Level 2 or 3 SHA-contracted primary facility and use it for primary care.
Know your county referral hospital as the Level 4 or 5 pathway when a case escalates.
Confirm any private clinic is contracted before treating it as an SHA-billing venue.
Keep referral letters when you escalate.
Confirm SHA is active before a planned outpatient visit at Level 4 and above; PHF at Levels 2 and 3 is broader in access.

Sources

SHA Primary Healthcare Fund: sha.go.ke/primary-healthcare-fund, accessed 26 August 2026. Outpatient care package named: consultations, diagnoses, lab tests, X-rays, ultrasounds, prescriptions, drug administration, treatment for NCDs, STIs, HIV, immunisations, reproductive, maternal and child health.
SHA Social Health Insurance Fund: sha.go.ke/social-health-insurance-fund, accessed 26 August 2026. SHIF outpatient services package named: doctor consultations, diagnoses, lab tests, imaging, prescriptions, drug administration, minor surgical procedures.
SHA Emergency, Chronic and Critical Illness Fund: sha.go.ke/emergency-chronic-critical-illness-fund, accessed 26 August 2026.
SHA contracted facilities: sha.go.ke/contracted-facilities.
SHA benefit tariffs: sha.go.ke/benefit-tariffs, accessed 26 August 2026.
Social Health Insurance Act 2023 establishing SHA and the three-fund architecture.
SHA toll-free helpline 0800 720 601.