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What to do when a hospital refuses SHA in Kenya (2026)

Step by step at the admissions desk: verify active status, confirm the facility is contracted, check the service is covered, know your ECCIF emergency rights. Escalation ladder to SHA and the Ministry of Health.

AO
by Reviewed by Michael Mwangi 11 min read Updated 26 August 2026Verified 26 Aug 2026

The three checks, in order

A refusal at admissions almost always traces back to one of three failures. Doing these checks in order takes about 10 minutes and often resolves the refusal without escalation.

Check 1: is your SHA active?

Open eligibility.sha.go.ke or dial *147#. If your status shows inactive or in arrears, that is the refusal. Two paths to reactivate:

If your status is active but the hospital still says otherwise, move to Check 2. Their view of you and yours may not be the same.

Check 2: is the facility contracted?

The hospital may not be on the SHA contract network at all, or may have exited recently. Verify at sha.go.ke/contracted-facilities [Source 2]. Public Level 2 to 6 facilities are contracted by default; private facilities contract individually. If the facility is not on the list, refusal is lawful. See which hospitals accept SHA.

Even where the facility is on the contract list, their contract may cover outpatient but not surgical admission, or the reverse. Ask the admissions clerk to specify which service is not covered under their contract, and confirm this by phoning 0800 720 601 while at the desk.

Check 3: is the specific service covered?

SHA has explicit exclusions [Source 3]: cosmetic procedures, IVF, herbal or chiropractic treatment, vaccines outside KEPI, drugs outside the Kenya Essential Medicines List, weight management drugs, and private-ward-only admissions. If the service is on the exclusion list, refusal is lawful and clearing arrears will not help. Your options then are to pay out of pocket, use private insurance if you have it, or seek a covered alternative pathway (for example, a covered generic drug instead of an excluded branded drug).

Your rights in an emergency

"Emergency" per ECCIF scope: severe burns, head injuries, fractures, seizures, unconsciousness, snake bites, rabies exposure, and other acute presentations requiring immediate intervention. Ambulance evacuation to the nearest medical facility is also under ECCIF. ICU, HDU, NICU, PICU, and burns unit admissions for life-threatening conditions are covered as critical illness care.

The conversation at admissions, scripted

Admissions clerks are under pressure. A polite, structured conversation with specifics gets a faster resolution than an angry one. Something like:

  • "My SHA member number is [number], my National ID is [number]. Can you check my status on the eligibility portal and tell me what it shows?"
  • If active: "My status is active. What is the specific reason SHA cannot cover this admission?"
  • If they say the system is down: "Can we call 0800 720 601 together to confirm my status manually?"
  • If they say the facility is not on contract for this service: "Can you show me that in your contract summary, or refer me to the nearest facility that is contracted?"
  • If it is an emergency: "This is an emergency. Under ECCIF, emergency care is covered regardless of my active status. Please admit and bill ECCIF."

What to write down

Every refusal you might later contest needs a paper trail. Note:

  • Hospital name, physical location, date and time.
  • Full name and role of the staff member you spoke to.
  • The exact reason given for refusal.
  • Any error message on the eligibility screen (take a photo if visible).
  • Your SHA member number, National ID, and the specific service you were seeking.
  • Names of witnesses (family members present, other patients, security guard).
  • Any receipts if you ended up paying out of pocket. Retain the M-PESA SMS.

Without this documentation, an appeal or media escalation has nothing to stand on. With it, SHA and the Ministry of Health can trace the interaction and take action.

The escalation ladder

  1. Hospital administrator on duty. Ask the admissions clerk to escalate to the medical superintendent or CEO's office. Many refusals resolve here because the clerk was applying an out-of-date policy.
  2. SHA toll-free helpline 0800 720 601. Explain the refusal, provide your SHA number, the facility name, and the reason given. The agent can confirm your status, the facility's contract scope, and escalate internally.
  3. SHA branch office. For unresolved disputes, walk into a SHA branch (HQ on Ragati Road, Nairobi; or a county branch). Written complaint, receipts, timeline.
  4. Ministry of Health. The Ministry oversees SHA. Complaints can be filed via the Ministry's Directorate of Standards and Regulatory Services.
  5. Consumer Federation of Kenya (COFEK). COFEK handles consumer-rights complaints and has taken cases against health facilities and insurers. Useful when SHA and the hospital are both stonewalling.
  6. Media. Standard Health, Nation Health, KTN, Citizen have all covered SHA refusals. This is a last resort but effective when documentation is airtight.
  7. Judicial review. For cases involving denied emergency care resulting in harm, the High Court has jurisdiction. Retain counsel; the Legal Aid Kenya network can help those unable to afford private counsel.

If you paid out of pocket because of refusal

If you paid cash for care that should have been covered by SHA, retain every receipt. Once you have escalated the refusal and SHA agrees the service should have been covered, the reimbursement process runs via the SHA claims department. Timelines are slow. This is a strong argument for verifying status before non-emergency admission rather than relying on reimbursement after.

How to prevent this at the next admission

  • Check your SHA status via *147# the week before any planned admission.
  • Confirm the facility's current contract status via sha.go.ke/contracted-facilities.
  • If you carry any arrears, clear them before the admission date. See SHA arrears and the 2% penalty.
  • Request a written admission-under-SHA acknowledgement at the desk.
  • Take your National ID and a copy of your latest afyayangu.go.ke status printout.

Sources

  1. SHA Emergency, Chronic and Critical Illness Fund scope: sha.go.ke/emergency-chronic-critical-illness-fund, accessed 26 August 2026.
  2. SHA contracted facilities: sha.go.ke/contracted-facilities, accessed 26 August 2026.
  3. SHA benefit tariffs and exclusions: sha.go.ke/benefit-tariffs, accessed 26 August 2026.
  4. SHA eligibility check: eligibility.sha.go.ke.
  5. SHA toll-free helpline 0800 720 601.
  6. Social Health Insurance Act 2023 establishing the three-fund scheme.