The government’s decision to fold teachers into the national health insurance system is easing pressure on public finances while opening up care options across the country, Social Health Authority chairperson Dr Abdi Mohamed has said, even as new safeguards are introduced to check abuse of the scheme.
Speaking in a Radio Generation interview on Monday, Dr. Abdi said the move away from a private insurance arrangement under the Teachers Service Commission was driven by rising costs and limited access to healthcare facilities.
He noted that the previous cover insured about 360,000 teachers at a cost of Sh24 billion, with projections showing the figure would climb further with additional enrolments.
“With the new premium, because there was an additional 50,000 that was supposed to be added, the premium was supposed to jump from 24 to either 26 or 28 billion,” he said.
Under the earlier setup, teachers were covered through a private medical scheme managed by Minet Kenya, formerly AON Minet, under a consortium contracted by the Teachers Service Commission.
The plan, renewed in November 2019, extended to teachers and their dependants and grew to become one of the largest employer-funded health covers in the region.
By 2025, the programme served over 400,000 teachers and close to 1.4 million beneficiaries including spouses and children.
Earlier records showed 341,837 teachers were directly enrolled in 2022 before the numbers increased.
The scheme offered a range of benefits including inpatient, outpatient, maternity, dental, optical, group life and funeral cover, with limits set according to job group.
It had replaced an earlier medical allowance model that was found to be insufficient.
Despite its scale, the programme faced mounting criticism over delays in approvals, restricted access to facilities and fraud concerns.
In 2025, Minet confirmed that some hospitals had been suspended over “fraudulent or unethical practices”, although it maintained that most of its network remained active.
Dr. Abdi said the shift to the Social Health Authority was part of broader health sector reforms aimed at bringing Kenyans under a unified system.
He explained that continuing with the private scheme would have pushed annual costs to between Sh26 billion and Sh28 billion, compared to a Sh15 billion top-up required under SHA.
“All that was then required was not the payment of the 24 billion, but 15,” he said. “We say that Sh15 billion is reasonable enough for us to do, plus the usual SHA.”
He added that the number of teachers now covered under the new arrangement had reached 415,000, including school heads and their dependants.
Dr. Abdi said the transition maintained the benefits teachers previously enjoyed, while removing restrictions that had limited where they could seek treatment.
Under the new system, access has expanded from about 800 facilities to more than 10,000 across the country.
However, the broader access has also exposed new challenges, including misuse of benefits by both members and service providers.
“So moral hazard occurs where the insured person does not care how they use the cover,” he said. “They will go back as many times as they wish.”
He said some healthcare providers were also exploiting insurance limits.
“Providers also do this, they simply look at your limit and then go for it,” he said.
To address this, SHA is introducing measures to ensure members use their cover in a more sustainable way.
“What we were trying to do is create some order, save the teacher from being misused in terms of their limits being depleted quickly,” he said.
He explained that once outpatient limits are exhausted, members often begin paying out of pocket or shift to inpatient claims, putting pressure on emergency support funds.
“What we are trying to say is just within your limit, use the same services, but as many times as possible so that you don’t exhaust it quickly,” he said.
Outpatient limits for teachers, he said, vary by job group and generally range between Sh100,000 and Sh200,000.
Going further, Dr. Abdi also defended the authority’s monitoring systems, saying suspicious claims are automatically flagged for review. He cited cases where one individual was linked to “50 wives and 75 children”, and another involving multiple hospital visits in a single day under different diagnoses.
“You can clearly see there’s something amiss,” he said.
He said flagged claims are paused as investigations are carried out to determine whether they result from error, fraud or system gaps.
“If you find that there was an error or it was fraud, then we take the necessary action,” he said.
The scheme has been in place for about four and a half months since its rollout in December, with SHA now analysing usage patterns across counties and facilities.
“You now need to find a way of stabilising and trying to see where is the utilisation, which hospitals are these, which county is the utilisation highest,” he said.
He added that the data being collected will help determine whether high usage reflects real healthcare needs or misuse of the system.
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