Authors: Sophie Otieno, Isdorah Akoth, Dr. Lilian Otiso

“No SHA, No Money, No Services.” (Community Health Promoter, Homabay County, Western Kenya)

The Social Health Authority (SHA) overhauled the existing Kenya health insurance and is designed to ensure equitable access to healthcare services for all Kenyans. It promises universal coverage and affordability, including free primary healthcare and programs for vulnerable households, and reduced financial barriers to care. Yet for pregnant and impoverished adolescent girls, these promises remain out of reach.

Why the SHA Leaves Adolescents Behind

According to county-level Demographic and Health Survey data from 2022. Homa Bay County shows that the teenage pregnancy rate among adolescents aged 15-19 is 23% which is significantly higher than the national average of 14.8%. The transition to SHA has exposed faults in a system that is leaving behind this group that is most in need.

Three main barriers keep pregnant adolescents from accessing SHA benefits: documentation requirements, unaffordable premiums, and confusion around the system.

The Documentation Barrier: Adolescents Shut Out

The requirement for an identification document (ID or birth certificate) for SHA registration and healthcare access immediately locks many adolescents out of care, as it overlooks the reality that many lack proper documentation, especially orphans and those from marginalized communities.

An adolescent has come, wants an ANC profile. She is pale. She has no parents. She is an orphan. She has no one to depend on. So, when she comes, she is asked for ID, she is asked for SHA. So, how do we help such? (Health manager)

The consequences are severe. Without SHA registration, these young mothers cannot access essential antenatal care (ANC) services like obtaining an “ANC profile”, which includes critical tests for anemia, infections, and other complications. Some facilities turn them away entirely, or demand out-of-pocket payments they cannot afford.

The Cost Crisis

SHA’s requirement for new registrants to pay a full year of premiums upfront has likely created the most significant barrier to care. Adolescent girls facing poverty and gender inequality simply cannot afford this cost. Even registered dependents in low‑income households are often blocked by delayed or unpaid contributions.

Last month I did not pay for SHA, when I go for my clinic visit they will confirm that I had not made my payments. I will have to complete the others as well, and that is when I can be treated. (Pregnant adolescent)

Not being able to pay SHA premiums or fees for a skilled delivery, the adolescents have little to no choice but to use the services of traditional birth attendants or to give birth at home, unattended. This comes with higher risks, with reported cases of serious complications and even death.

Confusion and Misinformation

The SHA transition has been marred by poor publicity and lack of information in the community leading to misinformation. Conflicting messages between media announcements and the situation on the ground leave adolescents unsure of where to go, what to pay, or what they are entitled to, thus driving many away from care.

The Path Forward

Addressing SHA’s challenges requires acknowledging that the current system is failing to meet the sexual and reproductive health rights of adolescents. Addressing the most immediate shortcomings requires:

• Removing documentation barriers for adolescents, allowing guardian support or facility waivers for undocumented youth
• Reverting to affordable monthly payments or waiving fees for undocumented pregnant adolescents
• Ensuring facilities cannot deny maternal and newborn care regardless of SHA status
• Providing proper training and infrastructure support at facility and community levels for effective and consistent SHA implementation
• Conducting community sensitization activities about SHA by the government and other stakeholders

In conclusion, SHA’s current iteration has created a two-tiered system where those with documentation and financial resources access improved care, while the most vulnerable are left behind. It must be redesigned with the needs of the poorest and most marginalized at its center—not as an afterthought, but as the primary measure of success.

The teenage mothers of Homa Bay cannot wait. Their health and futures depend on a system that protects them rather than excludes them. Policymakers must act now to ensure no adolescent girl is left behind.

# SHAnooneleftbehind #adolescentgirlsSHA #NoSHAnocashnoservice