Top counties in SHA registration and what the numbers mean

Nairobi City, Kiambu, Nakuru, Mombasa and Kakamega are the leading counties in Social Health Authority (SHA) uptake since the transition from the National Health Insurance Fund (NHIF) on October 1, 2024.

The shift introduced the Social Health Insurance Fund (SHIF) as the new medical cover, replacing the old NHIF rates with a contribution rate of 2.75 per cent of a salaried Kenyan’s gross pay.

Data from the Kenya National Bureau of Statistics (KNBS) contained in the 2026 Economic Survey shows that the five counties account for the highest number of registered members out of the 20,997,620 total recorded at the end of 2025.

The second half of the top 10 counties comprises Bungoma, Kisumu, Machakos, Homa Bay and Kisii, reflecting high uptake in urban and more populous areas.

In contrast, the generally Arid and Semi-Arid Lands (ASALs) counties of Marsabit, Samburu, Tana River, Lamu and Isiolo recorded the lowest registration numbers, each accounting for less than 100,000 members or below one per cent of the total registered members.

Nairobi county leads with 1,635,778 members, followed by Kiambu with 832,307, while Nakuru has 730,260.

Mombasa, in fourth place, has 704,375, while Kakamega wraps up the top five with 700,043.

Bungoma has 574,181 members, Kisumu 545,448, Machakos 509,601, Homa Bay 487,475 and Kisii 465,994.

The ASAL counties lie at the bottom of the table: Marsabit (90,765), Samburu (69,027), Tana River (68,643), Lamu (66,457), while Isiolo has 46,968.

Additionally, 4,387,210 members did not indicate their county of residence during registration, with more males (2,279,272) than females (2,007,009) falling in this category.

The data shows that females constitute the highest proportion of registered members at 10,857,857, accounting for 51.7 per cent of the total tally, whereas males accounted for 9,926,987 or 47.3 per cent.

However, 212,776 registered members did not indicate their gender as either male or female during registration, with Kakamega, at 18,366, accounting for the largest number.

The top 10 counties with the highest number of registered female members are Nairobi (844,905), Nakuru (387,976), Kakamega (374,009), Mombasa (367,563), Bungoma (306,538), Kisumu (286,597), Machakos (275,475), Uasin Gishu (217,328), Nyeri (216,596) and Bomet (243,659).

Nairobi still leads the list of counties with the highest number of male members with 790,221, followed by Kiambu with 389,614, Mombasa (334,118), Kakamega (307,668), Bungoma (264,340), Kisumu (242,775), Machakos (232,336), Bomet (218,059), Homa Bay (214,526) and Kisii (211,514).

The Social Health Authority administers three funds under the Social Health Insurance Act, 2023: the Primary Health Care Fund (PHC), the Emergency, Chronic and Critical Illness Fund (ECCIF), and the Social Health Insurance Fund (SHIF).

Each fund has a distinct financing structure and performance outcome. SHIF operates as a contributory scheme financed through a 2.75 per cent levy on members’ gross income from both formal and informal sectors, while PHC and ECCIF are exchequer-funded.

In the financial year 2024-25, PHC received Sh10.2 billion and recorded benefit utilisation of Sh9.78 billion, resulting in a payout ratio of 95.5 per cent.

The ECCIF received Sh1.3 billion and recorded benefit utilisation of Sh1.2 billion, corresponding to a payout ratio of 95.2 per cent.

The Social Health Insurance Fund (SHIF), on the other hand, collected Sh57.7 billion in premiums but overshot its payouts to Sh91.5 billion, resulting in a loss ratio of 158.6 per cent.

The SHA registration figures point to a strong correlation between population density, urbanisation, formal employment and enrolment into the new health insurance regime, but they also expose a potentially serious financial sustainability challenge for SHIF.

The top-performing counties are not only population centres but also economic hubs with higher concentrations of salaried workers and organised businesses, meaning they are likely contributing disproportionately larger premium volumes compared to counties with high registration but lower household incomes.

Nairobi, with 1.63 million registrations, is likely far more valuable in premium terms than a similar number elsewhere because the county hosts the highest concentration of formally employed workers, corporate headquarters and high-income earners.

The same logic applies to Kiambu, Nakuru and Mombasa, which have stronger commuter, industrial and commercial economies than many other urban counties.

This means SHIF’s revenue income is probably heavily dependent on a relatively small cluster of economically productive counties.

That concentration creates systemic risk because if the formal sector weakens, leading to high unemployment, or remittances from informal contributors decline in those urban counties, the fund’s revenue base could deteriorate rapidly.

However, the most critical finding is the mismatch between SHIF collections and payouts.

SHIF collected Sh57.7 billion in premiums but paid out Sh91.5 billion, translating to a loss ratio of 158.6 per cent. In practical terms, for every Sh100 collected in premiums, SHIF spent about Sh159 on claims and benefits.

That implies either underpricing of contributions, overutilisation of services, weak cost controls, fraud leakages, or a combination of all four.

In insurance economics, a loss ratio above 100 per cent means the scheme is paying out more in benefits than it is collecting in contributions even before accounting for administrative costs.

A 158.6 per cent loss ratio is therefore structurally unsustainable if maintained over time.

However, the large payout deficit may partly be explained by the transition phase from NHIF to SHA, where pending claims or expanded benefit access created unusually high utilisation.

SHA inherited approximately Sh30 billion to Sh33 billion in pending debt from the defunct NHIF when it was dissolved in October 2024.

The government committed to settling this debt, targeting the full payment of hospitals with claims of Sh10 million and below.

By August 2025, reports suggested that in addition to the inherited debt, SHA had accumulated an additional Sh43 billion in new debt to healthcare facilities within its first nine months.

There is also the possibility that many newly registered members sought immediate treatment after years of inconsistent insurance coverage under NHIF.

Women accounting for 51.7 per cent of all registered members, outnumbering men nationally, could indicate stronger uptake among women due to maternal and child healthcare utilisation or greater interaction with primary healthcare systems.

Women generally utilise healthcare services more frequently, particularly reproductive and family health services, potentially increasing claims pressure on the system.

Overall, the registration success masks a deeper actuarial imbalance where benefit utilisation is growing faster than premium income.

Unless contribution compliance expands substantially, especially within the informal sector, or payout controls are tightened, the fund may increasingly require Treasury support to remain solvent.