The 2025 picture, in numbers
Total insured claims have grown 54% since 2022, while loss ratios for the medical line continue to climb above the rest of the insurance industry.
Total insured claim amount
Medical premium & industry loss ratio
Who is covered · 2025 membership
Benefit mix is stable. Total claims keep climbing.
Outpatient absorbs 55 cents of every shilling claimed and that share has barely moved since 2022. But the cost per visit is climbing fast.
2025 share of total claim amount
Average cost per visit by benefit
Compound annual growth, cost per visit
Cost rises sharply with age. Pricing rarely reflects it.
A patient aged 60+ costs nearly twice as much per inpatient visit as a child aged 0–5. Yet most corporate medical schemes in Kenya price every member the same.
Outpatient: avg cost per visit
Inpatient: avg cost per visit
Outpatient visits per person per year
Ten providers carry over half of all claims.
Concentration creates both a problem and an opportunity. Top providers cost roughly 2× more per inpatient visit than other facilities — but their dominance also gives insurers collective negotiating leverage.
Top 10 inpatient providers
Where the volume — and the spending — sits.
Globally, Willis Towers Watson ranks cancer, cardiovascular and musculoskeletal conditions as the top cost drivers. In Kenya, respiratory and gastrointestinal conditions sit much higher.
Top 5 outpatient diagnoses
Top 5 inpatient (non-maternity)
Service type breakdown
2025 outpatient visits by service type
Top 10 outpatient drug brands
Caesarean section dominates deliveries — and cost.
54% of all deliveries in this dataset are caesarean sections, against the WHO's recommended ceiling of 10–15%. A caesarean costs roughly twice as much as a natural delivery.
Share of maternity claims
Average cost per maternity event
Where to focus.
Six concrete actions surfaced by the data — each tied to a specific finding in the preceding sections.
Negotiate tariffs jointly
Half of all claims sit with the same ten facilities. Insurers can use that concentration to negotiate lower rates as a group.
Price by age
Cost per visit nearly doubles between 0–5 and 60+, but most corporate schemes price every member the same. Introduce age-based loadings.
Contain outpatient cost
Outpatient is 55% of all claims; medication and consultation are most of that. Roll out drug formularies and case management to cap spend.
Address maternity quality
Caesarean sections account for 54% of deliveries against WHO's 10–15%. Engage providers and consider tiered pricing on elective procedures.
Track risk per member
Standardise cost-per-life-covered metrics by benefit. Future reports can then track how risk and utilisation move year-on-year.
Improve diagnosis capture
19% of claims have no diagnosis code at all and only 1% use ICD-11. Push providers to comply with current standards.