Kenya's pursuit of universal health coverage has evolved over three decades through gradual reforms. But the boldest step to date was in 2022, when the government embarked on a complete overhaul of the health system under President William Ruto's economic transformation agenda.
The new Social Health Insurance Fund, which will be introduced nationwide from October 2024, aims to provide quality healthcare to all Kenyans, replacing the 58-year-old National Health Insurance Fund. A new system based on the Social Health Insurance Law passed in 2023 requires everyone to enroll in health insurance. This is supported by regulations that require all Kenyan residents to register.
The new health system will have a primary health fund for basic treatment in local clinics, a social health insurance fund for advanced services in large hospitals, and a social health insurance fund to cover emergency and long-term treatment. An Emergency, Chronic and Critical Illness Fund has been introduced.
The transition from the old system to the new system marks an important milestone in Kenya's journey towards universal health coverage. It is the first time a government has overhauled the country's health care system and tackled long-standing problems of inefficiency, corruption and service delivery head-on. In our efforts so far, we have chosen partial reforms.
However, the transition away from the National Health Insurance Fund faces serious challenges. These include funding shortages, reimbursement delays, and infrastructure constraints that impact service delivery. Additionally, this change has been met with public resistance, low enrollment rates, and concerns about the new member contribution model.
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I am a health economist and policy expert with nearly 15 years of experience studying African health systems. In my view, Kenya's new approach poses challenges that require strategic management, appropriate financing and close collaboration with key stakeholders.
Implementing health care reform is not easy. Unpredictable forces such as political interests, economic limitations, stakeholder influence, and public opinion interact invisibly. This makes the results difficult to predict and control.
To succeed, the Kenyan government must focus on transparent communication, strategic partnerships, and efficient reimbursement to build a sustainable health system. We would do well to learn from the efforts of other countries that have introduced universal healthcare, such as Ghana, South Africa, and India.
Kenya healthcare reform
In 2004, the government proposed a national health insurance scheme for financial protection. However, political and economic issues delayed its development.
In 2010 new reforms were introduced. These include special schemes for civil servants, medical subsidies for the poor, and revisions to member contribution rates with expanded benefits. The country then decentralized its health services in 2013. This made the provision of health services the responsibility of the country's 47 local governments. The central government retained policy functions.
Free maternity care was launched in 2013 and expanded in 2016.
In 2018, a pilot universal healthcare program was launched under the then Uhuru Kenyatta government to strengthen healthcare delivery and access.
In 2022, the Ruto administration began a review of the healthcare system, which led to the establishment of the Social Health Insurance Fund based on the Social Health Insurance Act.
Procurement of insufficient funds
The transition to the new system brought several funding issues to the forefront.
First, many medical facilities are facing financial difficulties due to delays in reimbursement from the National Health Insurance Fund. Some facilities are still waiting to be paid for services provided. The Ministry of Health has been slow to inject funds. These delays create financial burdens that prevent facilities from operating efficiently, and some people refuse to participate in the new system until their debts are resolved. This is impacting access to care.
Second, due to insufficient public awareness, many patients are incurring out-of-pocket costs during the transition, especially those requiring long-term treatments such as dialysis or cancer treatment. This is despite the fact that the Department of Social Health, which administers the new system, has offered to reimburse patients who have paid for the service.
Third, there are great concerns about the sustainability of Kenya's new healthcare system. The expected cost for full implementation is Sh168 billion (US$1.3 billion). However, the country's 2024-25 budget allocates Sh127 billion (US$982 million) for the overall health sector and Sh6.1 billion (US$47 million) for the Department of Social and Health Affairs. This is significantly less than needed.
The government plans to seek support from development partners and contributions from all eligible Kenyans and foreigners (those residing in the country for at least one year) to fill the funding gap. This raises questions about the long-term viability of this approach.
Fourth, there are delays in concluding contracts between social health authorities and health care providers. As a result, some facilities are refusing to accept patients.
Public resistance and lack of awareness
Public resistance and lack of awareness are obstacles to the transition. As of October 2024, only 1.9 million Kenyans had voluntarily enrolled in the new system. This is well below the Ministry of Health's goal of enrolling 12 million households (approximately 38 million people) by the start of the program.
Approximately 10 million National Health Insurance Fund members were automatically transferred to the new system. However, due to data accuracy issues, only 70% of the information was transferred correctly.
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Concerns about the new contribution structure are also increasing resistance. Salaried employees currently contribute 2.75% of their income. This is higher than the flat rate of the National Hospital Insurance Fund. This has led to calls for improvements to the system to ensure fairer contributions, especially for low-income households.
Another concern is that the new system offers limited coverage, fewer services, and lower reimbursement rates for specialized care than the National Hospital Insurance Fund. This can increase out-of-pocket costs for patients and reduce quality of care.
Digitalization is also a challenge. Since July 2024, citizens have registered for the services of social health institutions using various methods, including USSD codes and online platforms. However, participation has been slower than expected due in part to limited awareness and infrastructure issues. There are also concerns about data ownership and security.
What can the government do?
To successfully transition from the National Hospital Insurance Fund to the Social Health Insurance Fund and achieve universal health coverage, Kenya will prioritize clear communication, free from corruption, robust digital systems, adequate funding and efficient reimbursement processes Must be.
Learning from other countries such as Ghana, which emphasizes transparent communication to build trust, could help Kenya ensure effective public participation.
We can also strengthen our partnerships with technology providers by drawing lessons from Tanzania's integrated health insurance system, which improved data management and accountability.
As seen in India's approach, ensuring fiscal sustainability is critical to closing fiscal deficits and securing long-term financing.
Refund delays must be addressed. South Africa's National Health Insurance pilot demonstrated the importance of clear payment schedules and strategic purchasing to maintain provider trust and service efficiency.
By adopting these strategies, Kenya can effectively manage the challenges of transition and strengthen its health system.
