Kenya’s Big-Bang Health Reforms: The Promise of a New Future
By David Khaoya, PhD
Kenya is witnessing a unique moment in history. The government is moving swiftly to implement publicly financed, universal health coverage (UHC) reforms that center on primary healthcare. In many countries, including Germany and Colombia, the quest for UHC — where “all people have access to quality healthcare, when and where they need them, without financial hardship” — has taken years, if not decades. In Kenya the reforms are happening at unprecedented speed.
While Kenya’s accelerated approach is bold, it responds to an urgent need. Only 26 percent of Kenyans have medical insurance. This lack of coverage results in individuals and households paying high out-of-pocket costs for care. In fact, they cover almost one-fourth (23 percent) of all health expenditures in the country (with the government and donors making up the rest), as reflected in the most recent National Health Accounts (unpublished). At best, this forces people to choose between healthcare and other necessities, often resulting in people not seeking care when they need it. At worst, it threatens to drive many households into poverty.
“If the country can successfully implement these groundbreaking reforms and achieve UHC in this “big bang” approach, it will be historic…”
Conversely, universal health coverage offers the promise of access to healthcare and financial protection to everyone. What’s more, by centering its UHC reforms on primary healthcare, Kenya should be able to reduce overall health expenditures by avoiding the cost of providing expensive curative health services. If the country can successfully implement these groundbreaking reforms and achieve UHC in this “big bang” approach, it will be historic, improving the health and economic welfare of Kenyans and the country as a whole.
To kickstart the reforms, the government enacted four pivotal laws in October 2023:
· The Primary Health Care Act, which covers the delivery, access, and management of primary healthcare services.
· The Digital Health Act, which establishes a comprehensive, integrated digital health information system (i.e., a digital superhighway) and enables seamless continuity of care.
· The Facility Improvement Financing Act, which supports facility improvements.
· The Social Health Insurance Act, which establishes a social health insurance scheme and an agency to oversee it.
Together, these laws will replace Kenya’s National Health Insurance Fund (NHIF), which has been in place since 1998. Historically, the NHIF has suffered from a lack of participation and fragmentation. Participation in, and therefore contributions to, the NHIF were in most cases voluntary. With only a quarter of Kenyans covered, the system was never able to raise enough funds, which led to high costs. Further, the NHIF houses 83 different schemes aimed at different populations and health areas making comprehensive service delivery and financing difficult.
Under the new system, resources will be pooled through a mandatory social health insurance scheme that will promote access to care while financially protecting patients in case of illness. Contributions will be on a sliding scale, based on income, and the NHIF’s 83 schemes will be replaced by three funds: a tax-based Primary Healthcare Fund, a contributory Social Health Insurance Fund, and a tax-based Emergency, Chronic and Critical Illness Fund. Managed by a new Social Health Authority, the funds will collectively cover the cost of essential services at all levels of care and defray the costs of managing chronic illnesses (after social health insurance benefits have been depleted) and emergency treatment.
At the signing of the laws, Kenya’s President William Ruto touted, “These laws will transform healthcare in Kenya; they will save lives, empower communities, and make us a stronger and healthier nation.” The real test now lies in putting these laws into practice.
The Real Test: Putting Policy into Practice
Successfully reorienting a healthcare system needs both clearly thought-out technical strategies and savvy political leadership that combines long-term commitment and proactive and adaptable strategies to engage with stakeholders at all levels. Success requires the buy-in of leaders and citizens alike.
Technical Strategy
To move from policy to action, the four laws will need to follow due process. The government will need to design and develop regulations and establish robust and effective processes and systems to operationalize the laws and accelerate UHC. To be effective, regulations must be grounded in evidence. As a first step, a collection of partners, including the United States Agency for International Development (USAID) through its PROPEL Health project, are generating critical evidence. This includes estimating the yield/revenue from the proposed contributions; costing health services to inform an optimal essential benefits package; and developing a tool to identify households that should receive government subsidies for social health insurance premiums. Intentional, evidence-informed, technical processes, together with the restructuring of service delivery instruments such as primary care networks, are critical to the reforms’ success and in laying the foundation of UHC. But it is not enough to simply set these in motion. The government must also ensure they allocate adequate resources to operationalize and sustain the systems and processes they construct.
Political Will
Reorienting Kenya’s healthcare system also requires strong political backing. The current administration, who made UHC an election promise, demonstrated their support by selecting UHC as the theme of this year’s “Mashujaa” Day celebrations — a day where the heroes of Kenya’s independence are celebrated. UHC is a crucial pillar aligned to the government’s commitment of achieving its Vision 2030 — the national plan to transform into a newly industrializing, middle-income country. During Mashujaa Day, the president launched a community health promoters program — a critical aspect of the country’s ability to effectively provide primary healthcare services in the community. In addition, the government is systematically assessing the readiness of facilities’ ability to provide critical services. These actions — along with the laws themselves — are a positive first step.
“…for health reforms to take root, Kenya’s citizenry — not just the political establishment — need to be behind the effort.”
Engaged Citizenry
Most importantly perhaps for health reforms to take root, Kenya’s citizenry — not just the political establishment — need to be behind the effort. While public participation is a constitutional requirement for all Kenyan policies, the true will and participation of the people is critical to actualizing the promise of UHC. To this end, PROPEL Health is facilitating meetings to allow stakeholders to review draft regulations and provide input into the design and optimization of the essential benefits package, helping to ensure the process and resulting policies and programs are inclusive and responsive to people’s needs. But to guarantee local ownership of and ongoing confidence and community participation in the new system, the national government must take the lead in ensuring county governments — where the bulk of service delivery will take place — are prepared to implement the UHC approach.
While Kenya’s big bang approach to health reform diverges from other countries’ slower, more traditional paths, it just might be what’s needed. Achievement of the overarching goal — access to affordable, high-quality healthcare for all its citizens — will require sustained political will, an engaged and motivated citizenry, and precise and contextualized execution of the reforms. It is ambitious, but possible, and success offers the promise of a new future.
David Khaoya is the Kenya Country Director of the PROPEL Health project, funded by the U.S. Agency for International Development and implemented by a consortium of partners, led by Palladium.
