Reflections on implementing Universal Health Coverage in Kenya

Geoffrey Okumu, Options Consultancy Services

Image: Compass Media/Options Consultancy Services

In order to achieve sustainable Universal Health Coverage (UHC) three things must be realised;

1. access to quality essential services,

2. adequate coverage of essential services, and

3. financial risk protection.

In Kenya, despite efforts to ease the burden of health care on the consumer, out-of-pocket expenditure continues to make up 25% of the total health care spending. This inequality poses a barrier to the core objectives of UHC.

Options Consultancy Services’ Principal Consultant for Commodity Security, Geoffrey Okumu, looks at some of the key UHC related reforms that are currently underway in Kenya.

Firm policy commitments are paving the way for UHC

The Government of Kenya’s commitment to UHC is set out in the Kenya Vision 2030 which aims to transform the country into a newly industrialising, middle-income country providing a high quality of life to all its citizens by 2030. The vision anchors policy and legal frameworks that are guiding Kenya’s progress towards the Sustainable Development Goals (SDG).

In 2017, the Kenyan government reaffirmed its commitment to UHC, by including it as one of the Big 4 Agenda and designing priority reforms to accelerate progress. These included:

(i) increasing the share of (mandatory) pooled resources through a health insurance-based mechanism built on the National Health Insurance Fund (NHIF);

(ii) enhancing the NHIF capacity to function as a strategic purchaser of health services;

(iii) expanding coverage of health services equitably with emphasis on primary healthcare (PHC); and

(iv) improving public financial management to enhance public funds in the devolved health sector.

Alongside this, the UHC Policy 2020-2030 and its accompanying UHC Road Map provides the policy direction, strategies, and institutional framework for implementation through a multi-sectoral and sector wide approach involving all health stakeholders.

Testing the vision and learning lessons

In 2018, the government launched a UHC pilot programme, known as Afya Care. The programme was set up in four counties with high rates of both communicable and non-communicable diseases, and high maternal mortality (Isiolo, Kisumu, Machakos and Nyeri).

As part of this initiative, people living in these counties could access services free-of-charge, and in return, health facilities received conditional grants to improve infrastructure to provide better services. The result meant that significantly more people accessed services and health facilities reported a reduced level of stockout of medicines and supplies. For example, in Isiolo county the number of outpatients doubled from 277,572 in 2018, to 572,528 in 2019.

However, counties also faced several challenges during implementation. These included funds not being released on time which led to only some activities being implemented, and staff not adhering to guidelines due to limited capacity and changing priorities.

By the end of the pilot phase in 2019, the programme presented important lessons. However, the next phase for the national scale up did not take off due to inadequate allocation of resources.

Health insurance was seen as a key vehicle for delivering UHC, but progress has been slow

Between 2003 and 2018, the number of Kenyans enrolled on the NHIF doubled from 10% to 20%. But despite this progress, the government acknowledged that even though enrolment to NHIF is mandatory by law for workers in the formal sector, there are practical challenges of enrolling those in self-employment, who make up the majority. In addition, NHIF has been grappling with the challenge of intermittent contributions and people only enrolling when they are sick. In view of these challenges, the government has initiated major reforms aimed at enhancing NHIF’s capacity to deliver the promise of UHC to Kenyans.

Image: Compass Media/Options Consultancy Services

Changes in the legal framework will address the challenges of coverage and access

The current government, which came into power in 2023, has prioritised implementation of UHC with a stronger emphasis on PHC and building on lessons from the pilot programme. It is implementing major reforms, including four new legislations; the PHC Act 2023, the Digital Health Act 2023, the Facility Improvement Financing Act 2023, and the Social Health Insurance Act 2023.

The Facility Improvement Financing Act addresses the chronic underfunding of health facilities, allowing them to retain locally generated revenue to pay for immediate operating costs, such as buying out-of-stock medicines, and covering utility and maintenance expenses.

The Social Health Insurance Act provides for the establishment of three new funds: the Primary Healthcare Fund, the Social Health Insurance Fund (replacing the NHIF), and the Emergency, Chronic and Critical Illness Fund.

These changes in the legal framework are expected to significantly transform the healthcare landscape in Kenya and mark the turning point for UHC in Kenya.

Priorities for the future

If Kenya is to achieve UHC by 2030, the government needs to address the regional disparities in the quality and distribution of health care, particularly in the north-eastern and coastal regions. There is an urgent need to strengthen primary care facilities in rural areas that often suffer from shortage of staff, essential drugs, and basic medical equipment.

Since devolution of the health system began in 2013, county governments have had control over key health sector functions, including planning, budgeting and financial management, human resources and the provision of medical supplies. However, persistent bottlenecks such as insufficient financing, frequent stockouts of essential health commodities, and gaps in availability and capacity of human resources, continue to stall progress.

With funding from The Waterloo Foundation, Options is supporting three counties (Nakuru, Bungoma and Nairobi City) to address these challenges, specifically by enacting and institutionalising Facility Improvement Fund (FIF) laws to ringfence allocated funds and enhance cash flow to health facilities. We have also supported primary health facilities to attract more resources from the NHIF.

And by leveraging expertise from some of our other programmes such as E4A-MamaYe, we have involved civil society organisations to conduct supportive advocacy engagements around the need for increased budget allocation and hold government accountable for progress against commitments.

Undoubtedly, achieving the ambitious UHC goal will require substantial public sector investment and accelerated action by national and county governments and partners. Stakeholders will need to build on solid evidence and reorientate health systems to a PHC approach, to advance equity in both the delivery of essential health services and financial protection. Therefore, having created an enabling legal and policy environment, the government should focus on strengthening PHC to facilitate health promotion, disease prevention and early detection, thereby reducing the burden on the health system.