Delivering quality and affordable health services: Kenya’s road to Universal Health Coverage (UHC)
Currently ranked third in Africa in the Global Health Security (GHS) index 2021, Kenya is reported to have the best healthcare system in East Africa. However, this has not been achieved without a fair share of highs and lows over the years. Starting from 1965 after gaining independence from the British, Kenya’s healthcare services were centralized but it was not until the 1980s that actionable health strategies emerged resulting in a proliferation of health facilities (WHO 2017). Nevertheless, Kenya was still plagued by declining health outcomes signaled by worsening maternal and child health in the ’90s. During this period, an infant mortality rate (IMR) of 62 in 1993 increased by 12 percentage points to 74 in 1998 (Ministry of Health of Kenya 2019).
In 2010, Kenya promulgated a new constitution that shepherded a new dawn in governance and other aspects of society such as health. The Kenyan Constitution from 2010 gave prominence to health and guaranteed the citizens the right to the highest, attainable standards of health. The constitution has since contributed to the development of various health policies and programs that have resulted in improved health outcomes for citizens. For instance, maternal mortality reduced from 698 in 1990 to 510 in 2015 while under 5 years old mortality rate reduced from 74 to 42 in the same period (Ministry of Health of Kenya 2019).
The design and success of the UHC Program in Kenya
Universal Health Coverage (UHC) refers to a situation where individuals and communities access quality health services at a cost that does not lead to financial hardship. The Kenyan UHC program began in 2018 as a pilot program in four of Kenya’s 47 sub-national governments (Ministry of Health of Kenya 2018). The four were chosen because of high incidences of communicable diseases, non-communicable diseases, maternal and child deaths as well as road accident-related injuries (Shano et al. 2020). The Program is coordinated through the Ministry of Health of Kenya (MOH) which established a department to oversight, plan, monitor, and report on progress made on the UHC pilot.The department is also tasked with engaging stakeholders at the national level to identify key services and strategies for the improvement of the national UHC package.
The UHC model adopted a two-phase medium-term approach. The first phase was expected to abolish all user fees at the primary level (local health centres) and the secondary level (county referral) hospitals. The second phase is the rollout of a social health insurance scheme through the National Health Insurance Fund NHIF. In this second phase, contributions will be mandatory for all Kenyans above the age of 18 years while the government will complement the scheme by paying for the poor. By 2020, the program had enlisted more than 200 community health units, with 7,700 community health volunteers and over 700 health workers. Between 2018 and 2019, the project had supported 3.2 million Kenyans to access critical health care services (Ministry of Health of Kenya 2019).
Challenges facing the UHC Program in Kenya
Financing is the biggest hurdle facing the universal health coverage program in Kenya. Given the erratic projection of government revenue, the Kenyan government financing of UHC through taxes is not sufficient to guarantee sustainability. Notably, Kenya’s budget to UHC has reduced from 50 billion Kenyan shillings in the 2019/2020 financial year to 47.7 billion Kenyan shillings in 2020/2021 (The Star 2021). Health is also an underfunded government function evidenced by historical funding levels which have been below 6% of total government spending. Additionally, Kenya’s public debt is at an all-time high which has reduced the fiscal space for social programmes. The other challenge is the low coverage of the population under the National Health Insurance Fund (NHIF). NHIF is a contributory health insurance scheme and the proposed vehicle for delivering UHC across the entire population. It is mandatory for formal workers but voluntary for informal workers.
The scheme’s coverage among informal workers who form 83% of the Kenyan workforce remains low, only 17.7% of the population is estimated to be covered by the NHIF out of 2.9 million persons (Institute for Global Health Sciences, 2019). Health workers have also noted a lack of sufficient human resource and hospital equipment, this has resulted in citizens paying out of pocket to cover costs of medicine and laboratory procedures. Under resourcing of health care has been attributed to the constrained relationship between the national and the subnational governments which has affected the deployment of healthcare personnel and disbursement of funds from the national government to the subnational governments.
Recommendations for improving UHC in Kenya
The solution towards advancing UHC in Kenya is threefold; increasing the number of Kenyans covered by the NHIF, scaling up of human and structural requirements, reducing the cost of doing business to enhance employers’ contribution for employees, and addressing the intergovernmental inefficiencies that result in delayed remittances to the subnational governments.
To increase NHIF coverage, the government should roll out a strategy to reach the informal sector through their organized formations to increase their contribution to the scheme. Kenya has a large population of informal workers registered in welfare associations which provide opportunities for savings, and loaning and acquisition of assets. These are commonly known as Savings and Credit Cooperatives (SACCOs). One of the most popular SACCO is the boda boda SACCO formed by youth engaged in the transport business with an estimated number of 1.2 million to 1.9 million operators (The Star 2020). Incidentally, the boda boda transport business contributes to a high number of traffic injuries and fatalities. Strategic engagement with such a group shall not only increase money to purchase services for the general population but also intervene in a sector which increases health care costs and spending of the country’s health budget.
Secondly, the government should increase allocation to the health ministry to 13% of government spending in line with the Kenya Health Strategic Plan 2018-2023. The increased fund should be utilized to pay premiums for Kenya’s poor estimated at 10 million persons and in supporting the material and human resource capacity required for primary health care services.
Lastly, the passing of the NHIF amendment bill by parliament is a positive development that will increase NHIF’s financial stability. One of the requirements of the proposed law requires employers to match their employees’ NHIF contributions. This has the potential to greatly increase the premiums received by NHIF from the formal sector but has the potential to increase labour costs. For this to be successful, buy-in is required from employers who need to be supported in fulfilling this requirement by government reduction of the cost of doing business. Failure to do this means increasing the cost of doing business and making Kenya unattractive to investors.
The right to health is indeed an inalienable right for every person as espoused in Kenya’s 2010 constitution. Reduction of maternal and child deaths coupled with a reduced country disease burden greatly spurs economic growth and contributes to poverty reduction. Increasing UHC in Kenya will therefore unlock many economic benefits to the country and improve the quality of life for its citizens.
- Institute for Global Health Sciences (2019). Gender Disparities in NHIF Access and Use:A Barrier to Achieving UHC in Kenya. Retrieved from: https://globalhealthsciences.ucsf.edu/sites/globalhealthsciences.ucsf.ed...
- Ministry of Health of Kenya (2018). President Uhuru launches Universal Health Coverage Pilot Program Nairobi. December 13, 2018. Retrieved from: https://www.health.go.ke/president-uhuru-launches-universal-health-cover... of Health of Kenya. (2019). UHC Pilot expands health services to 3.2 Kenyans. Retrieved from: https://www.health.go.ke/uhc-pilot-expands-health-services-to-3-2-kenyans/
- Shano, Guyo, and Ileana Vîlcu (2020). A review of Afya Care – the Universal Health Coverage pilot program – in Isiolo county. Kenya Brief 5. Washington, DC: ThinkWell. Retrieved from: https://thinkwell.global/wp-content/uploads/2020/09/Isiolo-UHC-pilot-bri...
- The Star (2020). Align boda boda reforms with youth empowerment. Retrieved from: https://www.the-star.co.ke/opinion/2020-11-06-align-boda-boda-reforms-wi...
- The Star (2021). Covid pushes health budget to Sh121bn, but it's barely enough. Retrieved from: https://www.the-star.co.ke/news/2021-06-11-covid-pushes-health-budget-to...
- WHO. (2017). Primary health care systems (PRIMASYS): case study from Kenya, abridged version. Geneva: World Health Organization.CC BY-NC-SA 3.0 IGO.