As Kenya embarks on a bold journey toward universal health coverage, the recent healthcare reforms reveal a growing rift between ambitious policy promises and the hard realities of implementation. This shift from the long-standing National Hospital Insurance Fund (NHIF) to the newly established Social Health Authority (SHA) under the Social Health Insurance Fund Act of 2023 was intended to transform healthcare access nationwide. The goal: ensure every Kenyan, regardless of income, has access to essential medical services. Yet, even as the SHA launched on October 1, 2024, the system is already showing cracks, raising questions about the viability of Kenya’s healthcare aspirations.
Understanding Kenya’s Healthcare Structure
Kenya’s healthcare system operates on six levels, each designed to address specific needs in a tiered structure:
Level 1: Community Health Services – These grassroots services, led by community health workers, focus on preventive care to ease the burden on higher-level facilities.
Level 2: Dispensaries and Clinics – These provide primary care, immunizations, and maternal and child health services, often serving as a patient’s first point of contact.
Level 3: Health Centers—These facilities offer both outpatient and inpatient services and offer a range of health services, including laboratory diagnostics.
Level 4: Sub-County Hospitals – These hospitals deliver more specialized care, including surgeries and advanced diagnostics.
Level 5: County Referral Hospitals – Equipped with specialized staff and technology, these referral hospitals provide advanced medical services.
Level 6: National Referral Hospitals – At the top of the hierarchy, these national facilities offer highly specialized services and serve as training centers for healthcare professionals.
While this tiered system is structured to cover diverse healthcare needs, a persistent barrier remains: affordability. SHA was meant to bridge this gap, making care accessible to even the most underserved. But the journey from policy to practice has been far from smooth.
From NHIF to SHA: The Vision and the Reality
Established in 1966, the NHIF had long been Kenya’s central health insurance provider. Designed to support both formal and informal workers, NHIF faced mounting criticism over the years for its inefficiencies, cases of corruption, and gaps in service coverage. Public trust eroded, and many Kenyans were left without adequate protection. To address these issues, the Kenyan government introduced the Social Health Insurance Fund Act of 2023, mandating the creation of SHA to replace NHIF.
SHA was intended to be more than a rebranding exercise. Its mandate aimed to fix NHIF’s flaws and bring about universal health coverage by addressing the root causes of inefficiency. However, the road to reform has been rocky, with SHA facing its own set of implementation challenges that threaten its success.
Key Features of SHA and Social Health Insurance Fund (SHIF)
The SHA was launched with several reforms to improve healthcare access, affordability, and equity:
- Expanded Coverage – SHA extends coverage to a broader range of services, including primary care, emergency treatments, and chronic disease management. Unlike NHIF, SHA does not limit benefits to specific conditions, addressing a long-standing gap in health coverage.
- Mandatory Enrollment – SHA requires every Kenyan to enroll, unlike NHIF, which primarily targeted formal sector workers. This universal requirement aims to create a substantial risk pool essential for funding a sustainable health system.
- Income-Based Contributions – SHA uses a progressive contribution structure, deducting 2.75% of income, with a minimum of KSh 300. This approach is intended to spread costs fairly, reducing the burden on lower-income households.
- Efficient Service Delivery – SHA aims to minimize bureaucracy, implement stricter monitoring, and streamline processes to reduce delays in healthcare access. This new framework is expected to make healthcare more accessible and responsive to patient needs.
SHA Implementation: The Struggle Begins
Despite SHA’s lofty ambitions, its implementation has exposed deep-rooted issues. The rollout has been hampered by a range of challenges, many of which reflect the same systemic obstacles that plagued NHIF:
- Inadequate Infrastructure and Resources—Many health facilities remain understaffed and underresourced, particularly in rural areas. Without basic equipment and supplies, SHA’s expanded coverage holds little meaning. The lack of resources directly undermines SHA’s objectives, as facilities cannot provide even the most basic care.
- Administrative Hurdles—The transition from NHIF to SHA introduced new administrative requirements that have complicated the enrollment process. Many citizens report lengthy registration delays and difficulty accessing benefits, reflecting the same inefficiencies SHA was meant to solve.
- Public Mistrust and Corruption – Corruption has been a persistent issue within Kenya’s healthcare sector, and SHA is not immune. Years of mismanagement within NHIF have bred public skepticism, and without clear accountability measures, SHA risks repeating NHIF’s mistakes, leading to lower enrollment and compromised outcomes.
- Financial Strain on Low-Income Families – Although SHA’s contribution structure is progressive, the minimum contribution of KSh 300 remains a burden for families living on subsistence wages. For these households, even a minor fee can deter enrollment, limiting SHA’s effectiveness in achieving universal coverage.
Who’s Responsible? Key Actors in SHA’s Success
Securing SHA’s success requires a coordinated approach across multiple stakeholders, each playing a crucial role in driving change and ensuring the scheme’s sustainability:
- Ministry of Health (MoH) : The MoH oversees SHA’s alignment with Kenya’s health objectives, monitors progress, and addresses gaps in implementation.
- County Governments – In Kenya’s devolved system, counties are on the frontline of healthcare delivery, ensuring SHA benefits reach local communities, particularly in rural and underserved areas.
- Healthcare Providers and Professional Associations – Medical professionals and associations like the Kenya Medical Association (KMA) are essential in upholding quality standards, supporting SHA, and advocating for necessary improvements.
- Office of the Auditor General and Anti-Corruption Commission – Corruption significantly risks SHA’s credibility. These oversight bodies enforce accountability and investigate financial misconduct within the system.
SHA’s Impact on Health Outcomes: A Human Security Perspective
Healthcare access is not just a service; it’s a matter of human security. When citizens cannot access quality care, their health, productivity, and economic stability suffer. If left unresolved, SHA’s challenges threaten to widen the gap in health outcomes between Kenya’s rural and urban populations, exacerbating existing inequities.
Reports indicate rising morbidity rates, higher out-of-pocket expenses, and delayed treatments in areas where SHA’s implementation lags. For instance, in maternal and child health—a critical area for Kenya—many women in rural areas still face barriers to facility-based deliveries. Preventable diseases, from malaria to diarrheal infections, continue to claim lives in underserved communities where healthcare remains out of reach.
Systemic Failures in SHA
SHA’s shortcomings are not just administrative; they have tangible, often tragic, consequences:
- Delays in Chronic Illness Treatment – Patients with chronic conditions, such as diabetes and hypertension, face bureaucratic delays that worsen their health and increase the burden on hospitals.
- Understaffed Facilities – County hospitals and health centers struggle with inadequate staffing and funding, particularly in remote areas. This has led to cases of patient neglect, misdiagnosis, and preventable deaths, fueling public dissatisfaction.
- Maternal Health Vulnerabilities – Despite SHA’s promise, many rural women still give birth outside healthcare facilities, either due to cost barriers or a lack of accessible clinics. This puts mothers and infants at significant risk, undermining Kenya’s maternal health goals.
A Path Forward for SHA
SHA’s creation reflects Kenya’s aspiration to establish healthcare as a human right. But realizing this vision requires more than policy; it demands actionable changes that address structural issues. Kenya’s healthcare reform must prioritize infrastructure development, especially in underserved areas, while enhancing transparency and governance to restore public trust.
Strengthening oversight, addressing resource gaps, and fostering community engagement are essential if SHA is to fulfill its potential. Kenya’s commitment to universal health coverage isn’t just about policy—it’s about protecting the well-being of every citizen. If SHA’s systemic issues are left unaddressed, the dream of equitable healthcare could remain just that—a dream. However, with coordinated efforts from the government, healthcare providers, and communities, SHA has a chance to rewrite Kenya’s healthcare story, offering citizens the security of health coverage and a healthier future.