Kenya’s Social Health Authority – A Promise for Objective-Oriented Health System Reform?

Authors: 

• Lizah Nyawira – Senior Technical Officer, Evidence Generation and Learning – SPARC
• Boniface Mbuthia – Technical Lead, SPARC

Universal Health Coverage (UHC) remains a global priority, placing emphasis on equitable access to quality health services for all without financial hardship. Kenya’s recent health financing reforms, which include the establishment of the Social Health Authority (SHA), mark a significant step towards realising this goal. Enacted under the UHC framework, the SHA is designed to streamline and strengthen health financing, ensuring more equitable and efficient access to healthcare services across the country.

The establishment of the SHA is seen as a critical measure to address long-standing challenges within Kenya’s health system. These challenges include inequitable access to care, high out-of-pocket (OOP) expenditures, and fragmented and inefficient health financing mechanisms. By consolidating health financing functions, integrating existing schemes, and promoting pre-payment mechanisms, the SHA aims to reduce the financial burden on households and facilitate more inclusive access to healthcare.

A useful framework for assessing the potential of SHA reforms is the Objective-Oriented Health Systems Reform (OOHSR) lens, as articulated by Kutzin et al. This approach emphasises three key attributes: problem-orientation, consistency, and continuous evaluation. Each of these attributes offers insight into how the SHA can address key barriers and achieve its objectives.

One of the most pressing concerns for Kenya’s health system is its problem-orientation, which focuses on identifying and addressing the root causes of underperformance. Previous efforts by the National Health Insurance Fund (NHIF) to increase enrollment, particularly among the informal sector, were met with limited success. Vulnerable populations often faced financial barriers, which left them excluded from health insurance coverage. This, in turn, led to catastrophic health expenditures and deepened poverty. The SHA seeks to resolve these issues by mandating health insurance enrollment for all Kenyans through the Social Health Insurance Fund (SHIF). Strategies to achieve this include collaboration with cooperative societies and licensing bodies to increase enrollment within the informal sector. Additionally, government subsidies for the Primary Health Care (PHC) Fund and the Emergency, Chronic, and Critical Illness Fund (ECCF) will play a pivotal role in enhancing coverage. The adequacy of these subsidies will significantly influence the success of the SHA’s objectives, with the potential to either undermine or bolster progress.

Beyond financing, Kenya’s health system faces other deep-rooted challenges. Delays in fund disbursements due to public financial management bottlenecks hinder the timely delivery of health services. Such inefficiencies often fall beyond the health sector’s direct control, requiring a whole-of-government approach to resolve. Further systemic gaps, such as insufficient health infrastructure, human resource shortages, and inefficiencies in the health commodity supply chain, must also be addressed. For example, the Kenya Medical Supplies Authority has faced scrutiny over delays in the procurement and distribution of medical supplies. Addressing these inefficiencies—whether through the reform of KEMSA or alternative supply chain models—will be essential for building public trust. Trust is a key determinant in boosting enrollment and retention in the SHIF.

Consistency is the second key attribute of the OOHSR framework. It calls for alignment between reform objectives, design, and implementation. The SHA’s success will largely depend on its ability to maintain this alignment, particularly with respect to equity, efficiency, and financial protection. Central to this alignment is the establishment of a comprehensive benefits package. While the SHA has outlined some of the services covered, the benefits package remains a work in progress. Expanding this package is essential for managing public expectations, especially as health system capacity and financial resources are finite. Regular review and revision of the benefits package will be crucial for ensuring that the services remain relevant and responsive to the population’s needs. Clear communication of these entitlements to both beneficiaries and service providers will also be vital in building trust and enhancing accountability.

The third critical attribute of the OOHSR framework is continuous evaluation. One of the most significant risks to health reform is the failure to adapt to emerging challenges. The SHA’s sustainability will therefore depend on the establishment of mechanisms for real-time monitoring, evaluation, and learning. Drawing on lessons from previous reforms, such as the UHC pilot and the now-defunct NHIF, continuous evaluation will ensure that Kenya’s health financing reforms remain relevant and effective. This approach necessitates the development of systems to track key indicators such as enrollment rates, health service utilisation, and financial flows. By identifying and addressing bottlenecks and inequities in real time, the SHA can make iterative adjustments to policies and operations. Active engagement with stakeholders—including healthcare providers, government agencies, and beneficiaries—will further support this process. Applied research will be essential for refining SHA policies and implementation strategies, allowing Kenya to draw on evidence-based insights to inform its decision-making.

Looking ahead, Kenya’s SHA reforms have the potential to transform the country’s health financing landscape. By embracing the principles of problem-orientation, consistency, and continuous evaluation, these reforms can address systemic inefficiencies, promote equity, and ensure financial protection for all Kenyans. The goal of achieving health for all by 2030 is ambitious but achievable if lessons from past reforms are taken into account. The SHA must also adopt a systems-wide approach that extends beyond health financing to address broader systemic gaps in health infrastructure, workforce capacity, and supply chain management.

The SHA represents a bold step forward in Kenya’s UHC journey. If guided by the OOHSR framework, it can become a cornerstone of Kenya’s health system transformation. By addressing historical barriers, aligning reforms with strategic objectives, and fostering a culture of continuous learning and adaptation, the SHA has the potential to build a more equitable, efficient, and resilient health system. Such an outcome would not only benefit Kenya but also serve as a model for other countries seeking to reform their health systems in pursuit of UHC.