How Ruto's lofty UHC promise has gone up in the air

President William Ruto, Deputy President Kithure Kindiki, Kwale Governor Fatuma Achani and former Health CS Deborah Barasa during the official opening of the theatre block at Mkogani Sub-County Hospital in Kwale County, on February 25, 2025. [File, Standard]. Mercy Nasieku, 23, from Kajiado, has battled lupus since 2016. When she recently developed kidney stones that required surgery at a private hospital, her Sh350,000 bill was fully covered by the Social Health Authority (SHA). "I was shocked the approval was granted instantly," she says. Mercy still spends about Sh35,000 monthly on drugs not covered by SHA but says the surgery coverage saved her family from a major financial burden. Unlike Mercy, John*, a Nairobi-based patient managing an autoimmune condition, is less fortunate. He must raise between Sh200,000 and Sh300,000 for a single injection critical to his treatment. Previously, the National Health Insurance Fund (NHIF) covered at least Sh80,000 of this cost. With the transition to SHA, he is unsure of the support available, though he is fortunate to have private insurance. The injection is required once every 12 to 18 months. In Kangemi, Susan struggles even more. She was forced to raise Sh3,600 for her 17-year-old daughter's delivery bill. Without insurance or savings, she paid out of pocket. "I have not registered for SHA because I have no source of income. I cannot afford the annual premiums," says Susan, a casual worker. To join SHA, Susan is required to pay Sh7,092 annually, with the new monthly premium capped at Sh591. "My casual jobs cannot guarantee me a loan from the Hustler Fund, because I cannot repay it," she says. Under NHIF, deliveries were free under Linda Mama programme, but experts now warn the new premium requirement could increase maternal deaths, with already 21 deaths reported every day. The three cases reflect the mixed state of healthcare access in Kenya. Three years since President William Ruto took office with a pledge to deliver Universal Health Coverage (UHC), Kenyans and health experts say the country is still far from achieving affordable, quality care for all. SHA, established as the main UHC financier, has been plagued by financing gaps and graft allegations, raising questions about its long-term viability. The SHA established as the main UHC financier been dogged by graft. Healthcare financing remains the biggest hurdle, with many Kenyans still paying out-of-pocket for basic services.XN Iraki, an economist and professor at the University of Nairobi, notes that while the Kenya Kwanza administration promised quality and accessible healthcare, the sector has been overshadowed by controversy surrounding SHA. "SHA has been more about debating how to deliver services instead of actually delivering them," says Prof Iraki. Financial and health economist John Nyangi notes that financing is a critical component of healthcare. It determines whether facilities have equipment, drugs, and adequately paid providers. "When financing fails, patients are forced into catastrophic spending - selling cows, land, and other assets to cover hospital bills. This should not happen in a country working toward UHC," says Nyangi. Kenya's health financing remains heavily dependent on individuals, with at least 23 per cent of health spending coming from out-of-pocket payments, above the World Health Organisation's (WHO) recommended threshold of 20 percent, which is considered catastrophic. UHC was one of President Ruto's flagship agenda items, building on pilot programmes launched under former President Uhuru Kenyatta in Kisumu, Isiolo, Makueni and Nyeri. But the transition from NHIF to SHA has not been smooth. Despite having about 24 million members, SHA collections remain low. In the past 11 months, it has collected around Sh50 billion, compared to Sh80 billion under NHIF in 2023/24, raising concerns about its ability to meet growing claims. Currently, health facilities submit bills worth Sh10 billion monthly, but SHA collects only about half that amount, leaving a widening deficit. "The government made contributions compulsory before proving value," says Nyangi. "People should be motivated to pay because they see working systems, stocked dispensaries, available doctors, and functioning equipment. Instead, they are being forced to pay first, then hope services will improve. It feels like being asked for a tip before the meal is served." The health sector is also battling credibility issues. Allegations of fraud, over-billing, and ghost facilities, the very issues SHA was meant to eliminate, persist. Experts warn that without restoring public confidence, SHA risks becoming another failed experiment. "Social health insurance only works if people trust the system," observes Nyangi. "Kenya has the policy framework and the legal backing for UHC, but we are not yet there. Financing gaps, corruption, and mistrust must be addressed urgently, otherwise, the dream of UHC will remain just that- "a dream." Under the new law, contribution is capped at 2.7 percent of income, with the goal of creating a larger pool of funds to cover care. The UHC was officially launched UHC in October 2023. This was after establishing Community Health Promoters (CHPs) to handle promotive and preventive health by conducting routine household visits. There are at least 107,000 Community Health Promoters (CHPs) across the country, each trained and equipped with a smartphone. They earn a monthly stipend of Sh5,000, split equally between the national and county governments. But a section of counties are accused of not paying the stipends, for example CHPs in Isiolo have been on strike demanding pay. The promoters use Electronic Community Health Information System (E-CHIS), to digitalise and streamline community health services, improving efficiency and data management. Additionally, in realisation of preventive and promotive health and smooth referral services, CHPs operate within the established 172 Primary Care Networks. "CHPs is a game changer in early diagnostic of diseases and prevention of diseases. The national government has been consistent in sending stipends for the promoters," adds Nyangi. But he argues that the transition has not yet yielded the expected results-there is cumulation of debts. "SHA is not sustainable, we shall have a lot of debts accumulation that it will not pay. The debt will be the last straw, that is going to break the SHA," he says. In a previous interview, former Health CS Susan Nakhumicha told The Standard that UHC failed under former regimes due to lack of laws to oversee its implementation. Kenya Kwanza's health reforms have achieved notable milestones but still face major hurdles, says Brian Lishenga, chairperson of the Rural Private Hospitals Association of Kenya (RUPHA). Dr Lishenga cites better public engagement as a key gain, saying the SHA transition has given Kenyans "a clearer understanding of how healthcare financing works and how to protect it." Lishenga also lauds digitization, noting that e-contracting has replaced error-prone manual contracts and the Health Information Exchange will help fight fraud and speed up claims. Administrative costs have been capped at 5 percent, compared to NHIF's 12 to17 per cent, meaning "more funds now go to patient care." He further highlights the creation of the Emergency, Chronic and Critical Illness Fund (ECCIF) as a potential game-changer - if fully funded - to protect Kenyans from catastrophic health costs. However, Lishenga says delayed rollout of the ECCIF, financing gaps, and graft claims as key concerns. "People must see value - stocked facilities, available doctors, timely payments - before they are compelled to contribute. Right now, it's like being asked to pay a tip before you've been served," observes Dr Lishenga. Lishenga cautions that SHA's collections remain below claims, threatening its sustainability. The three years have also reported a share of graft-for instance, billions of money are reported lost at newly established SHA. This is even despite an allocation of Sh104 billion for the Digital SHA system, whose procurement is also debated on, having been opaque. Grey areas have also been reported with Edu Afya health scheme of payment, where ministry of Health overpaid Sh2.29 billion to NHIF. This covered the 2020 to 2024 yet actual services were only Sh5.3 billion, while Sh11.1 billion remained unaccounted for. Additionally, the Kenyan Government lost Sh3.7 billion mosquito nets tender to an international supplier- Wambo.Org, following illegality in procurement process by the Kenya Medical Supplies authority (Kemsa). There is also lack of clarity in procurement of Sh2.5 billion HIV testing kits, procurement done in 2024.

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