Kenya has recently taken a major step towards Universal Health Coverage (UHC) by introducing the Social Health Insurance Fund (SHIF). SHIF replaces the National Hospital Insurance Fund and is intended to provide more comprehensive access and coverage. While social health insurance can help countries attain UHC, international experience suggests that implementing such reforms is fraught. Here, we summarize concerns elaborated in a new paper, drawing lessons from past experiences both within the Kenyan context and beyond.  Our goal is to highlight areas that need further reflection if social health insurance (SHI) is to succeed in Kenya.

a) Affiliation:

Insurance schemes require enrolment of members. Formal sector affiliation is often straightforward, as it is automatically implemented by employers, but affiliating the informal sector is difficult. The informal sector, particularly low-income workers, often perceive social insurance as costly and of little value.

Informal sector coverage matters as most Kenyans are in the informal sector. Moreover, formal sector workers are more likely to be covered already. What have countries done to affiliate the informal sector? Kenya initially tried to enforce SHIF enrolment through a legal mandate, but this was overturned by the courts. Globally, the Philippines unsuccessfully tried partnering with organized groups of informal workers and discounting premiums to encourage enrolment. Rwanda’s Community Based Health Insurance scheme has enrolled 87 percent of the informal sector but faces sustainability challenges due to payment defaults.

Encouraging enrolment requires either more thoughtful mandates, or more thoughtful incentives, aligned to people’s demands. In India, experiments have demonstrated that free food was a sufficient incentive for families to at least start a vaccine course.  Are there similar incentives that might work in Kenya? Of course, even if there are, the cost of these incentives must be balanced against the expected revenue from premiums to ensure the scheme’s sustainability.

While SHI is generally thought to generate new finances for health, World Bank research shows that many countries with SHI still rely heavily on general revenue. The Kenyan government should be transparent about the fiscal assumptions it is making. If NHIF’s history is a guide, no more than ¼ of the informal sector will sign up for SHIF voluntarily.  This is not trivial: the difference in revenue between ¼ and full coverage of the informal sector is roughly USD 570 million (using the average wage to calculate premiums).

b) Means Testing:

The Kenyan government intends to subsidize the poor, who will be identified through means-testing. However, Kenya’s past implementation of means testing in social protection programs has been problematic.  Across several programs, different means-testing approaches have all performed poorly, with high inclusion and exclusion errors. For example, 65 percent of beneficiaries of the Health Insurance Subsidy Program  (HISP) for the poor were in the richest two quintiles.

Poor instrument design is not just a technical matter. Despite already having an effective means-testing regime for its celebrated conditional cash transfer program, the Mexican government opted for a less robust means-testing approach for its social health insurance program (Popular Health Insurance) to accelerate affiliation for political reasons.  This worked, but undermined targeting and the scheme’s finances.

A universal scheme, with a single affordable premium, could eliminate the need for means-testing in Kenya. However, such a system would generate less revenue, requiring significant budget funding. Kenya’s government should therefore consider establishing a robust, independent entity to implement a standardized means- testing instrument for SHIF (and all other social protection programs).

c) Empanelment:

While a well-designed demand-side insurance scheme can improve a health system, it cannot substitute for adequate, accessible and functional infrastructure and a skilled workforce on the supply side. Under NHIF, many facilities failed to meet empanelment requirements, resulting in a pro-urban distribution of accredited facilities. The distribution of health workers is similarly skewed.

Mexico’s PHI scheme, facing a similar challenge, allowed some empanelled facilities to operate without providing the full benefit package.  This approach risks undermining public confidence in the insurance guarantee.  The Mexican government did, however, recognize the infrastructure gap from the outset of PHI, and established a special fund with dedicated resources to upgrade health infrastructure in marginalized areas.

The Kenyan government must also tackle infrastructure gaps.  As this is costly, it could roll out SHI in phases, starting with a smaller benefits package. As the infrastructure and workforce capacity expand, the benefits package could be progressively enhanced.  This would address current inequities and ensure that the insurance package was truly guaranteed.

While SHIF is new, it is not unprecedented. Many countries, including Kenya have implemented similar reforms, at least in part. By learning from their successes and failures, Kenya can improve the chances of SHIF’s success. Notably, beyond the technical design of the scheme, ensuring transparency and accountability will be critical in building public trust and ensuring that SHIF outperforms NHIF.

Authors: Jason Lakin is an Associate Professor at Shiv Nadar University in Chennai, India.

Gladys Wachira is a research analyst at the Institute of Public Finance in Nairobi, Kenya.

Competing Interests: None

Handling Editor: Neha Faruqui