Ruto's healthcare gamble: Healthcare reforms must impact lives of all Kenyans

UHC reforms through the experience of odinary Kenyans.[ File, Courtesy]

There is a question Kenya has avoided for too long in its debate about Universal Health Coverage (UHC): What does healthcare reform look like to a Kenyan who has no money when illness strikes? This question is particularly important as the country approaches another election year.

President William Ruto's administration has undertaken one of Kenya's most consequential healthcare reforms in decades. National Health Insurance Fund (NHIF) has been replaced by the Social Health Authority (SHA), primary healthcare has received renewed attention, Community Health Promoters(CHPs) have been deployed, digital health systems are expanding, and the government reports millions of SHA registrations, billions of shillings in claims payments and thousands of contracted facilities.

These are significant institutional changes, but healthcare is not experienced through a policy document. It is experienced in a dispensary, a health centre, a county hospital or an emergency department. The real test of reform is therefore much simpler; does the public health system work when a Kenyan needs it?

From a constitutional right to a daily struggle

The starting point of this conversation should not be SHA. It should be the Constitution. Article 43 guarantees every person the right to the highest attainable standard of health, including healthcare services and reproductive healthcare. It also protects the right not to be denied emergency medical treatment. The 2010 constitution therefore represented a profound philosophical shift. Healthcare was no longer merely a service available to those who could afford it. It became an economic and social right. Yet fifteen years later, the distance between constitutional promise and lived reality remains troubling.

Kenyans still encounter public facilities without adequate medicines, equipment and health workers. Families still borrow or sell assets to pay medical bills. The quality and availability of care can vary dramatically depending on where one lives. The problem is not that Kenya lacks good health policies.The problem is implementation, financing and accountability.

Health is not an ordinary commodity. A person does not choose when to suffer a heart attack. A child does not schedule pneumonia. A pregnant woman cannot postpone an obstetric emergency until she has enough money.This is why healthcare is treated as a social good. From the perspective of philosopher Amartya Sen's capability approach, health is also fundamental to freedom: people cannot fully work, learn, participate in society or pursue economic opportunities when preventable illness limits their capabilities.

Healthcare policy is an economic policy. When a family sells productive assets to pay a hospital bill, it loses future income. When a young person cannot obtain treatment for a chronic condition, the economy loses productive years. When a mother delays treatment because of cost, the eventual treatment can become more expensive. Investing in health is therefore investing in Kenya's human capital.

SHA cannot be the whole health system

The Government has a legitimate case to make about SHA. By June 2026, the Ministry of Health reported 31.39 million SHA registrations, 5 million SHA contributors, Sh147.37 billion paid in claims and 11,034 contracted facilities; but we must be careful not to confuse activity with outcomes. Registration is not utilisation, utilisation is not quality, coverage is not automatically financial protection, and a digital health system cannot substitute for a functioning hospital.

The Government's decision to introduce the HAKIKA contracting framework in September 2026 is revealing. The framework was presented as a response to concerns around tariffs, claims processing, payment delays, pre-authorisation, system reliability and empanelment. This matters because hospitals cannot operate on promises. They need predictable cash flow to pay workers, purchase medicines, maintain equipment, pay suppliers and keep services running. If a facility provides care today and waits indefinitely for reimbursement, the provider becomes the financier of the health insurance system. Eventually, the patient carries the consequences.

The central policy question should therefore be; is SHA strengthening the public healthcare system, or merely creating a new mechanism for purchasing healthcare?

The public hospital is the real test

The Kenya Health Facility Census provides a sobering picture. About 90 per cent of facilities reported providing basic outpatient services, but only 2 per cent offered the complete basic outpatient package. Only 68 per cent had basic laboratory services and 47 per cent offered maternity services. These numbers expose an uncomfortable truth; the existence of a health facility is not the same as access to comprehensive healthcare.

We have sometimes confused a building with a health system. A public hospital needs doctors, nurses, medicines, laboratory reagents, oxygen, electricity, water, ambulances, equipment, maintenance and effective management. A digital platform cannot provide any of these by itself, a tablet cannot replace a nurse; an electronic claims system cannot replace an ambulance and a SHA registration number cannot treat malaria.

Technology should make healthcare better. It should never become a substitute for making healthcare functional. The Government has reported significant progress in digital health, including more than 10,000 facilities connected to national digital systems and more than 100,000 Community Health Promoters deployed.

These investments are welcome, but the Government must now demonstrate the harder outcomes: fewer stock-outs, shorter waiting times, faster referrals, lower household expenditure and better clinical outcomes.

The patient is still paying

Kenya's healthcare financing problem cannot be hidden behind insurance registration statistics.WHO's latest Kenya assessment puts household out-of-pocket spending at approximately 24.2 per cent of current health expenditure, while Kenya's UHC service coverage index stands at 53.That means financial protection remains incomplete.The poor are particularly vulnerable because illness can consume income that would otherwise pay for food, education, rent or transport.

Analysis of the Kenyan health market also shows that household financing remains substantial, while healthcare costs are affected by medicines, professional costs, infrastructure, distance, pricing and market forces. This is where the political economy of health becomes important.We must ask: Who pays? Who controls the money? Who determines prices? Who supplies medicines? Who receives reimbursement? And who carries the risk when government does not pay on time? These are not technical questions.They determine whether a Kenyan can actually afford healthcare or not.

Medicines are an economic policy

The medicine supply chain illustrates this perfectly. Kenya remains heavily dependent on imported health products and technologies, exposing the country to international prices, currency fluctuations and global supply disruptions. Analysis of Kenya's health-product market notes that local manufacturing has historically met only a minority of Kenya's health-product needs. This makes local pharmaceutical manufacturing more than an industrial-policy issue. It is a health-security issue.It is an affordability issue. It is a UHC issue.

The Government has now set a target of increasing local production of essential medicines, including a goal of meeting 50 per cent of the Kenya Essential Medicines List through local manufacturing. That is a welcome direction, but Kenyans should demand measurable implementation. How many essential medicines are manufactured locally? How much do they cost? How much does government procure? How much reaches KEMSA? How much reaches the county facility? Ultimately, how much does the patient pay?This are pertinent questions because when a patient is told at a public hospital to buy essential medicine from a private pharmacy, the health system has transferred part of the cost back to the household.

Primary healthcare must become real

The Government is right to place primary healthcare at the centre of UHC. Prevention and early intervention are generally more economically efficient than waiting for disease to become complicated and expensive. Hypertension should be detected before it becomes a stroke. Diabetes should be managed before it results in kidney failure. Pregnancy complications should be identified before they become emergencies.Having this in mind primary healthcare therefore cannot become another slogan. It requires medicines, diagnostics, trained health workers, functioning community units and referral systems.

A Community Health Promoter who identifies a high-risk pregnancy must be able to refer the woman to a facility capable of managing the complication; otherwise, we will have merely moved the diagnosis closer to the community without strengthening the system that must provide treatment.

The health worker is the system

Kenya cannot achieve UHC while treating health-worker disputes as isolated labour problems.

The nurses' and doctors strikes and subsequent disputes involving other health cadres exposed deeper problems involving remuneration, collective bargaining agreements, internships, staffing and working conditions.The Government has taken steps to expand internship placements and address staffing, but Kenya needs something bigger: a national health-workforce strategy based on actual population need.

We need to know how many doctors, nurses, clinical officers, pharmacists, laboratory professionals and other cadres the country needs, where they are needed and how many positions remain vacant. We also need to confront the economic cost of training health professionals, absorbing them in the healthcare system  and subsequently losing them to other countries.The health worker is not merely an expenditure line. The health worker is health infrastructure.

Devolution needs a new health compact

Devolution brought healthcare closer to citizens, but it also created significant differences in county capacity. Some counties can mobilise more resources and attract more professionals than others while others struggle with staffing, procurement, infrastructure and management. The national government cannot design UHC and assume counties will automatically deliver it. Neither can county governments blame the national government for every failure in a facility they manage.

The citizen does not care which level of government failed.They know only that the medicine was unavailable. Kenya therefore needs a new national-county health compact with clear responsibilities, predictable financing, transparent transfers and measurable service-delivery targets.

What should the next phase of reform deliver?

The next phase should be about rebuilding the public healthcare system, not merely redesigning its financing. First, SHA claims should be paid predictably and within enforceable timelines. Second, Kenya should publish facility-level information on claims submitted, claims paid, rejected claims and payment delays. Third, essential-medicine availability should become a publicly monitored performance indicator. Fourth, Kenya needs a national health-workforce plan linked to population need. Fifth, primary healthcare must receive adequate sustained financing. Sixth, public hospitals should be evaluated on outcomes; waiting times, medicine availability, referral completion, patient satisfaction and quality of care, not simply the number of facilities constructed.Seventh, procurement must be transparent enough for citizens to see what their money bought.Eighth, local production of medicines and medical technologies must be accelerated. Ninth, chronic and catastrophic illnesses require genuine financial protection because these conditions can destroy household finances. Finally, healthcare policy should not be designed only by bureaucrats, politicians, consultants and industry stakeholders but patients must have a meaningful voice in healthcare planning thus public participation is not optional but mandatory.

The 2027 health question

As Kenya enters an election year, healthcare should not become another contest of slogans.The Government can point to SHA, digital transformation, primary healthcare, Community Health Promoters, claims payments and investments in specialised care. Critics can point to medicine shortages, provider-payment concerns, workforce disputes, public-facility weaknesses and continued out-of-pocket spending.

Kenyans should therefore demand something more useful than competing political narratives. Every party seeking to govern should be required to answer: how much will you spend on health? How will you finance it? How much will reach primary healthcare? How will you guarantee essential medicines? How will you recruit and retain health workers? How will you strengthen county hospitals? How will you protect households from catastrophic health expenditure? How will you prevent corruption and waste in procurement? Most importantly,what will you do differently for the Kenyan who cannot afford private healthcare? Those questions should be asked of every political formation, not because healthcare should become another campaign slogan, but because the Constitution already settled the principle that healthcare is a right. Hence should not be used as a political tool!

The Big Question

Four years into President Ruto's administration , Kenya has changed the architecture of healthcare financing  but it has not yet rebuilt the public healthcare system that ordinary Kenyans depend on.We must understand that the architecture is not the house. SHA is not the hospital. A registration number is not treatment. A digital platform is not medicine. A reimbursement promise is not a functioning hospital and  a new health policy is not an improved health outcome.

The Government should therefore be judged not only by what it has launched, but by what the citizen can actually access. If only 2 per cent of facilities provide the complete basic outpatient package, if out-of-pocket expenditure remains above 24 per cent of health spending, and if public-facility patient satisfaction is reported at only 16 per cent, then Kenya cannot afford complacency.These statistics should not be weapons for one political camp against another rather they should be a national alarm bell.

Kenya cannot build Universal Health Coverage simply by changing the name of an insurance institution while leaving the foundations of public healthcare fragile. The real health revolution will be visible when the patient enters a public hospital and finds a doctor.When the nurse is present.When the laboratory works.When the medicine is on the shelf.When the ambulance arrives.When the referral is completed.When the hospital is paid on time.When the healthcare worker is treated with dignity.And when the patient leaves without selling the family's future to pay for today's illness. That is what Article 43 demands. That is what justice demands. That is what sound economics demands.And that is what Kenya's Universal Health Coverage promise should mean. The question is therefore not simply whether Kenya has changed NHIF to SHA rather what kind of health system that financing is building. Do we build a health system where public money merely purchases healthcare wherever it can find it? or a strong public healthcare system in which every Kenyan; rich or poor, employed or unemployed, urban or rural, can expect competent, timely and dignified care? That is the big question.