Ruto's UHC promise: Big reforms, unfinished business

President William Ruto during the official opening of the Kenya Health Summit at the Kenyatta International Convention Centre (KICC), Nairobi, August 18,2026. [PCS]

Universal Health Coverage was one of the flagship promises of President William Ruto’s administration, built around the pledge that no Kenyan should be denied quality healthcare because of an inability to pay.

Four years into the Kenya Kwanza administration, however, the country remains some distance from that goal, with experts and health sector players questioning whether the ongoing reforms can deliver meaningful universal access before the next General Election.

The administration has undertaken sweeping changes to the health financing and delivery system, including the replacement of the National Health Insurance Fund (NHIF) with the Social Health Authority (SHA).

Parliament has also enacted four major pieces of legislation intended to anchor the reforms, the Social Health Insurance Act, Digital Health Act, Primary Health Care Act and Facility Improvement Financing Act.

The government has also embarked on digitisation of health services, expanded primary healthcare and increased the number of Community Health Promoters.

But the transition has been accompanied by persistent challenges, including delays in SHA approvals and payments, shortages of medicines and medical commodities, healthcare workers’ strikes, financing constraints and concerns over accountability.

At least 33 million Kenyans have registered with SHA, comprising 22.2 million principal members and about 10 million dependants. But only about five million members are currently remitting contributions, highlighting the gap between registration and effective participation in the scheme.

For University of Nairobi economist Prof XN Iraki, the remaining time before the 2027 General Election is insufficient to complete the UHC journey.

“We cannot achieve UHC in one year. What will change?” poses Iraki.

Speaking to The Standard, Iraki said the country had already entered a political phase, with attention increasingly shifting towards the 2027 elections.

While acknowledging that the government had succeeded in registering millions of Kenyans under SHA, he said the greater challenge was making the system function effectively.

“SHA has been a work in progress. We all long for the day it will stabilise,” says Iraki. “UHC is yet to be achieved. Universal health services, where every Kenyan would be covered and sleep in peace.”

Iraki also questioned whether the cost of the new financing model matched the benefits available to contributors, given that contributions are capped at 2.75 per cent of income.

He further questioned why Kenyans continued to pay medical bills from their pockets despite the expansion of the national health insurance scheme.

“Why pay from the pocket with UHC?” poses Iraki. “This is a big question.”

The economist said achieving UHC would require more than changing the mechanism through which healthcare is financed, arguing that greater emphasis must also be placed on preventive healthcare.

For former Health Minister and Kisumu Governor Prof Peter Anyang’ Nyong’o, however, UHC is not a new policy conversation and should now move from aspiration to implementation.

“Every Kenyan should have the right and opportunity to access healthcare regardless of the disease they are suffering from,” Nyong’o tells The Standard.

Kisumu was among counties that pioneered UHC alongside Isiolo, Nyeri and Machakos.

Nyong’o argues that the legal framework governing healthcare under devolution already provides a basis for delivering universal healthcare, with responsibilities divided between the national and county governments.

“We just implement the law and we will be okay,” he says.

He credits devolution with significantly expanding access to health facilities but says infrastructure alone cannot guarantee quality healthcare.

“What devolution has done is that health services have increased in the country exponentially. And I think this should be maintained because when somebody is sick, you do not want them to die, simply because they cannot access a hospital,” he observes.

The remaining challenge, he says, includes ensuring adequate healthcare workers and sustainable financing.

For Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN) executive director Allan Maleche, the success of UHC should ultimately be measured not by the number of people registered under SHA but by what happens when a patient walks into a health facility.

“For me, UHC should be judged from the patient's experience,” says Maleche.

“Can an ordinary Kenyan walk into a health facility, get the care and medicines they need, and walk out without being pushed into financial hardship?”

“If we can achieve that consistently across the country, then we can say UHC is working,” he adds.

Maleche says the biggest challenge remains the gap between policy and implementation, with financing, corruption, accountability and implementation failures reinforcing one another.

“You can have a very good policy on paper, but if hospitals are not paid, medicines are unavailable or there are not enough health workers, the patient does not benefit,” he observes.

Nyong’o also wants the debate on financing to take into account the different economic capacities of Kenyans.

He argues that social health insurance should be financed according to ability to pay, with companies and higher-income groups contributing more while the poorest households are protected from contributions.

The Kenya National Union of Nurses and Midwives Secretary General Seth Panyako says UHC predates the Kenya Kwanza administration and has been pursued by successive governments under different policy labels.

“UHC is not an agenda that started with this government. It started a long time ago. Only it comes with different names, just like how someone puts on different clothes,” Panyako said in a recent interview with The Standard.

He says the two critical pillars of UHC are adequate human resources and sustainable financing.

Panyako argues that universal social services cannot depend primarily on contributions from a relatively small formal workforce.

“You cannot finance a universal service when money is coming only from a few working people. This will definitely collapse. This is a hurdle that is yet to be dealt with,” he said.

“If UHC is clinched on SHA, then it is bound to fail. I am not seeing any light at the end of the tunnel,” he added, while saying nurses were willing to work with the government to develop a sustainable model.

Panyako also linked problems in the health supply chain to inefficiencies within SHA, saying hospitals have struggled to obtain essential medicines.

“Shall drugs get to patients by themselves?” he posed.

He further criticised the SHA service model, particularly the principle that people can access services when they fall sick without having to maintain a period of paid-up contributions.

Under the defunct NHIF, members were required to have three months of paid-up contributions before accessing some services.

President Ruto rejected that approach during the recent Health Summit, arguing that illness does not wait for people to complete their contributions and patients should receive treatment when they need it.

The Government maintains that the reforms are already transforming the health sector.

At the Health Summit, Ruto acknowledged that significant gaps remained but defended his administration’s record, saying the ultimate objective was to ensure every Kenyan could access quality and affordable healthcare regardless of their financial circumstances.

The President said the reforms were intended to move Kenya away from a system in which access to treatment depended on the size of a patient's wallet.

“For years, Kenya lived with access to health depending on the size of a patient’s wallet,” he said.

He said families had been forced to sell livestock, exhaust savings, borrow money or organise fundraisers to meet medical bills.

“Sickness became a pathway to poverty. It was wrong and also unjust,” he said.

Ruto also cited improvements at the Kenya Medical Supplies Authority (KEMSA), saying the facility fill rate had increased from below 40 per cent to at least 91 per cent.

He said more than 5,024 health facilities had been contracted under SHA.

The President further identified digitisation as a critical component of the reforms, arguing that electronic health records would improve visibility and accountability in patient treatment and health spending.

“If you had amputation of legs several times, this wasn't healthcare, but theft from sick people,” he said.

But Kelin says the success of the reforms will ultimately depend on whether they translate into better experiences for patients.

“The true measure of UHC is what happens when a registered person becomes sick and seeks healthcare,” says Kelin.

The organisation says Kenyans should judge SHA on whether patients can obtain necessary services without significant out-of-pocket payments; whether health facilities are reimbursed fully and on time; whether medicines and diagnostic services are available; and whether the benefits package covers essential healthcare needs.

It also questions whether poor and vulnerable Kenyans can access services without administrative or financial barriers.

“Are poor and vulnerable Kenyans genuinely benefiting from SHA, or are they still being left behind? There are still significant barriers that can disproportionately affect poor and vulnerable people,” says Kelin.

For the organisation, accountability remains one of the greatest tests facing UHC.

“The challenge is not simply that the health sector needs more money. It is also whether the resources already available are translated into actual healthcare,” Kelin observes.

The debate therefore increasingly centres on whether Kenya's health reforms can close the distance between policy and the patient.