Social Health Insurance for Universal Health Coverage in LMICs: A Policy Analysis of the Attainments, Setbacks, and Equity Implications of Kenya’s National Health Insurance Fund

Abstract

Background Growing evidence suggests that healthcare financing is one of the key factors for the attainment of Universal Health Coverage (UHC) in low- and middle-income countries (LMICs). Social Health Insurance (SHI) has recently earned global recognition as a possible financing mechanism to enable affordable and equitable healthcare services in resource-scarce settings. However, the path to establishing such schemes is known to be ridden with structural and political contextual challenges. Methods This work aimed to identify the enabling factors for the implementation of SHI as a financing tool for UHC in LMICs, using Kenya's National Health Insurance Fund (NHIF) experience as a case study. We used health policy lenses to analyse how actors' behaviours interplayed with other dimensions of policymaking to shape the development of Kenya’s NHIF and interpret their perceptions of policy outcomes. Drawing from 21 semi-structured interviews and an analysis of published and grey literature, we gathered qualitative as well as quantitative evidence to perform a retrospective case analysis of the NHIF experience in Kenya. Results One of our key findings is that only 17% of Kenya’s population are covered by SHI. Despite the predominance of the informal labour market in Kenya (83%), only 27% are covered by the NHIF, implying very low uptake and/or retention rates. There was little stakeholder engagement in the policy implementation process and minimum adoption of expert advice. Health financing policies were heavily influenced by political affiliations and positions of power. In addition, the purchasing and payment of healthcare was flawed, with inefficiencies including slow bureaucratic reimbursement procedures, little knowhow by rural hospital clerks, misappropriation, and a preference for private healthcare providers. The group-based parallel schemes run alongside the national scheme and the penalty payments for defaulted premiums increased the equity gap of the NHIF’s benefits for Kenya’s population. Conclusion Although the SHI system was perceived to increase the coverage and quality of Kenya’s health services, substantial structural and contextual challenges appear to have hindered its potential to finance the attainment of UHC, which should be a stepping-stone towards comprehensive healthcare attainment. Based on Kenya’s experience, we identify informal sector participation, efficiency of purchasing and payment of healthcare, and political engagement as key bottlenecks for the implementation of SHI schemes in LMICs.