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Affordability of life: Why a large population of Kenyans continues to live without any form of health insurance

An equation of quality and timely healthcare services equates to good healthcare and an expensive bill. The health schemes cushion people from expensive bills, by funding medication at a time of need. But is this really true? What is the cost of getting health insurance cover? With the minimum wage of an average Kenyan at 504.00 KES per day, are the insurance schemes feasible? In the case where a Kenyan is unable to pay for insurance, how do they face the health system? Is their life equated to a deposit?

  1. Health insurance in Kenya

2.1 Health provisions in the law

Health is classified under economic and social rights in the constitution of Kenya under Article 43(1)(a) which states that:

“ Every person has the right to the highest attainable standard of health, which includes the right to healthcare services, including reproductive healthcare;”[1]

Subsequently, Article 43(2) further emphasizes the need of health services by stating that:

“A person shall not be denied emergency medical treatment.”[2]

The Health Act of 2017 under Section 33 provides for the establishment of a National Health Insurance Fund (NHIF) to provide social health insurance coverage to Kenyans. The NHIF has the mandate to collect and manage funds for social health insurance, enroll members and register beneficiaries, and contract with healthcare providers to provide services to members and beneficiaries. Provisions from the Constitution and statutes form the foundation of healthcare operations and guide its policies and decision-making processes. The NHIF is intended to promote affordable, accessible, and quality healthcare services for all Kenyans, including those in rural and marginalized areas.

The Health Act of 2017[3] also sets out the benefits that NHIF members are entitled to, including inpatient and outpatient medical services, maternity and newborn care, ambulance services, and specialized medical care. The NHIF also covers chronic conditions, such as cancer and diabetes, and provides access to preventive services, such as vaccinations and cancer screenings. To finance the NHIF, members are required to make contributions based on their income, with employers also required to contribute on behalf of their employees. The NHIF is also able to receive funds from the government, donors, and other sources.[4]

The NHIF is overseen by a Board of Trustees appointed by the Cabinet Secretary for Health, with the board responsible for overseeing the management and administration of the Fund. The NHIF is also subject to regular audits and reports to ensure accountability and transparency in its operations. Overall, the establishment of the NHIF represents a significant step towards achieving universal healthcare coverage in Kenya, with the goal of providing equitable and affordable healthcare services for all Kenyans.[5]

2.2 Types of health insurance covers

The most known NHIF cover is a government-run health insurance cover that provides medical insurance to all Kenyan citizens and legal residents. Alternatively, private health insurance which is offered by private insurance companies in Kenya can be purchased by individuals, families or corporates. It covers a wide range of health services including inpatient and outpatient care, dental, and optical care among others.

The third type of health insurance is Community-Based Health Insurance (CBHI), which is run by communities or self-help groups. It is designed to provide affordable healthcare services to low-income households who may not afford private health insurance. Corporate Health Insurance is provided by employers to their employees. It covers a range of health services such as inpatient and outpatient care, and dental care. Lastly, Micro Health Insurance is a type of health insurance cover that is designed for low-income earners and people living in rural areas. It covers basic health care services such as hospitalization, maternity care, and basic surgeries. Different institutions offer varying health covers with regard to coverage, payment and reliability. The cost of healthcare in Kenya is above the roof, therefore, health insurance cover is essential. With the average Kenyan earning below the minimum wage of 504.00 KES per day, are the insurance schemes feasible as they require monthly payments with rates increasing with the better the package? Needless to say, health deterioration is not subjective but a matter of probability. It is apparent that to obtain the highest attainable standard of health as provided for under the Constitution of Kenya, a person is required to be well-off.

  1.  Accessibility of health insurance to  citizens

The National Hospital Insurance Fund (NHIF) set up in 1966 is the social health insurance scheme that seeks to provide accessible, affordable, and quality healthcare to all Kenyan citizens. Initially, NHIF provided obligatory insurance services to formal sector employees, however, in 1998 its membership mandate was increased to cater to employees even in the informal sector. It has remained to be the main insurance service provider in the country. Membership in the NHIF is mandatory for formal sector workers, who pay an income-rated monthly contribution through statutory deductions, whereas it is voluntary for informal sector workers, who pay a flat rate contribution directly to the NHIF.[6]

Its membership is open to all regardless of socioeconomic status. However, joining the scheme depends on an individual’s willingness, preferences and ability to pay.[7] In fact, NHIF is not registered with the Insurance Regulations Authority as it is not legally mandated to offer commercial services. [8]Apart from NHIF, Kenyans are free to enroll with private medical insurance providers, community-based health initiatives and many more. All these schemes have their offices spread throughout the country. 

While all insurance service providers are open to all citizens, access to benefits largely depended on the package, with those contributing more, enjoying more.[9] These packages are termed to be specifically tailored to suit everyone’s pocket. The Community-based health insurance schemes mostly target the lower-class citizens who may not be able to afford the other insurance plans.  But even such initiatives don’t have any arrangements to subsidize contributions for the poorest citizens.

3.1 Process of attaining a health cover

 The process of registering for health insurance is normally very easy and varies depending on the specific insurance provider. Most companies require the applicant to follow a step-by-step process that entails all the pertinent information, which will then be used in the underwriting and approval process.[10] Enrollment in a health insurance service could mean everything from inpatient and outpatient cover, maternity cover, ambulance services, optical and dental services to chronic disease management.

  1. Statistics of Kenyans with insurance

According to the Kenya Demographic and Health Survey; Key Indicators Report 2022, only one in four persons in Kenya (26% of females and 27% of males) have some form of health insurance. Majority of the population is entirely dependent on the state for their health, and largely, “how they wake up feeling”.[11] A relatively bigger number of the citizens continue to stay away from insurance covers and rely on out-of-pocket payments to get over the counter medication, even though many times such payments result in impoverishment. Oftentimes, people who cannot pay for a health insurance cover, cannot afford to pay for private healthcare. The realities of the financial burden of healthcare continue to edge an entire population closer to its termination.

The proportion of persons covered with any health insurance is higher in urban areas (39% among females and 41% among males) than in rural areas (20% among females and 19% among males)[12].  This difference has been largely associated with outreach of these schemes to the people living in rural areas. There is very little knowledge on medical insurance in some rural areas of the country. Some people still don’t understand how these schemes function, and there are those that don’t know that NHIF now extends its “umbrella” to people who are not employed in the formal sector.

  1. Why many people are not registered on covers

“ People who register for health insurance are pessimistic, and if nothing happens, your money is gone, so it’s throwing money down the drain. You do not want to do that when you do not have the money to begin with.”

Cost is ranked as the first reason why most Kenyans refrain from enrolling in a health insurance scheme. With a fast-crumbling economy, monthly payment deductions are more of a liability than an asset.

Lack of information and misinformation. People do not know where and how to enroll for a health insurance cover. Some do not know of the importance of having a cover. Others are misinformed about the purpose of health insurance. For people who are well informed, some step back from enrolling due to unfavorable terms and conditions from the insurance companies. Majorly, unfavorable terms range from illness and accident coverage and payment plans. The list of unfavorable terms and conditions is endless.

  1.  Perks of health insurance cover with exceptions
  2. Cost coverage

Depending on the insurance package one pays for, insurance ensures that some or all of the costs of treatment are covered, be it medication, hospitalization and even consultation costs. This offers some form of bulwark against depleting personal savings while seeking medical assistance.

  1. Assurance

Simply put, insurance is some form of life savings that is meant to come to your rescue during a crisis. Having health insurance relieves you from anxiety and stress that is likely to affect someone when their kin fall sick. The insured is certain that come what may, the insurance cover will protect the beneficiary and his/ her dependents.

6.1 The Covid-19 pandemic and chronic disease management

Insurance is not for the things we know are going to happen, but for the things we can’t predict.” ∽ American businessman and philanthropist, Warren Buffett.

The COVID-19 pandemic took us through an extraordinary period of world history. The pandemic brought fear, pain and most devastating deaths due to the illness. The alien virus came “like a thief”, unexpectedly and suddenly claiming lives. And at this moment of uncertainty, many people expected their health insurance covers to come to their rescue. But contrary to this expectation, many insurance firms chose to distance themselves from Covid-19 bills citing the fact that such treatment costs would result in huge losses for them. The few that continued to cover the Covid-19 treatment cost did so under certain conditions. The IRA told the Senate that insurers will not pay for treatment in private hospitals where bills range from Sh600,000 to Sh1.2 million. Instead, they will cover expenses incurred in public hospitals where bills for treatment of the infectious virus are estimated at Sh135,000, the regulator told lawmakers in a statement.[13]

Similar to the virus is the chronic disease cancer which is least suspected by its victims. Research shows that cancer mortality rate is on the rise in Africa.[14] With more cases of diagnosis, it is important to be prepared for the unpredictable. Health insurance covers should be especially resourceful when it comes to cancer treatment. Cancer treatment is strategic, lengthy and costly. Health insurance cover can enable you to get through the treatment provided that you do not deplete the specific funds allocated for treatment. Well, such a twist of conditions discourages most people from taking the step to join an insurance scheme. With the high cost of treatment,  one has to wonder, how future proof are these covers? How effective and reliable are they?

7. Universal health coverage

The Universal Health Coverage (UHC) is a global health system that was initiated to ensure that people access quality medical health care without having to endure financial destitution.  UHC has two fundamental goals: optimizing the impact of healthcare services and eradicating financial crises, impoverishment or bankruptcy that may arise from high healthcare costs.[15] Low- and middle-income countries (LMICs) are increasingly adopting universal health coverage (UHC) as their health policy priority.[16] In fact, during his inaugural speech in 2017, former president; Uhuru Kenyatta, declared it as one of the big four agenda.

Kenya’s UHC pilot program was launched on the 13th of December 2018 in five counties, namely: Machakos, which was selected because of the high number of casualties resulting from reported accidents, Kisumu, selected because of the rife of infectious diseases like malaria, Isiolo, which had a high rate of maternal mortality and Nyeri which had a prevalence of non-communicable disease.  Studies show that implementation of the program was destined to fail from the outset in Kisumu.  In Nyeri county it was terminated because of financial constraints  while Machakos and Isiolo counties continued with the program up to its conclusion.

Fortuitous as it might have been, launching the National UHC program in the year where the World has experienced the biggest Health Crisis in a century would have been a master stroke by the Ministry of Health but alas! The failure to effectively transition the pilot into a fully functional national project presented instead another opportunity for private allies to cash in and citizens to keep wallowing.[17]  While there are many discussions around the Universal Health Coverage, people are curious to know when the project will be re implemented.

7.1 What are the challenges facing the implementation of this initiative?

 Inadequate Financing

Kenya’s expenditure on health as a percentage of the total government expenditure oscillates between 4% & 6% when viewed against the 12% recommended in the Kenya Health Sector Strategic Plan, and the 15% in the Abuja Declaration which Kenya is a party to.[18]  This means that the healthcare systems in Kenya remain largely underfunded and heavily reliant on private-sector sources.

The Fourth Schedule of the Constitution of Kenya 2010 introduced the devolved system of government. It distributed the functions between the national and county government as follows: National government: leadership in health policy development; management of national referral health facilities; capacity building and technical assistance to counties; and consumer protection, including the development of norms, standards and guidelines. County governments: responsible for county health services, pharmacies; ambulance services; promotion of primary health care; licensing and control of undertakings that sell food to the public; cemeteries, funeral parlors and crematoria; and refuse removal, refuse dumps, and solid waste.[19] Many stakeholders have complained about the devolution of functions without adequate funding, with the Council of Governors complaining about untimely and inadequate disbursement of funds.

Inconsistencies in payment for initiatives meant to provide free health care such as Linda mama, Eduafya etc,[20] and the diversion of funds meant for facility improval and UHC improvement that lead to the failure of the implementation of the initiative.

Inadequate healthcare personnel

The World Health Organization recommends that the most suitable doctor patient ratio should be 1: 1000, while the nurse patient ratio should be 1:120. According to the Kenya Medical Association, the current doctor patient ratio in Kenya stands at 1:6505, and the nurse patient ratio is 1:1250. In addition to this, there is an unequal distribution of healthcare workers in the country, with many specialists being located in major towns. Some hospitals remain conspicuously understaffed.  All these factors have led to overworking of the few health workers who are present. Many people are unable to seek medical attention due to the high cost of treatment. For a system that was meant to eradicate financial destitutions that result from treatment, its implementation needed full hands-on deck.

There is also the issue of poor pay, with many workers going for months without pay. Healthcare workers have also complained about being insufficiently protected. This is true considering the issue of inadequate Personal Protective Equipment (PPE) available to front line healthcare workers, during the COVID-19 pandemic. These poor working conditions have resulted in an additional shortage of healthcare personnel with many opting out in search of greener pastures.

8.  The equation of life to a deposit

Anyone who lives in constant worry of what would happen to them if they get ill, or whether they will be able to afford care or time off work, lives in a state of unfreedom[restriction]. Any model of society that makes this worry inevitable is itself diseased (William Shoki, 2021).[21]

Sadly, life has been equated to a deposit in hospitals repeatedly. When seeking help, people in dire states have been required to make payments as assuarities before life saving procedures are embarked on. Consequently, many lives have been lost at this stage, and many families have been left helpless and hopeless. Regrettably, this is the norm in society, having to worry whenever you get ill.

     9. Conclusion

“Health

Health, is more important than

wealth, for you can’t buy health,

with money! You can buy a lot of

things, but without your health,

days are no longer sunny! If we

enjoy good health, we’re fortunate,

we should never take it for granted…”

Audrey Heller

One of the many uncertainties that we have in the world is health. Despite all the efforts that people make, illnesses are unpredictable and are sometimes the factor that determines whether you remain financially stable or you fall into poverty. A health insurance, however uncertain, offers a cushion you did not think you needed.  It helps balance the complex and difficult equation that is life.

The Constitution of Kenya enshrines the right to the highest attainable standard of health as a fundamental human right, regardless of an individual’s socio-economic status. While it is true that access to healthcare may be easier for those who are financially better off, the government is obligated to provide affordable and accessible healthcare services to all Kenyan citizens, regardless of their financial status. Additionally, there are various initiatives and programs in place aimed at ensuring that marginalized communities and vulnerable groups have access to healthcare services. These programs need to get funding and more awareness created towards them, in order to achieve healthcare for all.

Dolce Okoth is a second year LL. B student at the University of Nairobi. She is passionate about

research. She  can be reached via email address dolceokoth@gmail.com

Maangi Moraa is a second year LL. B student at the University of Nairobi. She is passionate about research. She can be reached via email address maangimoraa@gmail.com


[1] Constitution of Kenya 2010 Article 43(1)(a)

[2] Constitution of Kenya 2010 Article 43(2)

[3] Health Act of 2017, Section 33.

[4] Ibid

[5] Ibid

[6] Edwine Barasa, Khama Rogo, Njeri Mwaura & Jane Chuma (2018) Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage, Health Systems & Reform, 4:4, 346-361, DOI: 10.1080/23288604.2018.1513267 pg 347

[7] Mulupi et al;Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya.  BMC Health Services Research 2013, 13:474 http://www.biomedcentral.com/1472-6963/13/474

[8] i³ Actuaries and Consultants; Draft Comprehensive Report; SECOND DELIVERABLE FOR THE DEVELOPMENT OF A COMPREHENSIVE LEGAL AND REGULATORY FRAMEWORK FOR REGULATION, SUPERVISION AND DEVELOPMENT OF HEALTH INSURANCE IN KENYA FOR THE INSURANCE REGULATORY AUTHORITY 23 April 2021 pg 13

[9]Mulupi et al;Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya.  BMC Health Services Research 2013, 13:474 http://www.biomedcentral.com/ 1472-6963/13/474

[10] https://lifecareinternational.com/is-health-insurance-mandatory-in-kenya/ <accessed 13th April 2023>

[11] Mulupi et al;Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya.  BMC Health Services Research 2013, 13:474 http://www.biomedcentral.com/ 1472-6963/13/474

[12] Kenya Demographic and Health Survey; Key Indicators Report 2022

[13] https://nation.africa/kenya/news/insurers-won-t-pay-all-covid-hospital-bills-in-about-turn-1906256 <accessed 13th April 2023>

[14] Mapping Cancer in Africa: A Comprehensive and Comparable Characterization of 34 Cancer Types Using Estimates From GLOBOCAN 2020,https://www.frontiersin.org/articles/10.3389/fpubh.2022.839835/full , Last Accessed 4/20/2023, 2:59 PM

[15] WHO 2010, as adopted by https://kma.co.ke/component/content/article/79-blog/125-challenges-facing-the-attainment-of-universal-health-coverage-in-kenya?Itemid=437 <accessed 13th April 2023>

[16] Sachs JD. Achieving universal health coverage in low-income settings. Lancet. 2012;380(9845):944–947. doi:10.1016/S0140-6736(12)61149-0. as adopted in the article;Edwine Barasa, Khama Rogo, Njeri Mwaura & Jane Chuma (2018) Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage, Health Systems & Reform, 4:4, 346-361, DOI: 10.1080/23288604.2018.1513267

[17]https://kma.co.ke/component/content/article/79-blog/125-challenges-facing-the-attainment-of-universal-health-coverage-in-kenya?Itemid=437 <accessed 13th April 2023>

[18]Ibid

[19] Kenya Health Policy 2014–2030 pg 3

[20] Ibid

[21]Darmi Jattani,Oscar Ochieng; Can People Afford to Pay Out of Pocket for Health Care in Kenya? https://ieakenya.or.ke/blog/can-people-afford-to-pay-out-of-pocket-for-health-care-in-kenya/ <accessed 13th April 2023>

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