ARTICLE BY NICHOLAS OKUMU
As I reflect on my time at Lenana School, I’m
reminded of the powerful sense of equality
that came from studying alongside classmates
from vastly different backgrounds.
Whether wealthy or from modest means, we shared the same dorms, the same classrooms and the same opportunities.
It felt like a microcosm of what true equality could look like in society—where our differences faded in the pursuit of a common goal.
Many of the readers here who went to national schools may relate to this conversation. Now, Kenya is attempting to create a similar sense of equity in healthcare with the Social Health Authority.
On paper, it promises a universal system where everyone contributes based on their ability to pay and receive equal care. The idea echoes the unity and fairness I experienced at Lenana. Yet, despite the noble vision, I worry that the SHA is fostering more division than unity.
Instead of creating inclusivity, the system risks generating resentment and deepening inequalities. Is the SHA truly delivering on its promise of health equity, or is it widening the gap between those who have access to quality care and those who don’t?
The SHA’s model relies on pooling resources, where wealthier individuals contribute more to support those less able to pay. This structure has worked in systems like the UK’s NHS and Canada’s Medicare, but it is not without flaws.
In the UK, many wealthier citizens often seek private care for quicker access to specialists, creating a two-tier system. A similar trend is emerging in Kenya, where the benefits package under the SHA falls short of covering basic healthcare needs for many families.
For example, only Sh2,000 per family per year is allocated for dental care, a sum that barely covers even basic treatments.
This token allocation does little for families facing more serious health challenges, pushing wealthier individuals toward private healthcare while those with fewer resources struggle to access meaningful services.
Without significant improvement, the SHA risks reinforcing a system where quality care is determined by financial means.
Moreover, there is a deeper challenge with the SHA’s approach to resource distribution, particularly in rural areas.
The Primary Healthcare Fund, intended to support local clinics and grassroots-level care, is underfunded at Sh6.1 billion. This is insufficient to ensure equitable access to healthcare across the country.
Public health expert Julian Tudor Hart’s Inverse Care Law—a principle suggesting that those in greater need of healthcare often receive the least— comes to mind here.
In Kenya, urban areas with better services stand to gain more from the SHA, while rural and marginalised communities, where the need is greatest, continue to struggle with access.
For the SHA to avoid exacerbating this urban-rural divide, investment in rural infrastructure and personnel is essential.
A successful healthcare system must also be built on public trust. Sociologist Paul Starr has argued that the success of health reforms hinges on the public’s belief that the system will work for them.
This is particularly relevant in Kenya, where a history of corruption and mismanagement has eroded trust in public institutions.
The SHA faces a challenge here, especially because it has outsourced claims management to private entities. While this might streamline processes, it also introduces conflicts of interest.
If these entities prioritise profits over patient care, it risks further undermining public confidence. If Kenyans believe their contributions aren’t being used effectively, wealthier individuals may turn to private insurance, creating a more fragmented system and deepening inequality.
To understand how Kenya’s SHA could be improved, it helps to look at examples from other countries. Rwanda’s community-based health insurance system has managed to provide basic healthcare to even the poorest citizens through inclusivity, transparency and government oversight.
The strong investment in primary care has made Rwanda’s system a success. By contrast, Nigeria’s health insurance scheme has struggled. Despite good intentions, underfunding, corruption and a lack of trust have left many Nigerians without coverage.
Kenya’s SHA must learn from these examples, focusing on transparency, adequate funding and building public trust to create a system that works for all.
NICHOLAS OKUMU, Orthopaedic surgeon and a 2024 Global Surgery Advocacy Fellow