For decades, Kenyans without health insurance have had one option when they fall sick, or a hospital bill arrives. Reach out to friends and family to gather what they can for their healthcare.
By 2023, official figures showed only about a quarter of Kenyans had any health cover. And most of these were people working in formal sector jobs. For the remaining 75%, who had no cover, falling sick meant paying out of their own pockets at health facilities. The few exceptions include maternity care and basic services in local clinics.
The World Health Organization estimates that half of all people worldwide impoverished by out-of-pocket health expenditures live in Africa.
In 2023, shortly after taking office, President William Ruto’s government pushed through a major health financing law, the Social Health Insurance Act. This new law scrapped the National Hospital Insurance Fund, the state insurer since 1966. The insurer had collected members’ contributions and paid their hospital bills, yet only managed to cover about a quarter of Kenyans. The new law replaced it with a new body, the Social Health Authority.
Every Kenyan, formally employed or not, is now expected to register with the authority and contribute 2.75% of their income. The law was immediately challenged in court. Petitioners argued that it had been rushed through without adequate public participation; that the executive bypassed parliament; the burden of 2.75% contribution was too heavy; and that tying healthcare access to registration and contributions violated constitutional rights.
In July 2024, the High Court agreed that public participation had been inadequate and struck down parts of the law. But an appeal court put the ruling on hold, allowing implementation to begin in October 2024.
That a reform was needed is not in doubt. The failures of the old system had been widely documented. But what almost no one remembers is that Kenya tried to pass health financing reform similar to the 2023 law nearly 20 years earlier. Championed by then health minister Charity Ngilu, this was vetoed by then president Mwai Kibaki.
In each case, the goal was the same: to increase health insurance coverage, to pool contributions, and move Kenya towards universal health coverage. So why did a reform built on the same basic model fail in 2004, yet pass in 2023, in just six weeks?
I set out to answer this in my PhD research. It struck me that most of the problems facing healthcare provision in Kenya hadn’t changed. We still had low health insurance coverage. Out-of-pocket expenditures remained high, as did the disease burden. And the national insurer was still dogged by corruption and inefficiency. So what had changed?
My paper concludes that three factors made the 2023 reform possible, where 2004 had failed: concentrating power in the presidency (which enabled the bypassing of institutions that might have opposed or slowed the reforms); co-opting opponents who had blocked the previous attempt; and framing the reform as a fight for the ordinary Kenyan.
This matters, because it changes how we think about reform. We often assume that big changes happen when the moment is finally right. But Kenya’s case suggests conditions for reform can be strategically built.
What I found
For my research I interviewed 48 people intimately involved in the formulation or review of one or both reforms. These executive-level respondents included presidential advisers, insurers, ministry of health officials, external aid agencies, a former health minister, and members of civil society. I also drew on parliamentary records, media reports and policy documents.
I wanted to know why a reform was needed, how each reform was designed, who drove it, who supported or opposed it and why, and how any resistance was overcome. I corroborated their accounts with archival records – especially relevant for the 2004 attempt. I compared a “successful” and a “failed” reform, to reach a conclusion.
One important caveat. The study focuses on the design and how the law passed, not whether it’s working.
I found that while the challenges affecting the health system were nearly identical in both periods, what had changed substantially was the politics, in three distinct ways.
First is executive dominance and institutional bypass. In 2023, the reform process was run from the president’s own office, rather than the health ministry. This top level leadership shielded it from opponents, but also enabled what I call institutional bypass – going around the bodies that would normally shape and check such processes, like the health ministry, the national insurer, and the parliamentary processes of scrutiny and public participation.
Parliamentary scrutiny was shortened (from 14 to three days), and the reform driven through before opposition could organise. Rather than reforming the old insurer, the government scrapped it altogether. By stripping away every point at which the law could be slowed, amended or blocked, the president was able to speedily pass the reform in weeks, with minimal changes.
In 2004, by contrast, the reform was led by the health minister, without strong presidential backing. Without this support, she couldn’t push the bill past the treasury, private sector, employers, and insurers who opposed it. The bill was eventually vetoed by the president.
Second is elite realignment. The powerful players who had blocked the 2004 reform shifted to supporting or not actively opposing the 2023 reform. These included the formal employers’ lobby, private insurers, unions, treasury, and even some external donors. This appeared to be part of a deliberate strategy. Employers, for instance, didn’t have to match their employees’ contributions. This is the very cost they fought against in 2004. And private insurers were left as second payers, topping up the public cover rather than being displaced by it, as they had feared in 2004.
Third is the populist framing applied. In 2023, the reform was sold not as a technical fix, but as a moral cause. The president framed the old system as one where the “poor subsidised the rich” and dismissed opponents as “cartels” profiting from a broken system. The reform itself was presented in a populist way as a fight for the ordinary Kenyans – the so-called “hustlers”.
Framed that way, opposing the reform – even for sound reasons – became difficult. And there were credible grounds to oppose it. The 2.75% contribution was too heavy; the legislative process was rushed; and public participation had been inadequate. But in that moral frame, raising any of these looked like defending the rich or status quo. The framing helped justify speed and sidelining of institutions.
Why this matters
The most striking implication is that a reform doesn’t just pass because the timing is right, or because there are real problems. At any moment, there are countless problems competing for policymakers’ attention. But reform can be strategically designed to pass, by concentrating power, bypassing institutions, co-opting opponents, and framing it as the people’s cause.
This isn’t just a Kenyan story. Many countries are trying to build universal health coverage, and they keep hitting the same walls: tight budgets, competing priorities, powerful opponents, hesitant leaders. Kenya shows how to get around those “walls”.
But this also raises important questions for democracies. The same tactics that pushed a much needed reform over the line also reduce scrutiny and public debate that give a law legitimacy. So whether this reform truly helps the ordinary Kenyan depends on whether the government keeps its financial promises once the political moment has passed.
And because it was rushed through, the reform is left vulnerable. Opposition leaders are already talking about undoing it, making it a contested issue heading into the 2027 elections.
Zil Audi-Poquillon receives funding from the Economics and Social Research Council (ESRC), part of UK Research and Innovation (UKRI), Grant number ES/P000622/1- which funded her PhD studentship. The funder had no role in the study design, data collection, analysis, interpretation of data, the writing of the PhD research or this article.
By Zil Audi-Poquillon, PhD Candidate – Health Policy and Health Economics, London School of Economics and Political Science
