Kenya’s decision to replace the National Hospital Insurance Fund (NHIF) with the Social Health Authority (SHA) was not simply the result of a long-standing need to reform healthcare financing.
A new analysis suggests the reform succeeded because the political conditions surrounding it were dramatically different from those that defeated a similar proposal nearly two decades earlier.
Kenya’s 2022 Demographic and Health Survey found that only about one in four Kenyans had some form of health insurance, with coverage significantly lower among rural and poorer households.
That gap has long made universal health coverage a major policy challenge.
The reform Kenya had tried before
The idea of pooling health contributions and expanding insurance coverage was not new when President William Ruto’s administration introduced the Social Health Insurance Act in 2023.
A similar reform had been proposed in 2004 under then Health Minister Charity Ngilu. However, the initiative failed to secure sufficient political backing and was eventually vetoed by President Mwai Kibaki.
Nearly 20 years later, Ruto’s administration pursued a comparable objective but moved much faster.
The 2023 legislation abolished NHIF and established the Social Health Authority, with contributions structured around 2.75 per cent of income under the new system.
The legislation faced legal challenges over public participation and other constitutional issues. Courts subsequently suspended some provisions while allowing much of the framework to proceed.
Three political factors changed the outcome
According to research by Zil Audi-Poquillon, a PhD candidate in health policy and health economics at the London School of Economics and Political Science, the difference was largely political.
The researcher interviewed 48 people involved in the development or review of the two reforms and examined parliamentary records, policy documents and media reports.
The study identifies three major factors.
First, presidential control was stronger.
Unlike the 2004 attempt, the 2023 reform was driven from the presidency. This gave the administration greater ability to overcome institutional resistance and accelerate the legislative process.
The research argues that parliamentary scrutiny was shortened, while several institutions that might have slowed or altered the reform had less influence over the final outcome.
Second, former opponents were brought into the new arrangement.
Groups that had resisted aspects of the earlier reform, including employers, private insurers and other stakeholders, were presented with a different framework.
Private insurers, for example, were positioned to complement public health coverage rather than being displaced entirely.
Third, the reform was framed as a people’s cause.
The Ruto administration presented SHA as part of a broader effort to correct inequalities in the old system.
Ruto frequently described the previous arrangement as one in which the “poor subsidised the rich”, while portraying resistance to reform as opposition from powerful interests.
That political framing helped build support among ordinary Kenyans and made opposition more difficult.
Reform success is not the same as policy success
The analysis comes with an important qualification.
It examines how the reform was designed and passed, rather than whether SHA has ultimately delivered better healthcare outcomes.
That distinction matters because speed can help governments overcome political resistance, but it can also reduce opportunities for public scrutiny and institutional checks.
Kenya’s experience therefore offers a complicated lesson: major reforms may require political momentum, but the same concentration of power that enables change can also create questions about legitimacy and accountability.
As SHA continues to reshape healthcare financing, its long-term success will ultimately depend not only on how effectively the system was introduced, but on whether it delivers affordable and accessible healthcare to the Kenyans it was created to serve.
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