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Paper short abstract

Kenya’s 2023 SHI is framed as pro-poor UHC, yet access to care is conditional on registration and paid-up contributions. Targeting and digital checks filter eligibility; and outsourced purchasing favours private providers – raising risks of exclusion & household health debt.

Paper long abstract

Kenya’s 2023 Social Health Insurance (SHI) reform is framed as a transformative, pro-poor pathway to universal health coverage (UHC). This paper argues that despite the progressive rhetoric, SHI assembles market logics and debt-prone form of UHC. It expands the role of insurance and private providers, while access becomes increasingly conditional and stratified.

We draw on 48 elite interviews (2024) and documentary analysis of laws, regulations, budgets, and donor/technical reports (2022–2025), to trace how this model is assembled. We identify four linked mechanisms. First, “universality” is implemented as compulsory insurance membership, where registration and paid-up status makes access conditional, including for publicly-funded primary care services, shifting risk to households. Second, selective inclusion is institutionalised through proxy means testing and differentiated entitlements, creating administrative exclusion and encouraging private “top-ups”. Third, purchasing rules (such as “money follows services”) and outsourced claims administration route public funds through mixed markets, privileging private providers amid chronic underinvestment in public facilities. Fourth, actuarial and credit logics deepen financialisation through premium-financing loans, leading to household health debt.

We show how SHI design can lead to exclusion at the point of care, and debt-based coping for households. The paper offers an empirically-grounded account of how UHC reforms can institutionalise conditional access and health debts in high-informality settings. We conclude by outlining alternatives proposed by Kenyan actors, including tax-financed entitlements and sustained investment in public provision