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Paper short abstract

Why did Kenya adopt SHI in 2023, having rejected a similar reform in 2004? Using interviews and documents, this paper shows how executive control and populist framing aligned the problem, policy and politics streams – enabling rapid reform adoption.

Paper long abstract

Kenya adopted a major social health insurance (SHI) reform in 2023 after a similar bill in 2004 was vetoed, despite broadly comparable constraints. What changed, and what does this show about power and agency in health policymaking?

Drawing on 48 elite interviews (2024), and documentary analysis (Hansard, media, and policy documents), this paper uses comparative process tracing, guided by Kingdon’s Multiple Approach. It argues that 2023 reform was not an ‘accidental’ alignment of streams, but a deliberate political work. It was pushed by presidential populism that helped ‘couple’ the streams together in three ways.

First, the Executive moralised and reframed health financing inequities as an urgent crisis affecting “ordinary people,” and used this to build political pressures. Second, a familiar contributory insurance design was repackaged as a ‘bottom-up’, pro-poor reform, making it easier to sell politically. And third, decision-making was centralised in State House, which narrowed public debate, weakened bureaucratic and legislative veto points and delegitimised opponents as “cartels” blocking change. Populist strategy linked a crisis narrative (problem stream), a packaged reform design (policy stream), and a mobilised governing settlement (politics stream), ensuring stream convergence. Alongside these strategies, elite support shifted in 2023 (notably Treasury, donors, and private sector), reducing resistance that proved decisive in 2004.

This account speaks to debates on reimagining development, by showing how reimagining public health can also mean reworking power. Reform adoption can expand social policy on paper while tightening control over participation and accountability.