Beyond the rhetoric: The political economy of exclusion in Kenya's social health programming

Abstract

This paper offers a close reading of Kenya's Social Health Authority (SHA) arguing that much-lauded health financing reform represents a sophisticated mechanism of structural exclusion dressed as universal coverage. Through critical political economy analyses of implementation data, we show how the SHA's institutional architecture systematically reproduces and exacerbates further existing social inequities along three very distinct pathways of exclusion. First, the intergovernmental framework creates an accountability gap between the national and county governments. However, consistent with earlier research into poor financial flows of money across a devolved system, county health departments unequivocally report on delays in paying both public and private providers in excess of six months, measured against a backdrop of increasing pressures to deliver services. Second, the strategic purchasing model has caused a crisis in the health provider network. Protracted reimbursement delays of 120-180 days, which are known to be a problem in social insurance schemes, have resulted in private facilities either withdrawing from the scheme or imposing an informal co-paying rate for SHA beneficiaries. Most critically, the enrolment mechanism is a de facto exclusionary mechanism. Whereas formal sector employees were automatically enrolled through payroll deductions, the informal sector, which represents 83% of Kenya's workforce, are faced with insurmountable barriers, including stringent contribution timeframes incompatible with irregular incomes, complicated digital registration requirements and historical distrust of government insurance schemes. Rather than achieving harmonization of policy goals, the SHA has resulted in a tiered system of coverage which correlates closely with socioeconomic status thereby institutionalizing the inequities that it claimed to cure. The results refute the underlying idea that technical policy measures will neutralize a decade of long-established political economy hindrances in the African health sector. Our results shed a lot of light on universal healthcare coverage. To create a genuinely participatory governance of health financing reform, we should not find better policy design but instead the unbundling of the structural power imbalance.