“Health for All?” critically explores global moves towards Universal Health Coverage and its language of rights to health, equity, social justice and the public good. Highlighting emerging ethnographic and historical research by both young and established scholars, the series explores the translations and frictions surrounding aspirations for “health for all” as they move across the globe. The series is edited by Ruth Prince.

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This piece is based on ongoing ethnographic research in Kenya on the moves towards universal health coverage and access to healthcare, during which I have closely followed the UHC pilot as well as ongoing experiments with health insurance and digital technologies.

In December 2018, Kenya’s President Uhuru Kenyatta launched a “Universal Health Coverage pilot”, dubbed “Afya Care – Wema Wa Mkenya” (Health Care – Good for Kenyans) to take place in four of the country’s 47 counties[1], involving a total of 3.4 million residents. The ceremonial launch took place in Kisumu county and was attended by the Director General of the World Health Organization(WHO), Dr Tedros Adhanom Ghebreyesus. Supported by the World Bank and Kenya’s Ministry of Finance, the “lessons learned” from the experiment are to feed into the expansion of UHC to the whole county by 2022. After months of discussing and planning for a national health insurance model, the government made a policy reversal, announcing that health services were to be made free in all government facilities for the duration of one year. In preparation for the launch, the county governments began enrolling residents into the UHC pilot through an ambitious digital registration drive.

In this essay, I focus on this digital registration, which began in October 2018 and involved the recruitment of hundreds of “UHC agents” using smartphones and digital apps. For the government, reaching full registration in the pilot counties was an important indicator of the enthusiasm of citizens for UHC and of its own commitment to “positioning Kenya as a leader in achieving affordable and quality healthcare in the African continent”.[2] Digital technology companies and platforms alongside NGOs and donors are heavily involved in the state-orchestrated UHC programme as it experiments with “innovative” digital technology to increase healthcare access. The UHC registration was followed, in April 2019, by the roll-out of a nation-wide biometric registration drive, Huduma Namba (“Service Number” in Kiswahili), aiming to create a national biometric identification system. I suggest that these projects to count citizens make people visible to the state and the private sector in particular ways, and that the multiple interests at stake require some scrutiny, as the relationships developing between the state, private enterprise, digital technology, NGOs and powerful players in global health as they pursue UHC are not unique to Kenya.

“Free health care for all!”

A language of hope surrounded registration. For the months leading up to the launch of the UHC pilot, citizens were told – in the media, on airwaves and on loudspeakers in meetings organized in markets, schools and sports grounds – to register for UHC’s “free health care”.[3] Doing so would give them access to such health care through possession of a “UHC card”, the “Afya” (health) card. A nationwide information campaign about UHC, which played out in newspapers and on radio and TV, told citizens that UHC was the enactment or realization of their right to health, a right included in the 2010 Kenyan Constitution.[4]

After decades of austerity and amidst rising costs of private health care, this language of rights and entitlements, of universality, solidarity, equality, and access to care, filled people with optimism. Among ordinary citizens, as well as civil servants, NGO staff and health workers, there was general agreement that “UHC is a good thing” and a sense that it was fostering something like solidarity. As a civil servant told me,

“I was very excited about UHC. I even went and got registered for UHC myself. Not because I really needed it, I have health insurance, but I wanted to be part of it. I told people, this UHC is a very good thing and you need to get registered. Some were skeptical and were telling me, there is no such thing as free healthcare, but I persuaded them. And I registered myself. I was enthusiastic, I wanted to be part of it, I wanted to share in it”

In Kisumu county, registration began in October 2018 and continued into 2019, after the launch of the pilot “free health care” scheme. At first sight, registration appeared straightforward: residents were told to find a UHC agent, who would register their details (using their National Insurance card or, if they did not have one, their mobile phone number) into a digital platform. Through this process they would receive a UHC card, which would give them access to a (unspecified) package of free healthcare services in government facilities. Details taken included name, gender, date-of-birth, residence, national identity number and mobile phone number, and the names, gender and dates-of-birth of any dependents. The agent in charge of registration also filled in a detailed socio-economic questionnaire (see below) and also took a photo of the individual using his or her mobile phone. These details were uploaded to the cloud, which then issued a UHC registration number. If the person being registered had a mobile phone, messages immediately appeared, welcoming the individual to “your UHC account” and thanking them for participating.

The mass registration for UHC offers a site to explore how the language of universality and entitlement surrounding “universal health coverage” was materialized and translated by citizens, civil servants, health officials, and the NGOs and other organizations involved in the process. It also tells an interesting story about relations between the state, digital technology and fintech companies, NGOs and social enterprises, as UHC becomes an opportunity for some organizations to reach a market.[5] 

Despite its apparent simplicity, the registration process turned out to be more complicated than expected, not only because of the partnerships between government, NGOs and the social enterprise and digital technology companies that designed the digital platform and managed the registration, but also because of the plurality of interests and motives at stake. While surrounded by a language of inclusion and the responsibility of the state for its citizens, registration also raised concerns regarding the use of identities and data extraction. For citizens, registration offered clear benefits: access to free health care. However, some were distrustful about what they perceived as the state’s agenda: what would happen after the one-year pilot, and were there other interests at play?

Registering citizens: digital technology and the promise of universality

In three of the four pilot UHC counties, the digital registration process was contracted out to PharmAccess, which describes itself as both an NGO and an “entrepreneurial organization”, and its digital platform, M-TIBA, a “mobile health wallet” and health finance platform. In the fourth county, another digital platform was chosen (Living Goods, a social enterprise started by a US citizen).[6] On its website, PharmAccess describes its mission as “to improve health care in Africa through technology and mobile innovations” and to “help build stronger health markets that make smart use of funds and give power to the individual.”[7] It is financed by the Global Fund and the Dutch government, among others. In 2016, PharmAccess launched M-TIBA, a mobile health wallet and digital platform that enables individuals to save money specifically for health needs and connects customers to private-sector health care providers. Designed by a partner, CarePay, a digital tech company that received initial investment from Safaricom, Kenya’s giant telecom company and M-PESA, its mobile money tool, the digital platform and health wallet were initially aimed at the bottom-of-the-pyramid market. Since 2016, M-TIBA has embarked on an ambitious project to register Kenyans into its mobile health wallet and connect consumers to (mostly private) health care providers, using CarePay’s digital platform. According to a blurb on its website, written in 2016, M-TIBA “is a first step in creating new digital solidarity mechanisms where people start paying for each other…The strength of M-TIBA is that….it allows us, with help from Safaricom, to identify vulnerable groups…and place the financial support directly in the power of their hands, on their mobile phone.”[8]

M-TIBA is a typical product among the new ecologies of health insurance and mhealth being experimented with across the African continent. Orientated to the “new business environment”, it positions itself as reaching the poor and vulnerable and expanding access to care, striving for government contracts while seeking a market and offering services that are, according to implementers, “financially sustainable” and “not dependent on donor money.”[9]  When the government decided to pilot Universal health coverage, M-TIBA was chosen as the digital health platform that could be best adapted to register citizens for UHC, as it had already negotiated a contract with the National Health Insurance Fund (NHIF) to conduct digital registration.

In the counties piloting the President’s UHC programme, PharmAccess recruited hundreds of “UHC agents”. While the initial plan had been to use the county’s community health workers, problems with smartphone access and literacy meant that it was mostly young people with smartphones who became agents. They were given a few hours of training in how to use the digital platform and told they would be paid 30 KES (less than 0.3 USD) per person registered. Given the pressure from the President to roll out the UHC pilot, they were encouraged to register as many people as they could, as quickly as possible.

Gathering data

Both the county governments and PharmAccess were keen to gather socio-economic data that could be used in developing social protection programmes for the county’s most vulnerable households. Indeed, before the central government’s decision to experiment with providing free healthcare services, the county government had planned to expand health insurance coverage as the means of ensuring access to affordable healthcare, and in 2018, as part of this process, M-TIBA had already began registering people into the NHIF using its platform. To gather the socio-economic data, PharmAccess had developed a “poverty mapping tool”, in cooperation with the Amsterdam Institute for Global Health and Development. When the UHC pilot was launched, this tool, already piloted, was incorporated into the UHC registration process and the M-TIBA/NHIF platform, allowing for the collection of socio-economic data in “real time”. The tool consisted of an online questionnaire that included questions about income and consumption, from the type of house one lived in, the kind of amenities one had, to the amount one spent weekly on mobile airtime, as well as questions about whether anyone in the household suffered from particular chronic diseases (such as hypertension, diabetes, cancer). The aim was to administer this questionnaire to all those who signed up for UHC.

Even with the energizing effect of the UHC launch in December 2018, registration targets were not easily reached. Some people refused to register or could not be contacted. By January 2019, it became clear to the implementers that some of the UHC agents were faking identities, encouraged by the policy of being paid per person registered. These were problems that were not easy to rectify: when PharmAccess changed the terms of payment (to a flat rate), the UHC agents organized themselves via a WhatsApp group to strike, refusing to register until payment was, in their terms, “fair”. The fact that it was possible to fake registration in the first place revealed the leakiness of the digital registration system, rolled-out in haste under government pressure to meet targets.[10]  Instead of registration taking place in location, using GPS and local chiefs, UHC agents were told to register anyone, anywhere, using only NI cards or only mobile phone numbers. Photographs, taken with the UHC agents’ own mobile phones, turned out to be poor quality, to the extent that in many cases, no human figure, let alone a face, was recognizable. These issues raised questions about the quality of the data collected, particularly given the amount of fake entries. PharmAccess claimed that once “cleaned” the data would be useful, but the county governments were not given access to it, and some officials worried that “there is too much competition instead of cooperation between the organizations involved”. Delays in printing the cards and sending them to local administrations for distribution created further problems and many did not receive their cards at all. However, this did not prove a barrier to accessing health-care as hospital computers were connected to the digital registration system and hospital clerks only needed to punch in the person’s name to find out if they were in the system. At health centers, people were already being treated for free. 

State registration projects, data mining and biometrics

In April 2019, on the heels of the UHC registration in the pilot counties, the national government launched its long-planned national biometric identification system, the National Integrated Identity Management System (NIIMS), which it termed Huduma Namba (“Service Number” in Kiswahili).[11] Huduma Namba is the Kenya government’s answer to the push towards biometric identification systems throughout the world (Breckenridge 2016).[12] Biometric identification is often presented by its advocates as the extension of more efficient forms of governance, enabling the state to better organize services. Proponents argue that, instead of having to register separately for a bank account, driving license, national identity card, and so on, a “single (biometric) source of truth” offers bureaucratic ease and efficiency (releasing citizens from the burden of carrying documents around and waiting in queues).

Critics point out that this is often a double-edged sword; evidence from India suggests that biometric technologies are not as proficient at inclusivity as they promise to be.[13] Furthermore, such systems, which are developed and managed by private companies contracted by the state (in Kenya’s case, initially the French company Idemia[14]), enable large-scale data extraction of individual citizens’ details in countries where data protection laws are absent.[15]

Such ambiguities surround Huduma Namba, and indeed court actions pursued by human rights groups delayed its launch. In early 2019, the Kenyan high court ruled that registration must be voluntary and citizens who are not registered cannot be denied access to services, nor can their biometric identities be shared by the state with third parties.[16] However, as the rollout in April 2019 received less-than-enthusiastic response from citizens, many of whom were also reluctant to queue for hours, the Communications Authority Director suggested that government would block all SIM cards of citizens who failed to register.[17]

In July 2019, a Member of Parliament proposed a bill to not only make registration compulsory but to also make access to vital social services (pensions, bank accounts, land registration, marriage registration, and registration for electricity connection, driving licenses, national health insurance and access to public health care) contingent on being registered for Huduma Namba.[18] As I write this piece, these arguments continue and the outcome is uncertain.[19] President Uhuru’s move, in November 2019, to sign a data protection bill into law has been widely welcomed, also by multinationals like Amazon, which are preparing to move into African markets.

Big brother and little brother

The registration for UHC, which proceeded in the four pilot counties, appears to be the little brother of the nation-wide mass registration for Huduma Namba. However, it brought forth similar concerns about the collection of data, personal identities and mobile telephone numbers. While many residents were optimistic about the promise of health care, the UHC agents I spoke to also encountered resistance to registration, an open disbelief in government promises (“there is no such thing as free health care”), a lack of trust, and questions from residents such as “what will the government do with my identity?”.

For users, the digital registration also proved confusing with messages arriving from both PharmAccess’s digital platform and from the National Hospital Insurance Fund, with which it had a contract. Received on mobile phones, these messages contained information about special offers or urged people to pay their monthly premiums. Since these messages were a result of registering for “free” health care, some wondered what their mobile numbers were being used for.

As registration for UHC proceeded, those involved in organizing and managing it, from county officials to PharmAccess staff, were cautiously optimistic. They hoped that the UHC pilot would be a success and that it would ensure, after years of struggling with a poorly resourced health system, more funding, more capacity, and better healthcare for all, supported by serious political will. At the same time, they were concerned that directives from central government were handed down without much information about purposes or consideration of their sustainability. All the energy seemed to go into “getting the numbers”, they said, as if the registration stood for the success of UHC itself. At the same time, the question of ownership of the data collected remains unclear.

By-and-large, the UHC registration drive was successful. A large proportion of the county’s population registered and, as health services were indeed made “free”, people flocked to hospitals and clinics for care amid an atmosphere of collective good will (even while many cautioned that it was not sustainable and could not continue). During the first months of the UHC pilot, promises indeed became reality: people got operations, medicines, and laboratory and radiology tests for free. By April, however, the health system was under immense strain. Problems emerged in the laboratory and medical supply systems, promised finances had not materialized or were caught up in political wrangling, and health workers, overwhelmed by patient numbers, went on strike. As hospital finances dwindled, services became increasingly triaged, with health workers instructed to tell people ‘We don’t take UHC now’ and patients reporting that they were told to either pay or use their NHIF card (which many do not have).

Without adequate resources and planning, the ‘free health care’ experiment has had mixed results. A UHC number and a UHC card, which so many queued up to register for and so many had invested hopes in, turned out to have little durability, even within the time-scale of the pilot. Then again, the UHC pilot was never presented as a lasting policy, but as a one-year experiment. What the experiment has done is to put the language of citizenship and its entitlements, rights to health care, and government responsibility firmly into circulation. It also intensified digital registration and the collection of data, with, as yet, no clear outcome in terms of improved access to healthcare for citizens, beyond the duration of the UHC pilot.

The experiment with UHC has proven to be as complicated as many policy makers, government officials, and citizens expected it to be. Clearly, there are multiple interests at stake, for the state, for the digital companies involved, as well as for the people it serves. Getting registration numbers has formed a major part of President Uhuru´s pilot programme. As the UHC pilot ends and the central government moves towards “scaling-up” UHC to the rest of the country, questions remain about the legacies and traces of these projects. Are these experiments with registration just experiments, to be discarded when better and more efficient systems are developed? Or will these forms of registration have other, more lasting effects? What will the government do with the numbers, and what will the other organizations involved do with them? Will data from the poverty mapping tool be used to formulate healthcare and welfare interventions, and by whom?  While citizens are wondering what to do with their UHC cards and whether they are now just pieces of plastic, the digital registration of identities and mobile phone numbers may prove to be of continuing value to the other parties involved.

In the recent UN Political Declaration on Universal Health Coverage, issued at the UN General Assembly meeting in September 2019, members states agreed that it is the responsibility of governments “to determine their own path towards achieving UHC” by the year 2030. In this light, Kenya’s pilot UHC was designed as an experiment and an incubator for ideas. As those involved often repeated, rolling out a “universal” policy in a local and national setting was meant to generate “lessons learned” for future implementation. Just as Kenya has looked to the experiences of Rwanda, Ethiopia and Thailand in developing a “roadmap for UHC”, so the Kenyan experiment may feed into policy-making elsewhere. The experiment is ongoing.[20] Meanwhile, Kenyan citizens are keenly scrutinizing whether these policy experiments will be sustained and whether they are being translated into better access to health care and social protection on the ground.

Notes

[1] The four counties are Kisumu, Nyeri, Machakos and Isiolo, chosen for their different epidemiological and population profiles. Okech, A. (2018). ‘Free Medical Pilot Scheme Gathers Steam in Four Counties.’ Daily Nation, 12^th November 2018, https://www.nation.co.ke/news/Drive-to-enrol-locals-in-free-medical-plan-starts-in-Machakos/1056-4847062-4rc06oz/index.html.

[2] https://www.healthpolicy-watch.org/kenyan-president-launches-benchmark-universal-health-coverage-pilot-to-become-nationwide-in-18-months.

[3] Kahongeh, J. (2018). ‘Uhuru’s Universal Health Coverage Explained.’ Daily Nation, 4^th December  2018. https://www.nation.co.ke/news/Universal-Health-Coverage-explained/1056-4895006-vclblfz/index.html.

[4] Merab, E. (2018). ‘Road to UHC: What It Will Take to Achieve Health for All.’ Daily Nation, 10^th July 2018. https://www.nation.co.ke/health/Road-to-UHC-what-it-will-take–to-achieve-health-for-all/3476990-4655230-jtp203z/index.html.

[5] McGoey, L. (2014). The philanthropic state: market–state hybrids in the philanthrocapitalist turn. Third World Quarterly 35(1):109-125.

[6] Living Goods “aims to save lives at scale by supporting digitally empowered community health workers”. See the Living Goods website, https://livinggoods.org/who-we-are/.

[7] See https://www.pharmaccess.org/update/global-fund-partners-with-pharmaccess-to-accelerate-universal-health-coverage-in-africa/, accessed November 1^st, 2019.

[8] https://www.pharmaccess.org/update/11312/.

[9] Pharmaccess´s role in the UHC registration drive should be seen within this larger context, where digital technology companies and NGOs enter into partnerships and position themselves in a bid to get government contracts and funding from global health and finance institutions like the Gates Foundation and the World Bank.

[10] Uber has recently been banned again in London due to the existence of fake profiles. This suggests that digital platforms face similar problems across the world. (I am grateful to Thomas Neumark for making this point).

[11] Dzuya, W. (2019). ‘Court Allows Huduma Namba Registration, Bars DNA Collection’. Citizen TV news, 1^st April 2019, https://citizentv.co.ke/news/high-court-allows-govt-to-begin-huduma-namba-registration-bars-dna-collection-238695/.

[12] Breckenridge, K. (2016). Biometric State. The global politics of identification and surveillance in South Africa, 1850 to the present. Cambridge: Cambridge University Press. See also Breckenridge, K. (2019). The failure of the ‘single source of truth about Kenyans’: The NDRS, collateral mysteries and the Safaricom monopoly. African Studies, 78:1, 91-111.

[13] Ratcliffe, R. (2019). ‘How a glitch in India’s biometric registration can be lethal’. The Guardian, 16^th October 2019, https://www.theguardian.com/technology/2019/oct/16/glitch-india-biometric-welfare-system-starvation. Rao, U. & V. Nair. (2019). Aadhaar: Governing with Biometrics. South Asia: Journal of South Asian Studies 42(3): 469-481. See also Dahir, A.L. (2020). ‘Kenya’s New Digital IDs May Exclude Millions of Minorities’. The New York Times, 28^th January 2020, https://www.nytimes.com/2020/01/28/world/africa/kenya-biometric-id.html.

[14] See https://www.biometricupdate.com/201905/idemia-ban-by-kenyan-national-assembly-appealed-as-biometric-national-id-drive-passes-15m.

[15] Nyabola, N. (2019). ‘If you are a Kenyan citizen, your private data is not safe’, Aljazeera, 24^th February 2019, https://www.aljazeera.com/indepth/opinion/kenyan-citizen-private-data-safe-190221150702238.html.

[16] Nyamori, M. (2019). ‘No healthcare, voting without Huduma Namba, Bill proposes’. The Standard, 18th July 2019, https://www.standardmedia.co.ke/article/2001334286/state-harsh-plan-for-those-without-huduma-namba

[17] Otieno, K. (2019) ‘Government to block sim cards whose owners fail to make Huduma Namba deadline’, Standard Digital, 18^th April 2019, https://www.standardmedia.co.ke/business/article/2001321603/huduma-namba-government-to-block-sim-cards;  see also Muriuki, B. (2019). ‘State House, Ministry disown sim card threat’, Citizen Digital, 18^th April 2019, https://citizentv.co.ke/news/egg-on-the-face-for-wangusi-as-state-house-ministry-disown-sim-card-switch-off-threat-241525/.

[18] Mungai, C. (2019). ‘Kenya’s Huduma: Data commodification and government tyranny’, Aljazeera online, 6^th August 2019, https://www.aljazeera.com/indepth/opinion/kenya-huduma-data-commodification-government-tyranny-190806134307370.html.

[19] Kakah, M. (2020). ‘Court: Huduma Namba Registration Can Go On’. Daily Nation, 30^th January 2020. https://www.nation.co.ke/news/Court-allows-Huduma-Namba-process-to-go-on/1056-5438464-7xoy4f/index.html.

[20] Okech, A. (2019). ‘New Health Scheme Is Not Free, Says CS’. Daily Nation, 25^th October 2019. https://www.nation.co.ke/news/Sicily-Kariuki-says-new-health-scheme-not-free-/1056-5323966-i4pfbxz/index.html.

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Ruth Prince is associate professor in medical anthropology at the University of Oslo, where she holds a European Research Council Starting Grant for “Universal Health Coverage and the Public Good in Africa”. Her current research focuses on health systems, chronic disease, universal health coverage, and new forms of social protection and welfare in East Africa.