“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.
Early this year, before the arrival of COVID-19, Kenya’s national health insurance (National Hospital Insurance Fund, NHIF) introduced a nation-wide re-registration exercise for members, involving updating outpatient health facilities for members in order to continue accessing healthcare services through NHIF with convenience and efficiency. Since the first COVID-19 case was announced on 13 March, the government has announced various safety measures including social distancing, curfews, lockdowns, and directed workers in both public and private sectors to work from home – only what was considered critical work was to be done physically from the offices whilst adhering to strict Ministry of Health guidelines. This has meant closure of public institutions including NHIF offices. Many of the poor beneficiaries of the health insurance fund, in both rural and urban areas, had not completed the NHIF ‘updating’ exercise – possibly because they had not received the information on their mobile phones, or were unable to use the NHIF website and mobile applications, which required use of smartphones and access to the internet. Consequently, a lot of confusion and frustrations have been experienced. Social media posts show that many people have been unable to access healthcare or forced to pay out-of-pocket for healthcare services (see for example, tweet excerpt below). Even with NHIF providing an extension to the ‘updating’ exercise to the end of April 2020, and a further extension to mid-May 2020 as a tweet by NHIF announces, many people continue to complain of the failure of NHIF registration platforms such as the NHIF website, mobile applications and USSD codes, and that the health insurance institutions’ customers care telephone numbers, emails and visits to the NHIF offices have not yielded positive results either. At the time of writing, a twitter thread by Kenyans reacting to NHIF post on social media illustrates that, also for middle-class Kenyans, access to healthcare through NHIF has been severely interrupted as COVID-19 safety measures remain in the country.
The UHC Promise
I wrote this piece before the pandemic as a reflection on social protection and access to healthcare, drawing on my ethnographic research on the Kenya’s national health insurance fund, the NHIF, and cash transfers for the poor populations. Since 2004, NHIF has been central to the Kenya government’s aspirations for Universal Health Coverage (UHC), informed by a concern for financial protection and inclusion, especially for the country’s poor population (Abuya et al. 2015). Over a decade later, the Kenya government rolled out its pilot scheme for Universal Health Coverage (Afya care), across 4 of the country’s 47 counties. During the launch, held in Kisumu in December 2018, the president emphasized UHC as “shared prosperity”, stating that UHC will address healthcare disparities and inequalities.
UHC formed one of the key pillars of the current government’s election campaign during the 2017 elections and since getting in to power, the government has persistently advocated for UHC across the country. It has presented UHC as “free” healthcare services, generating an atmosphere of hope among citizens. In 2018, the World Health Organization (WHO) referred to Kenya as a “trailblaizer in Africa,” while the UN Kenya Resident Coordinator described Kenya’s UHC as a “blueprint” for achieving UHC in Africa. This further amplified the language of optimism for improved and inclusive healthcare among citizens across the country.
UHC resonates with other social protection projects such as cash transfer schemes – the Kenya government’s social assistance programme, inua jamii (‘uplift the family/community’) – introduced by the government over the last decade and financially supported by the World Bank among other donors. These schemes target vulnerable populations: orphans and vulnerable children, the elderly persons, people with disabilities, and those living in hunger stricken areas. Since 2013, the government committed to provide health insurance subsidies (through the NHIF) for women and children through the free maternal healthcare scheme (Linda Mama (‘protect the mother’), the students’ healthcare scheme (‘eduAfya’) and the Health Insurance Subsidy Scheme for cash transfer beneficiaries. Over 200,000 households benefited from cash transfers and over 2 million women benefited from the Linda Mama scheme between 2013 and 2017.
Yet in 2019, the number of cash transfer beneficiaries of the health subsidy was substantially reduced to ca. 80,000 households, with no clear explanations by the government. Even those who remain beneficiaries of the health subsidy programme are finding that they have no insurance cover. For instance, my informants – recipients of cash transfer schemes in Kwale county, on the Kenyan coast – have often been unable to receive certain medical services or medicines, and sometimes are forced to pay for these services directly. Government and development experts have touted the cash transfer initiative as a success, but beneficiaries find it is an unreliable source of support (Ikiara 2009; Muinde 2018; Onyango-Ouma and Samuels 2012; Ward et al. 2010). Such complexities have also been reported in the other government health programmes such as the free maternal healthcare scheme (see for example Lusambili et al. 2020).
The move towards UHC alongside the continued promotion of social protection policies by the Kenya government and its partners invites citizens to feel a sense of entitlement to healthcare and welfare, reinforcing the state’s responsibility to care and addressing healthcare inequalities. Yet, in addition to the complexities highlighted above, this is happening in a country where the cost of living is rising at an alarming rate, with deepening poverty and socioeconomic inequalities, widespread unemployment and corruption crises, and diseases such as cancer and diabetes are on the increase. Questions therefore arise as to how – and whether – these projects to increase access to healthcare and widen social protection speak to citizens’ everyday lives?
In Kwale county, where I conducted fieldwork on social protection and access to health care, the households I studied, many of them headed by women, receive cash transfers (of approximately 20 USD per month) from the government’s social assistance programme (inua jamii). They became beneficiaries of the health insurance subsidies offered through NHIF in 2014. While Kwale is not one of the counties piloting the UHC scheme, the Kwale county government has been discussing introducing its own model of UHC (which in part includes health insurance subsidy program for vulnerable households to be rolled out through NHIF) to make health care more accessible to its poor citizens.
Hopes, frustrations, and disappointments in accessing health care
Mwalima, a household-head in her mid-forties and a mother of four children, is a beneficiary of both the cash transfer scheme for orphans and vulnerable children (Kiswahili, mradi wa mayatima) and the NHIF health subsidy scheme, which gives her free access to a defined set of healthcare services in government hospitals.
One afternoon I visited Mwalima in her house, but she was not in. Her neighbour explained that she had gone to see her ailing father. Her father lived close nearby. His home is known to me, so I went there. She sat with her mother and brother in what looked like a cooking place. We exchanged greetings. Mwalima told me she had come to see her father, who had been growing weaker for nearly a year. She explained how it had been expensive to treat her father because the treatment in the public hospital had become unreliable.
“It is cheap there and you want the treatment, but they keep on telling you the doctor is not there, and my father is in a lot of pain. Sometimes we cannot sleep. That’s why we go to the private [clinic]. We have sold nearly everything [referring to land].”
I intervened: “But you can use NHIF [the national health insurance card] in the public hospital.”
Mwalima continued: “Sometimes NHIF helps. Some other times when you really need help, you leave here you go to the hospital with the hope you will receive the treatment, and it does not work.”
She recalled frustrating experiences with the health insurance, NHIF. One day when she was expectant with her last child, she had some pains and she went to one of the referral hospitals in Kwale, about three kilometres from her house. The doctor said she needed a CT scan. When she went to the NHIF desk in the hospital to get approval for the service, she was asked to pay cash.
She explained to the officer: “I am in ‘mradi’ (the cash transfer scheme) and we were told we will be receiving treatment with the NHIF card for free.” But the officer still insisted that she needed to pay KShs. 1000 (USD 10) in cash. Mwalima had just received her ‘mradi’ money, so this time she was able to make the payment. She told me of a similar situation when she took her son to the same hospital:
“He had fever and was collapsing. His eyes started turning and it was late in the afternoon. I took a motorbike and rushed him to the hospital.”
There a doctor prescribed some medicines, to be given immediately. When she went to the pharmacy, the pharmacist looked at the doctor’s prescription and her NHIF card. Then he looked at the shelves and told her the medicine was not there. With disappointment all over her face, Mwalima told me:
“I could not believe it. I did not have money left after paying for the motorbike. I felt rejected. I called my mother’s sister and we met at another chemist in the market. She bought one dose, we gave him. The following morning, I woke up early in the morning. My son was still very unwell. My mother’s sister had given me Kshs 150 (USD 1.5). I took a motorbike again and went to the hospital to try my luck. This time I had hope. I gave the person at the chemist the doctor’s paper and the NHIF card, and you know what, I was given the medicine.”
Cases like Mwalima’s are common. Many cash transfer scheme beneficiaries who no longer benefited from the health insurance subsidy programme held mixed feelings about the NHIF. I asked members of a neighbouring household (which was not a beneficiary of the scheme) if they would make payment to the health insurance packages offered by NHIF under the informal sector. One of my informants there, a woman in her late thirties, said: “The NHIF card they gave us never worked. They removed me from ‘mradi’(the cash transfer scheme). You see the situation here (in the homestead). Children have been sent home for school fees. They don’t have food. The little money you have, you will choose: pay school fees and buy food or make that NHIF payment? You can’t do that.”
Waiting and failing: Navigating Linda Mama (The Free Maternal healthcare scheme)
It was not only patients who expressed frustrations. During a conversation with a hospital worker who dealt with NHIF claims, he opened the computer on his desk and showed me a list. Several of the claims the hospital had submitted to NHIF had been rejected on various grounds – for example, that treatment should be done by a specialist, or a certain test was not medically justified, or a patient needed to make some payment contribution.
While he acknowledged that he understood some of these rejections, he held that it was not clear why many of the claims were declined and why NHIF took such a long time to get back to the hospital (mostly between three and six months). He sympathised with the patients because they did not understand fully how NHIF worked. Many patients felt frustrated and blamed the hospital for failures by NHIF. According to the hospital worker, it was crucial that the hospital allow poor people to receive the treatment they needed, but then further challenges would arise when NHIF delayed payments to the hospital and/or rejected the claims. He cited lack of medicines and other healthcare supplies in the hospital as a result of failures by NHIF. A health worker supported the concerns raised by his colleague: “After three months, … claims are rejected. Then people keep wondering why there are no medicines in public hospitals.”
Experiences of endless waiting and disappointment also coloured people´s experiences of the free maternal healthcare scheme. Linda Mama allows mothers and expectant women to receive free healthcare in public hospitals as well as clinics. This does not always work smoothly. There are instances when women have been asked to pay for healthcare services, such as the case of Mwalima above, and on other occasions services were unavailable or not received at all. I observed expectant women being sent to private laboratories because the public hospital laboratory did not have the required reagents. While some could pay for tests in the private laboratories, others could not afford to do so.
One afternoon, I sat with a nurse at the registration/enquiries desk in the maternity ward. As we spoke, Hekima, a woman in her mid-thirties, arrived at the maternity ward. She was expectant and seemed to be in pain. I pulled a chair out for her. Hekima explained to the nurse that she had seen a doctor who sent her for a urine test. However, she was unable to have the test because the laboratory was not working at the time. So she decided to come to the maternity section because she experienced a lot of pain. The nurse took the hospital papers and the Linda Mama booklet that Hekima held on her hands. After a quick look at the documents, she turned to her and asked: “Are you alone?” Hekima nodded. The nurse sympathised with her: “Now how do I help you? Sometimes the laboratory does not work, they keep having problems there. I don’t know what we can do. You will have to go to the one [laboratory] outside the hospital gate. It is private and you will have to pay.”
Hekima looked at us in great distress and disappointment. She said she had been waiting in the queue for long to see the doctor and lamented that she was now unable to have the test done. I turned to the nurse and asked whether there was anything she could do. Then she asked Hekima: “Do you have some money with you to pay there?” Hekima replied: “I don’t have money mwenzangu (lit. my friend). I am in mradi wa mayatima (the cash transfer for orphans and vulnerable children) and the money has not come yet.” The nurse turned her face to me but before she could say anything, Hekima’s phone rang. She reached her hand bag and took her phone, painfully stood up, and slowly walked away as she talked on the phone. The nurse said, “You see, these are the things we go through here every day. You have been seeing them yourself. It breaks the heart to see poor people suffer this much.”
After some minutes, two nurses joined us at the desk. Another woman approached, carrying a well-wrapped baby in her hands. Unlike Hekima, her face was full of smiles. She politely greeted us and said how grateful she was for the care she had received from the nurses during the three days she was in the maternity ward. Suddenly, tears flooded her eyes and spilled down her cheeks. Then she said: “Thank you very much for the basin and those other things you gave me. May Almighty God bless you.” When the woman left, I told the nurses how I was struck by the woman’s gesture. The nurses smiled and one of them said to me:
“We just give our hearts to these women. They come here and you know here we use ‘Linda Mama’. Some of them have nothing and ‘Linda Mama’ does not cater for things like basins. They need tissue paper and bathing soap. This woman came here with nothing and we helped her.”
Showing me some worn-out files for the patients, another nurse added that they did not only purchase personal items for the women. The nurses improvised other items for use in the hospital: “As we speak now, we gave some orders for files, we have waited and waited. Look at these, we just decided to improvise new files by ourselves. For how long do we keep waiting, we don’t know. Even those sanitary buckets you see there, we told you we had to buy some of them by ourselves with our [personal] money.”
According to the nurses, out-of-pocket payments made access to maternity services a challenge for many women. Even so, they opined that things were much better when patients paid hospital fees directly to the hospitals. During that time, they remembered, the hospital management could use these funds to purchase some of the items needed in the maternity ward without having to wait for prolonged periods of time. With the introduction of a centralized county revenue kit, all funds, including those for the ‘Linda Mama’ are managed from the County´s Treasury. Often, these funds took months to arrive, leaving hospitals and clinics with no revenue to respond to emergencies or stock-outs.
Hope against uncertainties?
I have described how patients and health workers in Kwale navigate both mundane and persistent health care complexities, disappointments, frustrations and failure. While the promises surrounding UHC offer citizens a “way of maintaining ‘the principle of hope’ against a growing darkness and uncertainty” (Thompson 2013:2), their everyday experience of access to healthcare is more often coloured by disappointments, frustrations and failure. Citizens struggle with the day-to-day challenge of a reasonable standard health care access and provision. Public health facilities remain badly under-resourced and the national health insurance card does not offer reliable access to healthcare. Indeed, studies have shown that “creating an entitlement to service benefits…does not guarantee access to these services” (Barasa et al. 2018:354, see also Prince 2017). The spread of COVID-19 in Kenya, and the government’s safety measures to the pandemic, are exposing the complexities and uncertainties of accessing healthcare through the NHIF. This may have a more profound effect on the poor and their access to healthcare, even beyond COVID-19.
Jacinta Victoria Muinde completed her PhD in Social Anthropology in 2018 at the University of Cambridge. She is currently a Postdoctoral Research Fellow within the European Research Council-funded project ‘Universal Health Coverage and the public good in Africa’, led by Ruth Prince at the University of Oslo. Her PhD was on cash transfer schemes in a matrilineal context in rural Kenya. Current research explores how recently-introduced social protection and “universal” healthcare schemes, which propose an expansion of welfare and enactment of rights, are (re)shaping understandings of the state and citizenship, imaginations and negotiations of obligations, forms of solidarity, and networks of care.
 All names of individuals are pseudonyms
 ‘Mwenzangu’is Kiswahili term used in this community to refer to different relationships, for example, referring to a colleague, a relative, a friend, a neighbour or even strangers. Its usage in this conversation is imbued with a sense of care, respect and honour.
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Ikiara, G.K., 2009. Political economy of cash transfers in Kenya. Overseas Development Institute.
Lusambili, A.M., Naanyu, V., Wade, T.J., Mossman, L., Mantel, M., Pell, R., Ngetich, A., Mulama, K., Nyaga, L., Obure, J. and Temmerman, M., 2020. Deliver on Your Own: Disrespectful Maternity Care in rural Kenya. PloS one, 15(1), p.e0214836.
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