Universal health coverage: What Kenya can learn from other countries

As Kenya launched its ambitious Social Health Insurance Fund (SHIF) to replace the defunct National Health Insurance Fund (NHIF), a critical question arose: Can the country achieve universal health coverage (UHC) where many others have struggled?

The success of SHIF will depend not only on domestic reforms, but also on learning from countries - both within and outside Africa - that have successfully navigated this path. Models from Rwanda, Ghana, Germany, Japan, Singapore, Thailand and Costa Rica offer valuable lessons for Kenya as it shapes its health financing future.

Rwanda: The power of community and performance 

Rwanda's Mutuelles de Santé cover more than 90 per cent of the population, making it one of the most successful universal health coverage (UHC) models in Africa. Citizens enroll through local administrative units, with premiums adjusted according to income. The poorest are fully subsidised by the government. Community Health Workers (CHWs) play a crucial role in both enrolment and health education.

Funding is pooled at the district level and supported by the government and donor agencies. Providers are reimbursed through payment-by-results and fee-for-service models, with CHWs receiving incentives based on their outreach success.

Ghana: Ghana's National Health Insurance Scheme (NHIS) covers about 54 per cent of the population. Citizens register at district NHIS offices, and vulnerable groups such as the poor, children, the elderly and pregnant women are exempted from paying premiums. Funding comes mainly from a 2.5 per cent value-added tax (VAT) levy, payroll deductions from formal sector workers, and government grants. Providers are paid mainly on a fee-for-service basis, with some use of Diagnosis Related Groups. The system is overseen by the National Health Insurance Authority (NHIA). Solidarity funding is the backbone of Ghana's NHIS, but without transparency and enforcement, the system is at risk of leakage.

Germany: A dual system with compulsory coverage 

Germany has one of the most successful health insurance systems in the world known as the Social Health Insurance (SHI) model. This system is compulsory, meaning that everyone must have health insurance, either through a statutory scheme for employees or private health insurance for higher earners and the self-employed.

Funding comes from payroll taxes, with contributions shared between employers and employees. Premiums are based on income, so wealthier individuals contribute more. There are several non-profit public insurance funds responsible for providing coverage to the insured population. Private insurance is available for higher earners and those who choose to opt out of the public system, but it is highly regulated.

The German model emphasises primary care, with general practitioners acting as gatekeepers to more specialised services. The government also negotiates costs with providers, which helps to control spending and ensure the financial sustainability of the system. 

Key lessons for Kenya include the importance of mandatory coverage, income-based premiums and the role of primary care in controlling costs and ensuring access to essential services. Although Kenya's informal sector poses a challenge to mandatory enrolment, a unified identification system could help address this issue.

Japan: Efficient universal coverage 

Japan has one of the most efficient healthcare systems in the world, providing near-universal coverage. The Japanese system consists of two main schemes: the Employee Health Insurance system (for those employed in the formal sector) and the National Health Insurance (NHI) system (for the self-employed, pensioners and others outside the formal sector).

Both systems are tightly regulated by the government, which controls pricing, reimbursement rates and payments to providers. The system is mainly funded by payroll contributions from both employees and employers. The government ensures that everyone has access to care, regardless of income or employment status.

One of Japan's most remarkable features is its ability to keep healthcare costs low while maintaining high standards of care. This is achieved through strict control of hospital fees, efficiency in service delivery and a focus on preventive care. In addition, Japan's healthcare system uses a universal health card, which streamlines healthcare delivery and ensures efficient data management. 

Japan has also invested heavily in community health services and care for the elderly, which is crucial given that it has one of the world's oldest populations. For Kenya, Japan's model underscores the importance of universal coverage, preventive care and strong government oversight to keep costs manageable. The challenge for Kenya will be to adapt the Japanese model to its unique context, in particular by ensuring that those in the informal sector are included in the coverage scheme.

Singapore: The efficiency of savings and co-payments

Singapore's healthcare system is widely regarded as one of the most efficient and sustainable in the world, largely due to its innovative approach to healthcare financing. The system is based on a concept called Medisave, a mandatory savings scheme in which citizens and permanent residents contribute a portion of their income to an individual savings account earmarked for healthcare expenses.

In addition, Singapore uses Medishield Life, a catastrophic insurance scheme that covers significant medical expenses, and Medifund, a government fund that assists those who cannot afford medical services. The system places a strong emphasis on co-payments, which encourage individuals to take responsibility for their health and minimise unnecessary spending. It relies heavily on government management of both savings accounts and insurance schemes to ensure equity and access for all.

Key lessons from Singapore include the importance of personal responsibility for healthcare costs, a savings-based approach and robust government regulation to maintain a fair and accessible system. While Kenya's economic structure may pose challenges in implementing such a model, particularly in terms of individual savings levels, there are still valuable lessons to be learned from Singapore's focus on financial sustainability and prevention.

Thailand: Thailand's Universal Coverage Scheme (UCS) covers over 99 per cent of the population. All uninsured Thais are automatically enrolled and assigned to a local primary care facility. The system is fully tax-funded, with an annual per capita allocation of approximately $90. Outpatient services are reimbursed through capitation, while inpatient services are reimbursed through global budgets and DRGs- Diagnosis-Related Groups, a system for classifying hospital cases into groups based on similar diagnoses and treatment patterns, primarily used for billing and reimbursement purposes. The National Health Security Office manages the system, with public participation in budget planning.

Costa Rica: Costa Rica's health system covers over 95 per cent of the population through the Caja Costarricense de Seguro Social, which acts as both insurer and provider. All residents contribute through payroll taxes. Funding comes from employer contributions (9.25 per cent), employee contributions (5.5 per cent) and a government share (0.25 per cent). Provider services are funded through budget-based allocations, with a strong emphasis on preventive care delivered by local teams known as EBAIS.

Kenya can learn valuable lessons from the experiences of Germany, Japan, Singapore, Rwanda, Ghana, Thailand and Costa Rica in developing its SHIF. 

Universal coverage: Germany and Japan demonstrate that mandatory income-based health insurance schemes can be effective, particularly when supported by strong regulatory oversight and integration with social protection systems. Given Kenya's significant informal sector, models such as Germany's Social Health Insurance could serve as a framework for reaching these groups through identification systems and voluntary contributions.

Financial sustainability: Singapore's savings model and Germany's solidarity financing illustrate how a combination of taxation, savings and contributions from different sectors can ensure long-term financial sustainability. Kenya's SHIF could benefit from integrating payroll contributions, government funding and individual health savings accounts.

Focus on primary and preventive care: Kenya's focus on primary and preventive care is critical to controlling health care costs and improving health outcomes. Kenya should prioritise the development of primary health care infrastructure, particularly in rural and underserved urban areas, to ensure equitable access to care.

Government control and regulation: The experiences of Germany, Japan and Singapore highlight the importance of government control over pricing and regulation to maintain cost-effectiveness. For the SHIF to be successful, it is essential that the Kenyan government plays a strong role in managing the system and negotiating prices to avoid unnecessary costs.

Community involvement and solidarity: The examples of Rwanda and Ghana show that community involvement and solidarity financing are essential to build trust and encourage widespread participation. Kenya's SHIF should involve local communities in the enrolment process and provide appropriate incentives for participation, especially for the most vulnerable.

lowoko@ke.nationmedia.com