The constitution and subsequent legislation, including the Health Act of 2017, clearly delineate responsibilities between the national and county governments.
The national government is entrusted with policy formulation, standard setting, and regulation, while counties bear the constitutional and legal mandate to deliver healthcare services.
Counties are the custodians of primary and community health services, responsible for preventive and promotive care, and for ensuring access to affordable services to the last citizen in the most remote village. It is within this framework that the Social Health Insurance Act must now be put into operation.
And herein lies the stark reality: despite having the tools and legislative clarity, many counties are failing to match commitment with execution.
Recent data on SHA registration reveals wide disparities that can no longer be excused by differences in resources or geography. Mombasa has led with a registration rate of 57.96 per cent.
Bomet has followed closely with more than 50 per cent. These numbers are not accidental. They are the product of political resolve, effective mobilisation and an active engagement with the citizenry.
These counties have demonstrated that strategic leadership at the local level can turn national policy into lived experience.
Even more impressive is Bomet’s example. Often perceived as disadvantaged due to its rural setting, the town has defied expectations and shown that challenges of infrastructure can be overcome with proper coordination and focus.
Nyeri and Elgeyo Marakwet have likewise proven that where governors and health executives are aligned in their purpose, progress becomes inevitable.
Contrast this with Nairobi, the capital and most endowed county, which has registered only 29.32 per cent of its residents under SHA.
Despite boasting advanced infrastructure, access to the seat of national power, and a dense concentration of health facilities and personnel, Nairobi remains far behind in execution.
That more than 3.9 million Nairobians remain unregistered is an indictment of leadership inertia and systemic disorganisation.
Other urban counties—Nakuru, Kiambu and Machakos—are not faring much better. Their registration rates, all below 36 per cent, expose a troubling gap between potential and performance.
These counties, better resourced and more connected to national institutions ought to have been frontrunners in driving this reform. Instead, they appear distracted, mired in political infighting and inattentive to the health rights of their constituents.
Even more alarming are the figures emerging from arid and semi-arid lands. Samburu, Marsabit, West Pokot and Garissa have some of the lowest registration rates, hovering around 11 to 14 per cent.
These are precisely the regions where government-subsidised health coverage is most critical, where distances to health facilities are vast and out-of-pocket health spending is often catastrophic.
That these areas continue to be left behind not only betrays the constitutional principle of equity but also signals a deep failure in political will at the local level.
The law obliges counties to identify and register their indigent populations. This is not a discretionary act but a statutory requirement.
Counties are supposed to establish SHA registration desks, sensitise the public and coordinate with local administrators to ensure that no one is left behind. Many have not. This dereliction of duty is not just administrative – it is a profound moral failure.
Counties such as Kisumu, Embu and Tharaka Nithi offer a glimmer of hope. With registration rates above 40 per cent, they have embraced their mandate with seriousness.
They have conducted outreach, coordinated with community leaders and aligned local budget priorities with health outcomes. Their example shows that success is less about financial might and more about intentional governance.
Yet the silence from many county executive committee members for Health is deafening. There has been little visible effort to inform, educate or rally communities.
Few counties have dedicated funds or infrastructure to support SHA rollout. County assemblies, which are supposed to exercise oversight and ensure that county governments meet their obligations, appear equally muted.
What is at stake is far greater than the mechanics of policy implementation, it is the very credibility of Kenya’s devolved system of governance.
Devolution was envisioned as a transformative framework to bring services closer to the people, with healthcare as one of its most critical mandates.
If county governments are unable to lead in delivering and coordinating such an essential and constitutionally assigned function, then the foundational rationale for devolution comes into question.
If they cannot effectively mobilise their populations around the fundamental imperative of health coverage—arguably the most immediate and life- defining of public goods—how can they be trusted to manage more complex responsibilities that demand foresight, coordination and accountability?
The Social Health Insurance Act is a national aspiration. But its success hinges entirely on whether counties can deliver at the grassroots. This is where promises must be translated into access, where paper legislation must become tangible protection for the elderly, the poor, the disabled and the forgotten.
The opportunity for redemption remains. The months ahead offer a critical window to intensify registration, prioritise public health in county budgets and train and deploy community health promoters.
The national government must support this process but cannot implement it alone. This is a moment of reckoning. Counties must decide whether they are administrators of inertia or agents of transformation. The success of SHA will be the measure.
SHA registration exercise ongoing in Tana River county on November 30 last year /FILE
