MWAMISI: Counties must step up to SHA or universal health will falter

Kenya’s transition to the Social Health Authority is the most consequential health reform in a generation, promising predictable health financing, a functioning referral pathway and protection from catastrophic expenditure. But its success will be decided not in Nairobi, but in the 47 county health systems where citizens actually seek care.

The Social Health Authority operates within a comprehensive framework of health sector reforms that include the Primary Health Care Act and the Facilities Improvement Financing Act. These pieces of legislation are not stand-alone measures; rather, they form a coordinated package designed to empower counties with both the mandate and the practical tools necessary to deliver universal health coverage to every Kenyan. The Primary Health Care Act focuses on strengthening community-level services, ensuring that preventive and basic curative care reach even the most remote populations.

Meanwhile, the Facilities Improvement Financing Act provides counties with mechanisms to mobilise and utilise resources for upgrading health infrastructure, improving service quality and enhancing patient outcomes. Within this integrated system, SHA is expected to coordinate insurance and payment mechanisms, regulate service delivery and ensure financial risk protection for the population.

Success, therefore, hinges squarely on counties fulfilling their responsibilities. Any drift, neglect, or mismanagement at the county level will not merely impede service delivery but risk undermining the effectiveness of the entire reform agenda. The stakes are high, and the performance of county governments is the decisive factor in turning the promise of universal health coverage into a tangible reality for all Kenyans.

National reporting shows that while overall enrolment has grown, progress is uneven and some counties lag significantly. Recent data revealed stark disparities. Garissa has registered only 2.3 per cent of its population, Turkana just 3 per cent, Mandera 3.4 per cent, Wajir 4.1 per cent and West Pokot 4.3 per cent. These figures are far counties below national standards, particularly in arid and semi-arid lands where service is most needed. By contrast, counties in central Kenya and urban areas have recorded 18 to 20 per cent enrolment.

The Health Cabinet Secretary has acknowledged the registration gaps, citing poor connectivity, system glitches and weak infrastructure as barriers to uptake in remote areas. The Council of Governors has already signed an Intergovernmental Participatory Agreement with the Ministry of Health, providing the legal framework for counties to deliver SHA at the grassroots. Yet in many areas this has not been translated into practice, and citizens continue to leave facilities unregistered.

Some counties are showing what is possible. Turkana launched a rapid results initiative that registered almost 100,000 residents in a week, offering temporary waivers on contributions and improving its referral system. Uasin Gishu has also intensified outreach to expand coverage.

These examples prove that where there is political will and targeted mobilisation, registration numbers can rise quickly.

Every delay has consequences. A citizen turned away unregistered is not simply a number missing in the system. It is a patient denied treatment, a family pushed into debt, or a child going without medicine. Beyond citizens, health workers are feeling the strain. Doctors, nurses and clinical officers report growing frustration at being unable to assist patients when services are interrupted by registration failures or lack of cover. Staff are sometimes forced to improvise or turn people away, eroding trust, lowering morale and leading to overcrowding, burnout and a decline in service quality.

The Social Health Insurance Act requires universal registration, the Primary Health Care Act makes community health promoters the entry point to the system, and the Facilities Improvement Financing Act allows facilities to retain revenue to stabilise basic services. Counties should already be aligning their budgets and performance plans to these statutes. They should empower community health promoters to register households at scale, ensure every facility is contracted and claims-ready, and use facility revenues to maintain operations.

The Intergovernmental Participatory Agreement signed by governors and the Ministry of Health was meant to codify how national and county actors share roles, data and accountability. But signing was only a first step. Implementation through joint work plans, measurable targets and dashboards is now required.

Counties must also address operational bottlenecks that citizens feel most sharply. They need to expand household registration using mobile units, ward-level campaigns and market-day drives.

They must ensure facilities are able to submit clean claims promptly, with staff trained to use the SHA portal and equipped with proper ICT tools. Technical bottlenecks must be resolved quickly because a patient who queues all day only to be turned away may never return.

The Facilities Improvement Financing Act was created to keep facilities solvent for basics such as utilities, repairs and buffer stocks. Counties should enact regulations where pending, enforce financial autonomy for facilities within the law and ensure revenues are spent on visible service improvements. This will help keep clinics open and reliable even as reimbursements normalise.

Industrial action by doctors and clinical officers over the past two years has already disrupted services and exposed gaps in human resource management. SHA cannot thrive if clinics are periodically closed, if staff are casualised or if morale is brittle. Counties must resolve outstanding labour issues, pay salaries on time and integrate SHA performance metrics such as claims quality and service continuity into supervisory routines. The link between health worker conditions and patient experience is direct: when reimbursements are late, facilities ration services and staff are stretched; when staffing is unstable, waiting times grow and referrals breakdown.

Citizens will judge reform not by legal frameworks or agreements but by what happens at the dispensary, the health centre and the county referral hospital. They will judge it by whether registration tables work, medicines are available, staff are present and claims are paid without delay. National policy cannot rescue inertia at county level. Governors, county executives and chief officers must turn statutes and agreements into performance. They must enrol their people, contract their facilities, pay attention to data, protect their workforce and keep cash flowing to the frontline.

If counties rise to this challenge, SHA will take root. If they do not, it will falter, and the most vulnerable will pay the price.