By Rozzette Makundi
For many Kenyans, access to quality healthcare is no longer a matter of choice but of survival. Yet, there is a growing problem in our healthcare system that remains hidden in plain sight; the out-of-pocket payments.
While they might seem like just another household expense, these payments are wreaking havoc on the integrity of our health sector, increasing corruption and exacerbating the inequality of access to healthcare services.
In 2007, 2.5 million people were pushed below the national poverty threshold as a result of paying for healthcare services, according to a 2015 report on health policy projects. The impact has been even more severe in recent years, with estimates suggesting that between 1 and 1.1 million individuals are pushed into poverty due to out-of-pocket payments. This increased the percentage of poor people in Kenya by 2.2%, where the poorest households spend an average of 10% and 15% of their budget on healthcare. The figures are a clear indication that, for many, affordable healthcare remains a pipe dream.
The law is clear on healthcare
When Kenya transitioned to a devolved government structure in 2013, the aim was clear: bring healthcare closer to the people. County governments were given the responsibility to manage healthcare delivery, while the national government retained regulatory and policy-making powers. The primary healthcare legislative frame was reinforced.
The Kenya Health Policy, 2014-2030 is an important national health policy to achieve the highest standard of health responsively. Sessional Paper number 2 of 2017 gave direction towards implementing the health policy, and established principles to guide the investments, interpretation of targets, and performance of the health sector. Some of the principles include a people-centered approach to health and health sector interventions, a participatory approach to the delivery of interventions, and efficiency in the application of health technologies.
Notably, in October 2023, four new health Laws were assented to; The Primary Health Act, 2023, The Digital Health Act 2023, The Social Health Insurance Act 2023, and the Facility Improvement Financing Act, 2023. Arguably, therefore, Kenya has adopted a primary healthcare approach, which is believed to be an efficient and cost-effective way to organize our health system. This is further buttressed by the transition from the National Health Insurance Fund (NHIF) to the Social Health Insurance Fund (SHIF), which promises equity and greater access have been overshadowed by systemic failures. Out-of-pocket expenses, which often include informal bribes and misuse of user fees, are silently fueling the corruption that plagues our hospitals and clinics.
A report done by Medic East Africa and Medlab East Africa shows that Pocket (OOP) payments are the primary form of transaction in East Africa, but the trend poses a significant financial burden for low-income households due to the lack of government-mandated price controls in Kenya’s health expenditure standing in at 24%. Furthermore, a study commissioned by USAID Private Sector Engagement Program (PSE), in partnership with the Ministry of Health in 2024, identified that Out-of-pocket healthcare payments in Kenya are arguably high, with 4.9% of the population experiencing catastrophic health expenditure.
In theory, the legal framework should have enhanced accessibility to healthcare, but in practice, it has led to a fragmented system where accountability is lost, funds are mismanaged, and corruption thrives. Unfortunately, devolution has opened the door for a new kind of corruption, the misuse of public funds meant for essential healthcare services. The National Ethics and Corruption Survey conducted by EACC in 2023 identified County Health departments as one of the most bribery-prone public institutions, indicating the devolution of corruption in healthcare. Studies have also shown that inefficiencies in health care can be directly attributed to corruption.
Devolution has also opened the door for a new kind of corruption, the misuse of public funds meant for essential healthcare services. The lack of transparency in budgeting, absence of reliable data for planning, and weak auditing systems make it far too easy for public funds to be siphoned, robbing the people of their right to health, as enshrined under Article 43 of the Constitution 2010. This has created a situation where only those who can afford the informal costs of healthcare—bribes, hidden charges, and “unofficial” payments can receive the care they need. For the rest, the system is an obstacle course of bureaucracy and neglect.
The cure for out-of-pocket expenses in healthcare
The connection between out-of-pocket payments and corruption is undeniable. As long as Kenyans are forced to pay for care out of their own pockets, the opportunities for corruption will remain. The status quo only deepens the inequality in our healthcare system, leaving the most vulnerable without access to essential services. To create a truly equitable healthcare system, we must address the root cause of these financial barriers.
The solution to the problem bedevilling healthcare lies in strengthening transparency and accountability across the health sector. Better data management, clearer auditing processes, and increased citizen engagement in decision-making can begin to close the loopholes that allow corruption to flourish. Patients must be empowered to know their rights and what services they are entitled to.
Health workers, who are on the frontline in this fight, need better salaries and working conditions to reduce the incentives for informal payments. Most importantly, we need to demand that our leaders take responsibility for healthcare delivery—not just in policy, but in action. Only then can we ensure that healthcare is a right, not a privilege—available to all, regardless of income or location.
Rozzette Makundi is an advocate of the High Court of Kenya & Officer at Transparency International Kenya | rmakundi@tikenya.org.
