Proxy Means Testing as a Barrier to Universal Health Coverage in Kenya: A Critique of the Social Health Authority (SHA) Framework

Abstract

The implementation of Proxy Means Testing (PMT) of the Social Health Insurance Fund (SHIF) of Kenya is a pivotal step in the process of delivering the country towards Universal Health Coverage (UHC), which is a key pillar of the Bottom-Up Economic Transformation Agenda (1). The PMT model, as it was enacted within the framework of the Social Health Insurance Act of 2023, was devised as an equitable tool to calculate the contribution of fair premiums to the enormous informal sector of Kenya that comprises around 80 percent of the workforce (2, 3). Its goal was to use the household features that can be observed, including asset and housing facilities as well as geographical location to estimate economic capacities of households and efficiently distribute the subsidies to the poor (4).

Nevertheless, during the initial years of its operation, this complex policy tool has produced extreme unintended outcomes, posing significant obstacles to the same UHC objectives that it was to promote (5). Anecdotal and empirical evidence depict a broken system. Despite the fact that more than 25 million Kenyans are registered, the number of those paying premiums is approximately 3.1 million as at the beginning of 2025 (6). Such a disastrous mismatch between registration and revenue is not an administrative failure, but an immediate manifestation of deep structural vulnerabilities, operation failures and failure to trust the government.