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Background: The need to provide quality and equitable health services and protect populations from impoverishing health care costs has pushed universal health coverage (UHC) to the top of global health policy agenda. In many developing countries where the majority of the population works in the informal sector, there are critical debates over the best financing mechanisms to progress towards UHC. In Kenya, government health policy has prioritized contributory financing strategy (social health insurance) as the main financing mechanism for UHC. However, there are currently no studies that have assessed the cost of either social health insurance (SHI) as the contributory approach or an alternative financing mechanism involving non-contributory (general tax funding) approaches to UHC in Kenya. The aim of this study was to critically assess the financial requirements of both contributory and non-contributory mechanisms to financing UHC in Kenya in the context of large informal sector populations. Methods: SimIns Basic® model, Version 2.1, 2008 (WHO/GTZ), was used to assess the feasibility of UHC in Kenya and provide estimates of financial resource needs for UHC over a 17-year period (2013-2030). Data sources included review of national and international literature on inflation, demography, macro-economy, health insurance, health services unit costs and utilization rates. The data were triangulated across geographic regions for accuracy and integrity of the simulation. SimIns models for 10 years only so data from the final year of the model was used to project for another 7 years. The 17-year period was necessary because the Government of Kenya aims to achieve UHC by 2030. Results and conclusions: The results show that SHI is financially sustainable (Sustainability in this study is used to mean that expenditure does not outstrip revenue.) (revenues and expenditure match) within the first five years of implementation, but it becomes less sustainable with time. Modelling for a non-contributory scenario, on the other hand, showed greater sustainability both in the short- and long-term. The financial resource requirements for universal access to health care through general government revenue are compared with a contributory health insurance scheme approach. Although both funding options would require considerable government subsidies, given the magnitude of the informal sector in Kenya and their limited financial capacity, a tax-funded system would be less costly and more sustainable in the long-term than an insurance scheme approach. However, more innovative financing for health care as well as giving the health sector higher priority in government expenditure will be required to make the non-contributory financing mechanism more sustainable. [ABSTRACT FROM AUTHOR]

Background: Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya., Methods: The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27)., Results: The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership., Conclusions: Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI's role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers' relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system.