Externe Publikationen

Do free healthcare policies play a role in expanding national health insurance enrollment among informal sector workers? The case of the Afya Care pilot program in Kenya

Wamalwa, Phidelis / Christoph Strupat / Edmund Yeboah / MaryBennah N. Kuloba / Boniface Mbuthia / Manuela De Allegri
Externe Publikationen (2025)

in: BMC Public Health 25, article 3610

DOI: https://doi.org/10.1186/s12889-025-24760-3
Open access

Background Many Sub-Saharan African countries have shifted from fiscally unsustainable free healthcare models to contributory national health insurance schemes, which rely on payments from informal sector workers. Yet, enrolling these workers remains a key barrier to achieving universal health coverage. Using the case of Kenya’s Afya Care free healthcare pilot, this paper investigates whether earlier exposure to free healthcare influences informal sector workers’ later decisions to enrol and contribute to the national health insurance scheme (NHIS). Methods We used nationally representative household survey data from 2018 and 2020, collected before and after the Afya Care pilot. The analysis focused on 6,900 informal sector workers, applying a quasi-experimental difference-in-differences approach to estimate the effect of exposure to the free healthcare pilot on subsequent NHIS enrollment. Results Before the pilot, no significant differences existed between treatment and control groups. After the intervention, NHIS enrollment was 10.5% higher in intervention counties (p < 0.001). Informal sector workers exposed to Afya Care were 65% more likely to enrol in the NHIS compared to those in control counties (odds ratio = 1.65; 95% CI = 0.96–2.83). Heterogeneity analysis showed that the policy’s impact was stronger among the least educated (30% higher enrollment) and the poorest workers (18% higher). Conclusions Exposure to the Afya Care pilot positively influenced informal sector workers’ willingness to join the NHIS and improved equity in enrollment. However, overall participation remains low. To expand coverage, the government should intensify information campaigns to raise awareness, extend subsidies to make premiums more affordable, and fully finance those unable to contribute. Strengthening these measures will be crucial for advancing Kenya’s progress toward universal health coverage.