OPINION: Why Kenya must start treating prevention as part of healthcare financing

For many families, serious conversations about healthcare financing begin at the worst possible moment: when someone is already sick. A child develops a high fever in the middle of the night, a parent suddenly needs admission, or a routine medical review uncovers a condition that requires months or years of treatment.

Only then does the family begin asking difficult questions about which hospital they can afford, what treatment will cost, what their health cover provides and, if the money available is not enough, where the difference will come from. At that point, a health decision has also become a financial emergency.

This is one reason the conversation about health insurance in Kenya needs to evolve. We tend to think about health cover primarily as a mechanism for paying hospital bills, yet while financial protection when illness occurs is important, good health planning should begin much earlier, when people are still well.

Kenya is simultaneously dealing with infectious diseases, injuries and a growing burden of non-communicable diseases such as hypertension, diabetes, cancer and cardiovascular disease.

According to the World Health Organization, NCDs now account for about 41 per cent of annual deaths and half of hospital admissions in Kenya, which makes prevention and early detection as much an economic issue as a clinical one.

Many of these conditions develop gradually and can remain undetected until complications emerge. WHO estimates that about 5.5 million Kenyan adults aged 30 to 79 are living with hypertension, yet only 40 per cent have been diagnosed and just 7 per cent have the condition under control.

A person can therefore live with elevated blood pressure for years without obvious symptoms, while early detection may allow for regular monitoring, lifestyle changes and appropriate clinical management before serious complications develop.

When hypertension remains undetected or poorly controlled, the consequences can include stroke, kidney disease and cardiovascular complications, increasing both the health burden on the patient and the financial burden on families and the health system.

The same principle applies to diabetes, some cancers and several other chronic conditions, which is why wellness should no longer sit on the margins of healthcare. Regular screening, physical activity, appropriate nutrition, mental wellbeing, preventive consultations and adherence to treatment should increasingly be viewed as part of the same continuum as hospital care.

The objective should be to help people remain healthier for longer, identify risks earlier and manage existing conditions more effectively, rather than waiting until illness has progressed to the point where hospital treatment becomes necessary. This requires a gradual shift from a largely reactive model of healthcare towards one that gives prevention, early intervention and ongoing disease management greater weight.

The same thinking should apply to household finances. Families routinely plan for school fees, housing, retirement and other future expenses, yet healthcare is often financed only when a need arises, despite illness being both unpredictable and potentially expensive.

Kenya’s current health reforms rightly focus on strengthening financial protection and expanding access to healthcare, including reducing the burden of direct out-of-pocket expenditure on households. National systems and insurance arrangements, however, are only part of the response, because families also need to understand what protection they have before an emergency occurs.

While everyone is still healthy, households should already know what healthcare protection they have, which services are included, where treatment can be accessed, what would happen if someone required admission, whether parents and other dependants are protected and what resources would be available if a chronic illness developed. These questions are considerably easier to answer around a dining table than at a hospital admissions desk.

There is also an opportunity for insurers and other healthcare financiers to rethink their role within this continuum. Traditionally, the relationship between an insurer and a customer becomes most visible when a claim is made, yet the health challenges facing households increasingly require that relationship to begin much earlier.

Health financiers can support preventive screening, care navigation, health education, disease-management programmes, telemedicine, medication support and other wellness interventions that help people understand and manage their health risks.

This does not mean that every illness can be prevented, nor should wellness ever be presented as a substitute for appropriate clinical care, but it does recognise that an effective intervention may sometimes prevent a patient from reaching hospital in a more serious condition.

A person living with diabetes who consistently monitors their health, attends appropriate reviews and adheres to treatment may reduce the risk of serious complications, just as someone whose hypertension is detected through routine screening has an opportunity to manage the condition before an emergency occurs. These are first and foremost better health outcomes, but they also have implications for the affordability and sustainability of healthcare over time.

The industry must also confront complexity, because consumers should not need to become insurance experts before making sensible decisions about healthcare protection. Health products should be easier to understand, with clearer explanations of what is covered, what is excluded, the limits available, which providers can be accessed and what financial contribution may be required from the customer.

Affordability also deserves more nuanced thinking because, for some households, the challenge may not necessarily be the total annual cost of health cover but the requirement to make a significant payment at once. Flexible payment structures can help align healthcare financing more closely with the way households earn and manage income, while simpler entry-level options can give consumers who primarily want protection against large hospital bills an opportunity to begin before moving to more comprehensive cover as their circumstances improve.

The need for better preparation is significant. The 2024 FinAccess findings indicate that more than 5.6 million Kenyan adults experienced a health-related shock, with more than four million identifying health as their main shock. Closing the protection gap therefore requires solutions that are affordable, understandable and relevant to the different stages of people’s lives, alongside stronger investment in prevention and wellness.

The larger shift is ultimately about how we define health protection. A strong health system should be judged not only by how effectively people are treated once they become sick, but also by how well illness is prevented where possible, disease is identified early, people living with chronic conditions are supported and families are protected from financial distress when serious illness does occur.

Government has a central role through primary healthcare and universal health coverage, while healthcare providers must continue strengthening quality treatment and preventive care, insurers and other financiers must develop sustainable ways of funding that care, and employers can contribute through healthier workplaces and access to preventive interventions.

For households, however, the most important shift may be simpler: healthcare planning should begin long before anyone reaches an admissions desk, through understanding our health risks, screening early, managing our wellbeing and knowing what financial protection is available to the people we care about. The hospital door should be where treatment begins, not where health planning starts.

The author is the Head of Clinical Operations at Jubilee Health Insurance.