Beyond the Budget: What Kenya’s counties are teaching us about sustainable health financing

By Dr Boniface Oyugi, Cynthia Charchi and Dr Hope Simiyu

Every year, Kenya’s county governments allocate billions of shillings to health. Yet facilities still run short of medicines, mothers deliver without essential commodities, and critical equipment sometimes sits idle. How can both realities coexist?

The answer lies in a distinction that rarely features in public debate: budgeting for health is not the same as financing healthcare delivery. A budget line is a promise. Between that promise and a patient receiving care lies a long and obstacle-filled journey.

Funds enter county health systems through national transfers, county allocations, and locally generated revenue. They move through treasury and departmental budgets before reaching health facilities, where they should support procurement, outreach, and service delivery. In reality, bottlenecks emerge at every stage; delayed treasury releases, procurement backlogs, and uneven distribution, where some facilities run dry while others hold medicines that risk expiry.

A recent assessment by the Savannah Global Health Institute examined financing and service delivery across ten counties with the highest maternal and neonatal mortality burdens. What emerged was a picture of systems under strain, and of county teams quietly innovating within those constraints.

When salaries swallow the budget

In these counties, 60–91 percent of health budgets are absorbed by staff salaries before a single medicine is procured. In Turkana, wages consume 91 percent. In Tana River, only about KES 250 million remains after salaries to run 71 facilities, against an estimated medicine need of KES 450–500 million.

This reflects a structural mismatch: counties inherited nationally negotiated wage bills, while their allocations were never designed to meet the full cost of service delivery. No single county created this challenge, and none can resolve it alone.

Yet some are extracting more value from within these constraints. West Pokot, for instance, deployed trained accountants to sub-county levels, bringing financial planning closer to where decisions are made. It also introduced programme-based budgeting with clear financial codes, making spending more transparent and trackable. These interventions require leadership, not new resources.

National reforms are promising, but uneven

The Social Health Authority (SHA) aims to expand financial protection for Kenyans. The idea is sound, particularly for rural populations, but implementation is uneven. Coverage ranges widely, from about 3 percent in Tana River to 54 percent in Homa Bay.

Part of the challenge lies in structural assumptions. Standard registration efforts assume populations are settled and easy to reach. In nomadic regions, this approach does not work. Turkana adapted through the Kimormor model, combining health, livestock, education, and SHA services in coordinating outreach efforts. Enrollment improved measurably, demonstrating a model that can be replicated in similar contexts.

Kilifi addressed another gap by embedding a dedicated SHA coordinator across its facility network, ensuring claims processing is managed as a system function rather than an added burden on clinical staff. This simple adjustment improved claims clearance significantly.

Despite these innovations, reimbursement delays remain a major constraint, disrupting supply chains and affecting care quality. These are not abstract failures. A delayed reimbursement can mean a stockout of lifesaving drugs, turning a routine delivery into a life-threatening emergency.

Unlocking facility-level decision-making

The Facility Improvement Financing (FIF) Act allows facilities to retain and use their own revenue. Where implemented effectively, the results are tangible. Homa Bay has established mechanisms to redistribute revenue from high-volume facilities to smaller ones, strengthening the broader primary care network. Kilifi is piloting models that give facility managers spending authority, reducing delays and idle funds.

The lesson is clear: when facilities have both autonomy and basic financial management capacity, service delivery improves quickly.

Making better use of what already exists

In Homa Bay, routine stock data revealed a familiar pattern, some facilities had surplus medicines nearing expiry, while others faced stockouts. By treating existing data as an operational tool rather than a reporting requirement, the county built a redistribution system across its primary care networks. No new funding was required.

This underscores a broader point: many of the tools needed to improve care already exist. The challenge is not data availability, but its use. Bridging that gap is often a matter of decision-making, not resources.

What counties are teaching us

Across the country, county teams are not waiting for perfect solutions. They are building practical responses to immediate challenges. Turkana’s outreach model is expanding coverage in hard-to-reach areas. Kilifi’s system approach is strengthening claims management. Homa Bay’s redistribution network is cutting waste and preventing stockouts. West Pokot’s financial reforms are improving accountability at the point of service delivery.

These are not pilot projects awaiting approval. They are working solutions developed under real-world constraints. Kenya has already made significant investments in reforming its health financing architecture. Counties are doing the hard work of translating those reforms into services that reach patients.

What is missing is not effort or innovation; it is a structured way to share what works.

SGHI is working with the Council of Governors to establish a County Joint Learning Network to address this gap. The lessons emerging from counties are not local; they are national solutions waiting to scale. As these innovations are documented and shared, they offer a pathway toward a more resilient and equitable health system.

A budget allocation is only the beginning of the journey. The question that matters is whether it ultimately delivers care. Kenya’s counties are already showing us the answers. The task now is making sure those answers travel.