“Poverty is a social issue, not a mathematical problem”: Examining the lessons for beneficiary identification from implementation of the UHC indigent program in Kenya

Background: Kenya rolled out a UHC indigent program aimed to expand financial protection and health service access for poor households through subsidized health insurance under the national insurer, NHIF. As Kenya transitions to a new social health insurance framework under the Social Health Authority (SHA), understanding the implementation experience of the UHC indigent program is critical for informing the roll out of SHA’s indigent program. Methods: We conducted a qualitative process evaluation of the UHC indigent program using semi-structured interviews with 23 key informants from national and county health systems, development partners, and implementing actors, complemented by a validation workshop with 57 stakeholders. Our analysis was guided by Moore et al.'s process evaluation framework and Wu et al.'s policy capacity lens, examining implementation fidelity and capacities at multiple levels. Results: The program’s implementation deviated from its original centralized design, with counties exerting control over beneficiary identification due to national data gaps, incomplete rollout of the Harmonized Testing Tool, and political and operational constraints. Variations in targeting methods, reliance on under-resourced community health actors, and delays in biometric registration contributed to partial enrolment, exclusion errors, and mistrust. Although some counties reported increased service utilization, this was limited by unregistered dependents and lack of beneficiary awareness. Stakeholders expressed concern over SHA’s use of proxy means testing (PMT) for informal sector enrolment, citing risks of exclusion, manipulation, and failure to capture locally constructed definitions of poverty. Conclusion: Kenya’s experience underscores the need to align national targeting frameworks with local realities, invest in policy capacity across stakeholders, and prioritize community validation and communication in pro-poor programs. As SHA rolls out a new indigent program, these lessons offer critical guidance for enhancing fidelity, equity, and accountability.