Health insurance coverage, affordability barriers, and treatment gaps among Kenyan adults with diagnosed hypertension or diabetes before the Social Health Authority transition: a sex-stratified analysis of the 2022 Kenya Demographic and Health Survey
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Background
Kenya replaced the National Health Insurance Fund with the Social Health Authority in October 2024, making the 2022 Kenya Demographic and Health Survey the last nationally representative pre-transition baseline. Evidence on insurance coverage and treatment gaps among adults already diagnosed with hypertension or diabetes remains limited, including how these patterns differ by sex. We aimed to estimate the level, distribution, and correlates of insurance coverage and treatment gaps among diagnosed adults at the close of the NHIF era.
Methods
We conducted a survey-weighted cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey. Insurance status, prior diagnosis, and current medication use were reported by respondents. Analyses were sex-stratified and survey-weighted, with adjusted prevalence ratios estimated to assess associations between insurance coverage and treatment gaps. Wealth-related inequality was examined using concentration indices.
Results
The analytic sample included 1,932 diagnosed adults (1,384 women and 548 men). Any insurance coverage was 47.7%, largely driven by National Health Insurance Fund enrolment (43.4%). Overall, 63.8% of diagnosed adults were classified as having a treatment gap (not currently taking medication for at least one diagnosed condition), including 67.1% of women and 59.8% of men, with treatment gaps exceeding 60% across all wealth quintiles. Insurance coverage was strongly pro-rich, whereas treatment gaps were distributed across the wealth gradient. After adjustment, insurance was not strongly associated with lower treatment-gap prevalence among women or men, and formal interaction testing did not support effect modification by sex. Among women, lack of money for treatment was reported as a major barrier far more frequently among the uninsured than the insured.
Conclusions
Before the Social Health Authority transition, Kenya faced unequal insurance coverage, persistent affordability barriers, and substantial treatment gaps among respondents diagnosed with hypertension or diabetes. These findings provide a national pre-transition benchmark for health financing reform. They suggest that expanding enrolment is necessary but unlikely to close chronic-care treatment gaps unless public insurance arrangements also improve benefit depth, outpatient medicine access, and frontline readiness for continuous NCD care.
