In a groundbreaking study that sheds light on the persistent challenges faced by informal sector workers in Kenya, researchers have unveiled critical insights into the disparities surrounding national health insurance enrolment. This sector, often characterized by informal, unregulated labor, remains a significant gap in achieving universal health coverage. The meticulous assessment conducted by Wamalwa, Strupat, Singh, and their colleagues, published in 2025, meticulously quantifies and analyzes the socio-economic and structural hurdles that contribute to health insurance exclusion. Their findings are not only relevant to Kenya but resonate profoundly across global health policy domains striving to extend coverage to the most vulnerable populations.
The informal sector in Kenya, constituting a substantial portion of the workforce, operates largely outside the formal employment and social security frameworks. Workers within this sector often lack access to essential benefits, including health insurance, which leaves millions vulnerable to catastrophic health expenditures. The study underscores that despite policy efforts to broaden the National Health Insurance Fund (NHIF) coverage, a significant fraction of informal workers remain uninsured, thereby continuing to expose systemic inequalities within the healthcare financing system.
Employing robust quantitative methodologies, the researchers utilized nationally representative datasets to dissect the determinants influencing participation in the NHIF among informal workers. Their multivariate analysis reveals that income level, educational attainment, geographic location, and gender play pivotal roles in shaping enrolment patterns. Significantly, lower income groups and women disproportionately face barriers to health insurance access, a phenomenon that echoes the structural inequities entrenched in economic and social systems.
Geographical disparities emerge as a critical dimension in this complex landscape. The study identifies rural inhabitants, particularly those residing in remote areas, as the least likely to be enrolled in the NHIF. This geographical skew hints at infrastructural limitations, limited information dissemination, and perhaps cultural factors influencing the uptake of health insurance. Such spatial inequities exacerbate health outcome disparities, as rural populations often confront additional challenges in accessing quality healthcare services.
Education emerges as both a determinant and a potential lever for intervention. The research highlights that workers with higher educational levels are substantially more inclined to enroll in health insurance schemes. This correlation suggests that educational interventions could amplify awareness about health insurance benefits and enrollment processes, thus mitigating informational asymmetries that currently hinder uptake among less educated informal workers.
A striking revelation from the study is the nuanced role of gender in health insurance enrolment disparities. Women in the informal sector are less likely to possess NHIF coverage compared to their male counterparts. This gender gap may stem from intersectional factors, including economic dependency, caregiving responsibilities, and social norms that inhibit women’s autonomy in financial decision-making. Addressing this gender inequity demands tailored policy frameworks that accommodate the unique challenges faced by women in informal employment.
Structural policy barriers further complicate the enrolment landscape. The existing NHIF collection mechanisms, designed primarily for formal sector salaries, often fail to accommodate the erratic and unpredictable income patterns typical of informal work. Consequently, the inflexible premium collection and registration processes deter many informal workers who cannot consistently contribute. The study advocates for innovative policy redesigns that incorporate flexible contributions and technologically driven enrolment systems to increase accessibility.
The health implications of being uninsured are alarming, especially against the backdrop of Kenya’s epidemiological transition where non-communicable diseases are becoming more prevalent. Informal workers without insurance coverage face elevated risks of catastrophic health expenditures which can drive families into poverty. The research highlights how inadequate health insurance fortifications disproportionately affect informal workers’ health-seeking behaviors and overall well-being.
In light of these findings, the study calls for a reconceptualization of health insurance policies that transcend traditional formal sector paradigms and actively integrate the informal workforce. It stresses that achieving universal health coverage in Kenya hinges on specifically targeting these uncovered populations through inclusive, context-sensitive strategies. The researchers urge policymakers to innovate enrollment frameworks, expand subsidization for low-income workers, and intensify community engagement to dismantle barriers.
Technological advancements present promising avenues to enhance NHIF enrolment among informal workers. Mobile payment platforms, digital identification, and data analytics can enable more streamlined registration and premium collection, tailored to the informal sector’s characteristic work patterns. Leveraging Kenya’s robust mobile penetration could prove pivotal in bridging the health insurance coverage gap.
Community-based approaches are equally vital, according to the study. Grassroots mobilization, peer-to-peer education, and partnerships with informal worker associations can foster trust and knowledge dissemination. The researchers posit that embedding insurance schemes within community fabrics enhances acceptability and sustained participation, crucial for the informal sector’s heterogeneous and dispersed nature.
The economic ramifications of excluding informal workers from health insurance are profound. Beyond individual health setbacks, the lack of coverage perpetuates cycles of poverty, reduces labor productivity, and strains public health resources. The study articulates how expanding NHIF coverage can buffer economic shocks from health crises, thereby stabilizing livelihoods and contributing to broader economic resilience.
Importantly, the study highlights that health insurance enrolment is not merely a financial transaction but a multi-layered social process influenced by cultural beliefs, trust in institutions, and perceived quality of healthcare services. Misconceptions about insurance benefits and distrust toward NHIF administration deter enrolment and renewals. Therefore, enhancing transparency, service quality, and community feedback mechanisms should accompany coverage expansion efforts.
The researchers also anticipate future challenges, cautioning that demographic shifts, urbanization, and emerging health threats necessitate adaptable and sustainable health insurance frameworks. Kenya’s informal sector will continue to evolve, requiring dynamic policies that remain responsive to changing worker profiles and health system demands.
This seminal work thus provides a clarion call to global health policymakers. Kenya’s experience demonstrates the intricate linkages between socioeconomic inequalities and health insurance coverage gaps in informal employment contexts. Closing these gaps mandates multifaceted interventions that are socially attuned, economically feasible, and technologically innovative.
In conclusion, this comprehensive assessment unpacks the convoluted web of determinants behind national health insurance enrolment deficits among Kenya’s informal workers. By illuminating the intersecting axes of income, education, geography, gender, and institutional design, the study charts a decisive path toward equitable and inclusive health coverage. Its insights herald a new chapter in global health equity discourse, underscoring that no worker should remain uninsured or excluded from the right to health.
Subject of Research:
The study investigates inequalities and determinants of national health insurance enrolment among informal sector workers in Kenya, focusing on socio-economic and structural factors contributing to exclusion from coverage.
Article Title:
Who remains uncovered? Assessing inequalities and determinants of national health insurance enrolment among informal sector workers in Kenya.
Article References:
Wamalwa, P.N., Strupat, C., Singh, K. et al. Who remains uncovered? Assessing inequalities and determinants of national health insurance enrolment among informal sector workers in Kenya. Glob Health Res Policy 10, 62 (2025). https://doi.org/10.1186/s41256-025-00461-7
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