Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)


Global Inclusion and Social Development

First Advisor

Gillian MacNaughton

Second Advisor

Courtenay Sprague

Third Advisor

Joseph Harris


Universal health coverage (UHC) has been high on the international agenda and was included as Target 3.8 in the Sustainable Development Goals in 2015.Correspondingly, all UN members have committed to realizing UHC by 2030, and many low- and middle-income countries are currently working to expand access to affordable and quality health services to their populations. Kenya’s journey towards UHC started right after the country gained independence in 1963. The country’s efforts to achieve UHC were re-energized by 2010 constitutional changes that guarantee the right to health for all and devolve health services delivery to county governments. However, the impact of devolving the health function has been disparate. Makueni, one of the 47 counties in Kenya, has been praised for increasing access to affordable health services by establishing a county-level health insurance program, MakueniCare. According to WHO, MakueniCare increased the percentage of county residents with health insurance from 8.8% in 2013, covered under the national health insurance plan, to 91% in 2018, covered under MakueniCare. This qualitative case study drew on Kenyan constitutional law, government planning and policy documents, and semi-structured interviews with 30 key informants in government and NGOs to understand the drivers that led to the establishment of MakueniCare and to identify lessons for others working toward UHC. The study found that several drivers namely––global norms, decentralization, democratic competition, and the strategic action of progressive and social change-minded leaders coalesced to influence the adoption of MakueniCare. The study concluded that while all four drivers set necessary conditions for the establishment of MakueniCare, the most important factor was the election and appointment of progressive political and technical leaders at the county level who took advantage of the window of opportunity created by devolution to advance inclusive social change from the middle. They did so by using the fiscal and political resources availed through devolution to build strong institutions to promote transparency, participation, and accountability, and to end corruption, which made MakueniCare possible. This study provides timely insight into the factors driving UHC in Kenya and lessons for other low- and middle-income countries working towards UHC.


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