The political economy of universal health coverage reform in Kenya: executive dominance, elite alignment, and populist strategy (2004-2023)

Why do some ambitious social health insurance reforms get enacted, while others stall, even within the same country, and under similar structural constraints? This article compares Kenya’s failed 2004 National Social Health Insurance Fund Bill, with the reform enacted in 2023. It combines Kingdon’s Multiple Streams Approach (MSA) with political economy and populism theory, drawing on 48 elite interviews, and policy documents. Using outcome-explaining process tracing, the study explains why enactment became possible in 2023 but not 2004. MSA highlights how adoption depends on coupling across problem, policy and politics streams. Kenya’s case shows that in executive-dominant presidential systems, leaders can also make this coupling happen. Three mechanisms distinguished the 2023 episode: (i) executive dominance and institutional bypass, that compressed procedures and reduced veto points, (ii) elite re-alignment including a fiscal gatekeeper buy-in, which ensured a supportive political settlement, and (iii) populist strategy that moralised inequities, delegitimised opponents and justified expedited enactment. In 2004, the reform faced executive and elite fragmentation, which enabled organised resistance and presidential veto. By integrating MSA with political economy and populism theory, this study conceptualises populism as a coupling mechanism that can align streams by reshaping political feasibility and coalition incentives. Empirically, it provides a rare within-country comparison of health financing reform enactment in an LMIC, clarifying how power, elite bargains, and political strategies shape whether redistributive reforms become law. While these three mechanisms helped ensure the reform’s enactment, they however risk limiting the reform’s ability to increase coverage, specifically for the informal sector populations that it aimed at serving.