By all accounts, the health infrastructure of Kisumu County, a lakeside stronghold in western Kenya with more than 1.2 million residents, is a machine built on ambition. A lattice of performance indicators, strategic frameworks, and service-level agreements ostensibly guides its operations.
But behind this architecture is a more sobering truth. The system is failing in its execution.
Over the past four years, Kisumu has staked its healthcare renaissance on reforms both homegrown and national in scope from its own Marwa Health Insurance Scheme to Kenya’s broader Social Health Insurance Fund (SHIF).
In theory, these reforms promise universality, efficiency, and equity. In practice, they have collided with chronic underfunding, endemic mismanagement, and administrative inertia. The result is a county health system rich in documentation but impoverished in delivery.
The Bureaucratic Faith of SLAs
The gospel of reform in Kisumu’s health sector began with a promise dressed in contractual precision. Introduced through the Kisumu Social Health Insurance Fund Regulations in 2020, SLAs were designed as binding compacts between government and provider, requiring “seamless transfer of funds” and payment structures tied to measurable outcomes.
They spoke the language of efficiency, drafted in boardrooms and rolled out as if health systems could be fixed by alignment alone.
But almost as soon as they were implemented, the ground gave way. The budget reports tell a story the architects likely didn’t plan to read. Capitation payments stalled, reimbursements delayed, and liquidity crises spreading through facilities once promised stability.
Hospitals began to ration services. Administrators learned to fill out forms in triplicate and wait. “We ended up spending more time chasing payments than treating patients,” a weary health officer in Nyando remarked, not bitter, just tired. Informal charging returned. The idea of universal access quietly evaporated.
The SLAs still exist, cited in policy briefs and budget plans like relics of an order that never materialized. On paper, they symbolize accountability. On the ground, they symbolize abandonment. There is no outrage, not anymore, only the practiced frustration of medical officers who no longer ask when the funds will arrive and procurement staff who’ve stopped requesting basic supplies.
The Rise and Stall of Marwa
Few reforms captured the public imagination like the Marwa Health Insurance Scheme, launched in March 2021 with the promise of transforming access to care for Kisumu’s most vulnerable. It pledged to cover 90,000 low-income households, starting with 45,000 in its first rollout phase. County officials hailed it as a locally driven answer to chronic exclusions in national policy. The architecture seemed bold, precise, and aspirational.
The numbers, at first, followed the narrative. Insurance penetration jumped from 12% to 23%. More than 38,950 clinic visits were logged. Participating facilities saw a 60% surge in NHIF claims, a signal at least on paper that access had expanded. But beneath those metrics, the system was straining.
By late 2022, reports of payment delays, patient rejections, and bureaucratic logjams began to accumulate. Providers spoke of submitting claims into black holes. Patients described being turned away despite having valid coverage.
The illusion held, but only at the level of dashboards. “There was always a dashboard,” one policy advisor said dryly. “But the dashboard was not connected to reality.” It was a system built to perform data, not deliver care.
Audits found that while enrollment numbers rose, service quality had stagnated. Claims were processed sporadically. Trust, quietly but decisively, began to erode, first among providers, then among the insured. In Marwa’s collapse, one sees policy failure and a portrait of reform that mistook visibility for function.
The Performance Illusion
The 2023/2024 Budget Implementation Report reads like a catalogue of achievement.
Nearly 3.5 million outpatient consultations were logged. Immunization rates reached a confident 92 percent. Skilled birth attendance ticked slightly upward, and the average hospital stay dropped from seven days to five. The numbers suggest momentum, stability, even progress, and evidence, perhaps, that the machinery is finally working.
But step beyond the graphs and into the wards, and the illusion unravels. Some clinics operate with a single exhausted clinician. Others are rooms with broken equipment and no diagnostic tools.
Life-saving drugs, when they arrive, sometimes expire before use. Storage shelves meant for antibiotics and painkillers sit empty or are crowded with unusable stock. Promised infrastructure projects stall for lack of title deeds. In many facilities, basic questions about procurement go unanswered. No one knows what was spent, what was delivered, or what vanished into paperwork, because the institution has never been audited.
The metrics glow, but they don’t breathe. They flatten the story into percentages and averages, omitting the mothers turned away, the children misdiagnosed, the nurses improvising care without supplies.
The tragedy is not that the data is false—it’s that it’s incomplete. The system reports coverage. What it doesn’t report is abandonment.
A System in Free Fall
Financial management, the central pillar of health system sustainability, is where Kisumu’s system appears most precarious. An investigative report by the County Assembly’s Health Committee in 2022 laid bare the dysfunction.
Many hospitals lacked qualified accountants. Others failed to maintain asset registers or verify land ownership for their premises. In some facilities, expired pharmaceuticals, long past safe usage, had piled up in storage rooms for years, awaiting disposal approvals that never came.
The SHIF rollout only deepened the crisis. By mid-2024, over 29.3% of participating hospitals were reporting consistent system access failures. Only 42% of claims filed in the fourth quarter were paid. In some facilities, electronic claim submissions were impossible, in others, power outages and weak internet links paralyzed billing systems.
In a chilling parallel to the ghost schools once funded by Kenya’s free education fund, ghost claims and missing reimbursements now haunt Kisumu’s hospitals. Meanwhile, 74% of health facilities have reported persistent stockouts of essential medicines, diagnostic reagents, and consumables.
The SHA’s promise of digitization has collided with the analog reality of a county still held together by handwritten ledgers and informal workarounds.
Anatomy of Institutional Negligence
Beneath the operational failures of Kisumu’s health sector is something more corrosive. Not inefficiency. Not delay. But systemic negligence—a quiet and durable form of harm that settles into routine. A 2023 study of the county’s health system found that over a third of patients at Level 1 to 3 facilities were illegally charged for services.
Most received no receipts. No explanation. Just a shrug and a demand. In these spaces, access is negotiable, and poverty has no receipt trail.
The County Budget Review and Implementation Report catalogued facilities where the situation borders on the surreal:. Clinics staffed by a single person, some with no functioning toilets, no X-ray machines, no refrigeration to store vaccines. Children receive expired drugs or none at all. Women give birth in rooms without lighting. The fragility is neither accidental nor new—it has been studied, documented, and allowed to persist.
Oversight, too, has slipped into ritual. Assembly investigations record moments that read like satire. Hospital administrators refusing to surrender audit documents, citing “personal reasons.” Boards operating months beyond their legal terms. Some didn’t meet once in an entire fiscal year.
In theory, these institutions were designed to enforce accountability. In practice, they have served to deflect it. The collapse is not hidden. It is administered.
The Human Cost
The statistics are damning.
Kisumu recorded a maternal mortality rate of 495 per 100,000, though a county‑led health campaign has since driven that rate sharply downward, to around 343 by early 2024, a 30 percent drop over five years.
But so, even as women deliver more safely, the under‑five mortality rate remains grim. Approximately 63 per 1,000 (or 6,300 per 100,000), far higher than the national average.
Malaria prevalence, once over 50 percent, has fallen to 15.6 percent, but that remains one in six people living under the constant threat of fever and complications.
Perhaps most damning of all, nearly 60 percent of patients express dissatisfaction with public health services.
This verdict is drawn in waiting rooms where mothers are told to bring their own syringes and children wait days for antibiotics, the arithmetic of suffering that no statistic can fully capture.
What Must Be Done
There is no shortage of reform proposals in Kisumu—only a shortage of follow-through. A credible recovery plan would begin with financial triage. Qualified accountants must be posted to every sub-county facility. Asset registries should be digitized and regularly verified. The chronic understaffing of procurement officers and frontline health workers must be addressed not with policy memos but with actual hires.
These immediate measures, vital as they are, cannot substitute for structural repair. The system needs muscle memory absent of patchwork.
That means redesigning how information, money, and accountability flow. Health facilities must be equipped with real-time dashboards that link performance metrics to budget disbursements as permanent infrastructure, not as pilot projects. The county treasury should publish detailed, facility-level expenditure reports that communities can read without needing a consultant.
Internal audit committees, now rare, should become statutory. And oversight must be democratized. Not outsourced, not ceremonial. Community members should sit on facility boards, attend budget hearings, and hold the power to ask, Where did the medicine go?
The machinery of health in Kisumu is not irreparably broken. It is misaligned, underfed, and too often ignored. The greater danger is not collapse, but normalization that residents adapt to a state where being turned away, overcharged, or forgotten becomes routine.
But even buried in ledgers and acronyms, there is still a fragile possibility that public health can be reclaimed as a common good. For the people of Kisumu, this is not an abstraction.
The cost of dysfunction is paid in shortened lives, missed chances, and a public trust that grows thinner with every lost file. The time to act is not after the next audit. It is now.