Mechanisms for advancing universal health coverage in Kenya: a qualitative study

Background Universal Health Coverage (UHC) is a cornerstone of Sustainable Development Goal 3, yet its implementation in Africa shows mixed results. This study explores mechanisms driving UHC progress in Kenya. Method Realist interviews were conducted with 44 key informants across Kenya's health ecosystem, including government officials, private sector representatives, insurance agency members, and community and faith-based organizations. The study was guided by initial program theories from a realist synthesis of UHC in Africa, that identified political commitment and community engagement as critical mechanisms for successful UHC reforms. Through realist interviews, this study tested and refined these initial theories. Results Four interconnected mechanisms emerged as key drivers of UHC in Kenya: political commitment, community engagement, intersectoral collaboration, governance and accountability. Political commitment drives legislative reforms, resource allocation, and structural developments, while community engagement fosters co-ownership, accountability, and tailored healthcare solutions. Intersectoral collaboration leverages diverse resources and expertise to improve access to quality health care, while effective governance and accountability structures ensure resource efficiency and responsiveness to community needs. Conclusion This study confirms political commitment, community engagement, intersectoral collaboration, governance and accountability as critical enablers of UHC in Kenya. Our findings emphasize the need for inclusion of marginalized voices in UHC discussions, shifting from centralized community engagement forums to more inclusive, outreach-oriented approaches, sustained political will, coupled with the education of leaders, and active private sector involvement. By refining UHC program theory through iterative stakeholder engagement, this research offers context-specific insights for Kenya and other countries facing similar challenges.