This essay draws on my forthcoming paper in BMC Public Health on the financial determinants of hypertension and diabetes care in rural primary health facilities in Kisumu County. The paper is built on formal analysis. The problem it describes, however, is easy to state in plain language: a clinic can know exactly what a patient needs and still be unable to act in time.
Clinicians can diagnose hypertension. They can prescribe insulin. They can explain follow-up and complications. But if the facility cannot spend quickly when medicines run out, chronic care breaks down long before the science does.
The contradiction at the center of the study
At first glance, the problem can look like ordinary underfunding. Kenya’s non-communicable disease burden is growing, and primary care facilities are already stretched. But the field evidence pointed to something more specific.
All seven facilities in this study had annual workplans and budgets. All had bank accounts. Yet none had full formal autonomy to spend funds directly when urgent needs emerged. That means a facility could identify an NCD stockout, know where to buy the required medicine locally, and still be forced to wait for approval from a higher administrative level.
That is the contradiction: a system can appear financially organized on paper while remaining operationally paralyzed in practice.
What the evidence showed
Several findings kept repeating across the quantitative records and the interviews:
- 71.4 percent of facilities depended mainly on NHIF reimbursements and donor support.
- Only 28.6 percent received direct county funding.
- 57.1 percent relied on just two active funding streams.
- None had a dedicated NCD budget line.
- None had full direct spending autonomy.
- 85.7 percent reported frequent medication stockouts.
Taken together, those figures describe a system with narrow revenue options, weak protection for chronic-care budgets, and very limited local ability to respond when routine supply channels fail.
Why this is a governance problem, not just a supply problem
It is tempting to describe medicine stockouts as a logistics issue. Sometimes they are. But in this study, stockouts were also a financing-governance issue.
When approval for spending takes weeks, a facility cannot bridge a gap in central supply. When NCD care has no protected budget line, it competes with every other immediate operational pressure. When reimbursements are delayed, planning becomes performative rather than actionable.
This is why I argue that the sustainability of chronic care depends on facility decision space, not only on the total amount of money in the system. If the purse strings remain too far from the point of care, patients experience that distance as missed refills, interrupted treatment, and preventable complications.
Why this matters beyond one sub-county
The study was conducted in seven facilities in Seme Sub-County, so it should not be read as a statistical description of every county in Kenya. But the policy mechanisms it identifies are transferable.
Many decentralized health systems face the same tension:
- central control is used to protect accountability
- frontline facilities are responsible for service delivery
- chronic disease care requires continuity rather than one-off response
That combination creates friction. The deeper lesson is that accountability systems have to be designed so that they do not disable the very care they are supposed to protect.
Why NCD care keeps losing the budget fight
Part of the problem is visibility. HIV, TB, and malaria programs often enter budgeting conversations with protected lines, established reporting structures, and stronger institutional attention. Hypertension and diabetes care often do not.
When an NCD line is missing or weak, chronic care gets absorbed into general outpatient spending and loses every time a more immediate operational pressure appears. The result is not a dramatic single collapse. It is a slow, repeated erosion of continuity: no strips, no drugs, no local response, no trust.
That is one reason this paper matters. It names the problem more precisely. The issue is not simply whether money exists somewhere in the system. The issue is whether the people responsible for care can use it fast enough, locally enough, and predictably enough.
A harder definition of Universal Health Coverage
Universal Health Coverage is sometimes discussed in the language of benefit packages, digital systems, and enrollment reforms. Those matter. But a harder definition starts at the facility counter.
If a patient with diabetes arrives for review and the medicine is unavailable for weeks because the clinic cannot act without a distant approval, then UHC remains incomplete no matter how well the policy looks in a national presentation.
The practical question is not whether the system can describe care. It is whether the system can sustain care.
Why this evidence matters now
Kenya’s financing reforms will keep being judged by legislation, launch language, and institutional optimism. They should also be judged by four simpler operational questions:
- Can facilities access funds faster when essential NCD medicines run out?
- Are NCD budgets visible enough to survive ordinary budget competition?
- Are approval chains becoming shorter and more predictable?
- Do patients experience fewer interruptions in treatment?
Those questions are less glamorous than reform slogans. They are also closer to the truth of whether chronic disease care is improving.
The argument of the paper is straightforward: continuity of chronic care depends not only on financing volume, but on whether frontline facilities have enough decision space to protect treatment when the system is under strain.
That is where this essay begins, and where the policy conversation should become more honest.