Kenya has long grappled with a heavy disease burden and significant resource constraints. A new primary healthcare model aims to ensure every person lives within proximity of a health facility and can access critical care if needed.
Kenya has long grappled with a heavy disease burden and significant resource constraints. Photo Credit: U.S Army Southern European Task Force
Caleb Muli has lived with hypertension for the past six years. When his blood pressure is high and unstable, Muli, a resident of Yiuma Mavui village in the southern region of Kenya, is required to visit a health provider every two days for treatment, and weekly once his blood pressure stabilises. Muli’s nearest health provider is Ndalani Dispensary, a convenient walking distance from his home.
The availability and proximity of this care is made possible by a new system of primary health care networks (PCNs) being rolled out across Kenya. In the absence of PCNs, the 57-year-old would need to travel nearly 28km from Yiuma Mavui to Makueni Sub-County Hospital in Makueni County to receive the same care. The round trip would cost the peasant farmer about KES1,600 (about US$12), a steep cost in a community where many live below the World Bank’s extreme poverty line of US$2.15 per day.
“Going to Ndalani Dispensary often takes less than 30 minutes of my day,” Muli says. “I have a health provider there who cares about my health, and I receive services free of charge.”
Kenya’s healthcare system has grappled with the critical challenge of heavy disease burden amid resource constraints. Communicable diseases still account for the highest proportion of disease burden, with the leading causes related to HIV/AIDS, tuberculosis, and malaria. Malaria alone accounts for 13–15% of outpatient consultations. Non-communicable diseases are responsible for more than 50% of in-patient hospital admissions and 39% of all deaths annually.
The establishment of PCNs reflects a transformation that is taking place in the country’s health service delivery where marginalised, vulnerable, and hard-to-reach people like Muli can access affordable primary healthcare services close to their homes.
This model is seen as a promising gateway to achieving universal health coverage (UHC) as it lowers overall health expenditure while significantly improving the performance of Kenya’s health system.
Kenya’s innovative primary healthcare networks
Benson Musyoka, nurse-in-charge at Ndalani Dispensary, says the PCN model aims to ensure no one is left without access to critical health services. Some people, like Muli, can be treated at low-level health facilities like dispensaries; if more advanced care is required, the dispensary refers patients to health centres or hospitals.
The primary health care networks model seeks to eliminate these barriers by ensuring that 100% of the population lives within 5km of a healthcare facility.
Musyoka says, for example, that he has a record of all pregnant women in the remote rural village. “They get in touch with me during an emergency at night time,” he explains, “and I in turn request for an ambulance from Makindu Sub-County Hospital for immediate attention.”
Like Muli, a majority of Kenyans (63%), use public health facilities, which are unequally distributed across the country’s 47 counties. An average of 22 health facilities serve every 100,000 people. When plans were being put in place to pilot the PCN model in 2018, the national average distance between place of residence and the nearest low-level health facility in rural areas was about 10–15km.
Often, the only available mode of transport to travel to the health facility, other than walking, is boda boda taxis (motorbikes); this is an important barrier to access for people in remote areas, who comprise 70% of Kenya’s population.
The PCN model seeks to eliminate these barriers by ensuring that 100% of the population lives within 5km of a healthcare facility, which is one of the goals of the Kenya Health Sector Strategic Plan and in line with World Health Organization (WHO) recommendations.
Kenya began rolling out the PCN model in 2021. The country's Primary Health Care (PHC) Strategic Framework 2019-2024 was developed to support the UHC goal following the launch of the pilot program in 2018.
Faith Ndungu, an advocacy manager from the Health NGOs’ Network (HENNET), a coalition of health NGOs and civil society organisations in Kenya, explains: “[The framework] highlighted key challenges, namely primary care services were unavailable at the point of need, weak linkages between the community and PHC facilities, and issues surrounding governance and accountability.”
Healthcare delivery using a ‘hub-and-spoke’ model
Each PCN is designed as a ‘hub-and-spoke’ model: multi-disciplinary teams at primary referral hospitals (level four facilities) act as ‘hubs’ supporting several ‘spokes,’ including dispensaries and health centres (level two and three facilities).
Every healthcare facility across the country, from dispensary to large county referral hospital, is served by a community health unit staffed by a team of trained community health promoters who act as a link between the community or villages and formal health facilities. Community health promotors are often called ‘barefoot doctors’ due to years spent walking door to door, village to village educating people about best health, nutrition, and hygiene practices to prevent disease.
A community health promoter during a baby growth monitoring exercise in the community. Photo Credit: Joyce Chimbi
“If implemented well, PCNs deliver services to a catchment area, ensuring continuity of care through referral and counter-referral systems. They are also designed to reduce costs through more efficient use of resources, such as shifting services from higher to lower [level facilities] and sharing human resources and health products and commodities,” Ndungu says.
Counties such as Siaya, in western Kenya, have already met the 5km goal, while many others have met the current national average of one facility within every 9km radius and are progressively working towards 5km.
“The idea is to strengthen the team so that the targeted catchment population receive the best care for the best possible health outcomes.”
Ndalani Dispensary is in Makindu Ward within Makueni County, where the hub is Makindu Sub-County Hospital. Kamboo Health Centre is located 17km away, and seven dispensaries, including Ndalani Dispensary, can be found within 10km of Kamboo Health Centre. In Makindu Ward, each facility is served by 10 community health promoters.
Musyoka says the PCN model focuses on sharing resources across health facilities and the implementation of sustainable, cost-effective healthcare strategies.
“Health facilities can assist each other in many ways. I go to our level three facility, Kamboo Health Centre, every day and I assist in providing health services whenever the staff is overwhelmed,” he says. “I have assisted in cases such as labour and delivery. I have also consulted my colleagues in other health facilities within our PCN on various cases. The idea is to strengthen the team so that the targeted catchment population receive the best care for the best possible health outcomes.”
Musyoka further explains that Ndalani Dispensary does not have a functional refrigerator at the moment, while Kamboo Health Centre has one that is used for vaccine and medical supply storage. The two health facilities collect their vaccines from Makindu Sub-County Hospital and store them in the refrigerator at Kamboo Health Centre. Every day, Ndalani Dispensary collects its child immunisation doses and other medical supplies that require refrigeration from Kamboo Health Centre. Without this arrangement, Ndalani Dispensary would not be able to provide critical child immunisation services or medication that requires refrigeration, such as tetanus vaccines.
A critical pathway to universal health coverage
Kenya has prioritised PHC as a critical pathway towards achieving UHC and allocates as much as 57% of its health budget to PHC. According to the Ministry of Health, family planning integration coverage in Garissa County rose from 66% in 2021 to 87% in 2024, and skilled deliveries increased from 77% to 98% within the same period.
The government has thus far established nearly 160 PCNs and trained 248 master trainers—medical professionals or health experts who explain how the PCN model works—to support county-level PCN implementation. Overall, the government plans to establish 315 PCNs countrywide, with progress viewable on the PCN observatory dashboard.
The Primary Health Care Act 2023 that brought to life the PCN model established Kenya’s Primary Healthcare Fund (PHC Fund) to improve access to primary healthcare services for all. The community or end users pay for health services at subsidised rates through the government’s new Social Health Insurance (SHI) package.
The SHI fund is comprised of individual contributions to a common pool through regular premiums. This finances care services for contributors and their dependants. The PHC Fund receives contributions from the government as well as donors.
Musyoka says the PCN model is helping Kenya realise UHC as it is proving to be cost efficient and it builds a people-centred and resilient primary healthcare workforce. “PCN is about organising health facilities into one unit to serve a certain population, and to ensure that everyone within this catchment population is linked to a health facility and can receive a comprehensive set of services,” he says. “Our mission is to bring people as close as possible to health facilities.”
Community health promotors are a particular feature of Kenya’s approach...They play an important role in addressing harmful myths and misconceptions.
Community health promotors are a particular feature of Kenya’s approach to PHC and the PCN model. They play an important role in addressing harmful myths and misconceptions, often around witchcraft and traditional medicine, that keep people out of formal health facilities. As members of these communities, community health promotors promote formal healthcare based on their understanding of harmful beliefs.
While community health promotors have been part of the Kenyan healthcare system for decades, they were not institutionalised or formally recognised by the Ministry of Health. Starting in 2024, community health promotors now receive a small monthly stipend through a 50/50 cost sharing model between the government and other stakeholders including international health NGOs.
The government provides community health promotors with a health kit with items such as a glucometer for use during their door-to-door visits. Photo: Joyce Chimbi
Thus far, 100,000 community health promotors have been deployed to local communities across Kenya. They each use a digital recordkeeping system, explains Irene Onkoba, a community health promotor who serves 33 households in Kibra in Nairobi County, one of the largest informal settlements in the world.
“During daily door-to-door visits, we enter data as we receive it from the households into an app installed on phones provided by the government,” she says. “Before, we would use pen and paper for recordkeeping and submit a written report. Writing a report from 33 households visited daily was difficult. The digital system is easy and the data is highly accurate.
“At the Ministry of Health level, they can monitor the data even as we are entering it and detect disease outbreaks, as was the case with cholera and polio, and activate an immediate response. We are the link between the community and health facilities.”
Community health promoters embedded in primary healthcare
At the heart of the PCN model is preventive rather than curative health. Community health promotors also carry medical tools such as a weighing scale (to monitor baby growth), glucometer, thermometer, cord clamps or a nipper—to tie the umbilical cord to stop blood flow from a placenta to a fetus during an emergency delivery outside a health facility—a torch, and tea thermos for refreshments.
“Before we were integrated into the Ministry of Health, we used to only carry a pen and a paper during our door-to-door health visits. Today, we have been trained to provide basic medical services such as growth monitoring. We can now tell when a child is not hitting their milestones as expected or when they have malnutrition and quickly link them up with a health facility,” Onkoba says.
Musyoki says community health promotors are critical as they conduct door-to-door visits and serve small villages in rural areas. “Hygiene is critical to reducing disease burden,” he says. “Community health promotors educate communities about household nutrition and environmental hygiene. In our community, we are noticing a reduction in diarrhoea and vomiting among children under five. Diarrhoea is a leading cause of child mortality in Kenya.
“They also help us in uptake of immunisation by encouraging mothers to adhere to the national schedule and shun wakunga [untrained and unsupervised traditional birth attendants] in favour of health facility deliveries.”
A robust primary healthcare system is essential to realising UHC, as WHO estimates show that through a primary healthcare approach, 90% of essential interventions for UHC can be delivered. Ndungu says the government and other stakeholders are working to roll out the PCN model across the country so that each person in Kenya will be linked to a PCN in line with the PHC Strategic Framework (2019-2024).
Ultimately, Ndungu believes that “the success of the PCN model will be dependent on sustainability strategies by Kenya’s two levels of government—national and county—together with other stakeholders and Kenyans at large.”
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