Enrolment as Calculated Risk: Community Knowledge of Universal Health Coverage and the Limits of the Deficit Communication Model in Makueni County
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Date
2026-09
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Publisher
Journal of African Interdisciplinary Studies (JAIS)
Abstract
This article investigates the notion of enrolment as a calculated risk and its implications for universal health coverage in Kenya, focusing on Makueni County. Low enrolment in mandatory health insurance is conventionally diagnosed as a communication problem to be solved through better awareness campaigns. This article challenges that assumption. Drawing on a qualitative single instrumental case study of Makueni County, Kenya, with sixteen key informant interviews and five focus group discussions involving 48 participants analysed through reflexive thematic analysis, the study finds that community Universal Health Coverage literacy is broad but shallow. Awareness of the Social Health Authority is near-universal, but it is marked by three consequential knowledge gaps: an inpatient-only coverage limitation that leaves most common health needs unserved; an annual back-payment obligation discovered by many participants only at the point of hospitalisation; and a maternal-care regression following the withdrawal of a key maternity support programme. Information-channel trust follows a consistent hierarchy in which health workers are most trusted and politicians least, yet the Social Health Authority rollout relied most heavily on the least trusted channels. The central finding is that enrolment decisions are driven not by ignorance but by a calculated risk assessment of whether the scheme offers sufficient value relative to its cost, complexity, and reliability. Three structural features produce rational disincentives to enrol for informal-sector and vulnerable populations. The study concludes that low enrolment reflects a credibility and design problem that no communication strategy alone can resolve.
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Keywords
Kenya, calculated risk, community knowledge, enrolment, health literacy, institutional trust, Makueni County, means-testing, Universal Health Coverage
Citation
Amukuzi, M. K; Mulwo, A. K & Obuya, J. (2026). Enrolment as Calculated Risk: Community Knowledge of Universal Health Coverage and the Limits of the Deficit Communication Model in Makueni County, Kenya. Journal of African Interdisciplinary Studies,10 (9). 17 - 30