Global Social Policy, Ahead of Print.
All UN member States committed to realizing universal health coverage (UHC) when they included UHC as Target 3.8 in the Sustainable Development Goals in 2015. However, the global commitment to UHC has not been matched with action on the ground. According to the World Health Organization, about half of the world population lacks full coverage for essential health services. To accelerate progress toward UHC, a close understanding of factors that drive adoption of UHC policies at the national and local levels is essential. The purpose of this study was to investigate the impetus for establishing a sub-national health insurance program in Kenya—the Makueni county government health insurance program (MakueniCare)—which led to increasing the percentage of the county population with health insurance, the majority of whom live in poverty, from 8.8% in 2013 to 91% in 2018. This qualitative case study drew on Kenyan law and policy documents as well as semi-structured interviews with 30 key informants in government and NGOs to understand the drivers that led to the establishment of MakueniCare. Findings revealed that several drivers—namely, global norms, decentralization, democratic competition, and the strategic action of social change-minded leaders—coalesced to influence the adoption of MakueniCare. The study offers timely insights into the factors driving UHC in Makueni, Kenya and lessons for other low- and middle-income countries working toward UHC.