The Determinants of mental health financing in Kenya: towards a stakeholder-informed framework for sustainable financing

Abstract

Mental health services in Kenya face a severe funding crisis. Despite contributing approximately 15% of the national disease burden, the sector receives less than 1% of the health budget, resulting in inadequate services, medication shortages, and a treatment gap affecting three-quarters of those who need care. This chronic underfunding persists despite the progressive frameworks established by the Kenya Mental Health Policy (2015–2030) and the Mental Health (Amendment) Act, 2022. While existing research has documented the burden of mental illness and service availability gaps, the underlying determinants of fiscal neglect—particularly institutional stigma, political economy dynamics, and the internal prioritization logics of financing institutions—remain poorly understood. This study examined the determinants of mental health underfunding by exploring the perspectives of 32 key informants across the National Treasury, Ministry of Health, Social Health Insurance Fund, county health departments, service providers, civil society organisations, and community representatives. A qualitative case study design was employed, with data collected through semi-structured interviews and analyzed using reflexive thematic analysis. Four themes emerged. Institutional and governance barriers encompassed fragmented county governance post-devolution, mental health's marginal positioning within the Ministry of Health, inter-agency coordination failures between Treasury, MoH, SHIF, and county governments, and capacity constraints at all levels. Stigma and perceptions as a fiscal determinant included the perception of mental illness as less medically legitimate, productivity biases discounting treatment returns, and selective evidence dismissal — with 50% of participants questioning the KES 62 billion economic cost estimate despite its methodological equivalence with accepted figures for other conditions. Political economy and financing mechanism feasibility identified absent parliamentary champions, fragmented civil society advocacy, donor crowding-out, and rated SHIF benefit package expansion and conditional grants as the most feasible reform pathways. The stakeholder verdict converged across all participant groups on institutional stigma, political invisibility, and fiscal unprotection as three interlocking mechanisms sustaining the less-than-1% allocation. The study extended Modified Labeling Theory to fiscal policy decision-making, demonstrated the value of stakeholder-centred qualitative methods in health financing research, and generated evidence-based recommendations toward sustainable mental health financing and Universal Health Coverage in Kenya.

Keywords: mental health financing, health policy, stakeholder perspectives, institutional stigma, sustainable financing, Kenya, Universal Health Coverage