Global Context: A Radical Proposal for an Ailing System

A report published on Sunday, November 23, 2025, by the UK-based thinktank Re:State has ignited a fierce debate on the future of hospital-centric healthcare. The paper, authored by Head of Health Rosie Beacon, argues that hospitals in the United Kingdom's National Health Service (NHS) must become smaller, with fewer beds, to save the system from a state of "permacrisis." The core proposal is a fundamental shift away from large, centralized hospitals towards delivering diagnostic tests, outpatient appointments, and treatments in community settings and directly in people's homes. Beacon suggests this move would save billions, improve patient outcomes, and relieve pressure on overworked staff by adapting to the needs of an ageing population with chronic illnesses.

The Kenyan Reality: Overburdened Hospitals and Bed Shortages

While originating in the UK, the Re:State report resonates with the persistent challenges facing Kenya's public health sector. Major referral hospitals, such as Kenyatta National Hospital (KNH), are frequently characterized by overcrowding, long queues, and significant strain on resources. Patients across the country report delays in service and systemic inefficiencies. According to a 2025 Economic Survey, the number of beds in Kenya's public hospitals declined by over 2,200 between 2023 and 2024, falling from 40,814 to 38,552 and exacerbating the crisis. This reduction in capacity comes as the population's demand for healthcare continues to rise. Furthermore, data indicates Kenya's hospital bed density is approximately 1.4 beds per 1,000 people, a figure that, while debated, points to a significant infrastructure gap. The uneven distribution of facilities and staff, heavily favouring urban centres, further complicates access to care for millions in rural and underserved areas.

A Shift in Strategy: Kenya's Push for Primary and Community Health

The Re:State proposal aligns conceptually with the Kenyan government's own stated policy direction towards strengthening primary healthcare as the foundation for achieving Universal Health Coverage (UHC). The Ministry of Health's strategy emphasizes a shift from curative, hospital-based care to preventative and promotive health services delivered at the community level. Central to this strategy is the deployment of 100,000 Community Health Promoters (CHPs), who serve as the first point of contact for households, linking them to the formal health system. The goal is for CHPs, operating within community health units, to handle basic health promotion, disease prevention, and referrals, thereby reducing the burden on Level 4 and 5 hospitals. This approach, outlined in the Kenya Primary Health Care Strategic Framework 2019-2024 and the Community Health Strategy 2020-2025, aims to create Primary Care Networks (PCNs) that manage health proactively within the community, rather than reactively in hospitals.

Viability and Hurdles: Can a Decentralized Model Work in Kenya?

Despite the policy alignment, implementing a decentralized model faces significant hurdles. Kenya's healthcare system is grappling with financial instability, with many hospitals burdened by debts inherited from the former National Health Insurance Fund (NHIF) and facing delayed reimbursements under the new Social Health Authority (SHA). A recent survey showed that only 20% of primary care facilities received their full payments, threatening the viability of the very services intended to form the bedrock of UHC. Moreover, a Ministry of Health census from late 2023 revealed that 93% of Kenyan health facilities lack the necessary equipment for basic outpatient services, and 84% are ill-equipped for maternity services. For a shift towards community-based care to be successful, substantial investment is required in equipping these lower-level facilities and ensuring the CHP workforce is adequately compensated, trained, and supplied. The transition from a hospital-centric mindset requires not only financial investment but also a profound cultural shift among both the public and healthcare administrators. While the UK's debate over shrinking hospitals provides a compelling vision, the Kenyan context demands a focus on first building up the capacity and reliability of community-level care before any radical downsizing of central facilities can be considered. The conversation, however, is a critical one, forcing a necessary re-evaluation of how to build a resilient and equitable health system for all Kenyans.