Insurance coverage and treatment gaps among adults with hypertension or diabetes in Kenya: a sex-stratified analysis of the 2022 Demographic and Health Survey

Background: Kenya replaced the National Health Insurance Fund with the Social Health Authority in October 2024, making the 2022 Kenya Demographic and Health Survey the last nationally representative pre-transition baseline. Evidence on insurance coverage and treatment gaps among adults already diagnosed with hypertension or diabetes remains limited, including how these patterns differ by sex. We aimed to estimate the level, distribution, and correlates of insurance coverage and treatment gaps among diagnosed adults at the close of the NHIF era. Methods: We conducted a cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey. Insurance status, prior diagnosis, and current medication use were reported by respondents. Analyses were sex-stratified and survey-weighted, with adjusted prevalence ratios estimated to assess associations between insurance coverage and treatment gaps. Wealth-related inequality was examined using concentration indices. Results: The analytic sample included 1,932 diagnosed adults (1,384 women and 548 men). Any insurance coverage was 47.7%, largely driven by National Health Insurance Fund enrolment (43.4%). Overall, 63.8% of diagnosed adults reported not receiving treatment, including 67.1% of women and 59.8% of men, with treatment gaps exceeding 60% across all wealth quintiles. Insurance coverage was strongly pro-rich, whereas treatment gaps were distributed across the wealth gradient. After adjustment, insurance was not strongly associated with lower treatment-gap prevalence among women or men, with no evidence of effect modification by sex. Among women, lack of money for treatment was reported as a major barrier far more frequently among the uninsured than the insured. Conclusions: Before the Social Health Authority transition, Kenya faced both incomplete insurance coverage and substantial treatment gaps among adults diagnosed with hypertension or diabetes. These findings provide a critical pre-transition benchmark and suggest that expanding insurance enrolment alone may be insufficient to close treatment gaps without improvements in benefit depth, medicine availability, and frontline readiness for chronic care delivery.