Should Affordability Shape Treatment Guidelines in Kenya?

The everyday dilemma

A Nairobi oncologist once described a choice she faces often. The best treatment exists, but her patient cannot pay for it. Should she prescribe it anyway, knowing it may never be taken? Or prescribe what the family can afford, knowing it is second best?

This is not just a cancer problem. It happens every day in outpatient clinics across Kenya. A patient with high blood pressure or diabetes sits across from a clinician who knows the guideline, and knows the patient's budget.

Conditions like hypertension, diabetes and asthma last a lifetime. A treatment the patient cannot keep paying for is not really a treatment.

So here is the question: should Kenya's treatment guidelines be based on what patients can afford?

Two sides of the argument

Yes, affordability should count.

• A guideline no one can follow is a wish, not a standard.

• Many Kenyans still pay for care out of pocket, and SHA coverage is still settling in.

• Ignoring cost can push families into debt, or make them stop treatment when the first bottle runs out.

• Money spent on a costly drug for a few can mean fewer basic services for many.

  
  

No, affordability should not decide the standard.

• Poorer patients would get a lower standard of care by design.

• Prices change. Patents expire, insurance grows and procurement improves, so today's budget can lock in yesterday's limits.

• If we lower the standard to match what is affordable, no one feels pressure to fix how care is paid for.

The middle path: be honest, then be practical

The answer is not yes or no. It is openness about the choices we make.

1. Name the best option. Guidelines should state the treatment with the strongest evidence.

2. Offer clear alternatives. Add tiered, evidence-based options for settings with fewer resources.

3. Weigh cost in the open. Use published criteria for cost and budget impact, not quiet rationing at the bedside.

4. Report the gap. When the best option is out of reach, treat it as a policy problem to fix, not a clinical choice to hide.

What this looks like in everyday NCD care

In most common NCDs, good generic options already exist. The real challenge is keeping them available and affordable for years.

Condition	Best-evidence option	Practical, affordable option	Watch out for
Hypertension	Simple protocol, ideally single-pill combinations	Generic amlodipine, hydrochlorothiazide, enalapril or losartan	Stock-outs and monthly travel costs, not drug choice
Type 2 diabetes	Metformin, plus SGLT2 inhibitors for heart and kidney protection	Metformin, plus a sulfonylurea (gliclazide in older patients)	Test strips, syringes and cold storage often cost more than the drugs
Insulin users	Analogue insulin for patients with frequent low sugars	Human insulin for most patients	Cold chain and supplies
Asthma	Inhaled steroid-based treatment	Generic inhaled steroids	Reliever-only use (salbutamol alone) is cheaper but riskier
Heart attack and stroke prevention	Statins for high-risk patients	Generic atorvastatin	Under-prescribing, not cost

Hypertension. The drugs are cheap. The problem is keeping patients on them. The WHO HEARTS approach shows how: a short list of generic drugs, one simple protocol, and fewer pills per day. Facilities can help by stocking reliable generics and giving stable patients longer refills.

Diabetes. Metformin is first-line and cheap. Newer drugs like SGLT2 inhibitors protect the heart and kidneys and joined the WHO Essential Medicines List in 2023, but many patients still cannot afford them. A good guideline names them as preferred where affordable and gives a safe alternative where not. For insulin, WHO supports human insulin for most patients.

Asthma. Here the cheapest habit is the dangerous one. Many patients use only a salbutamol reliever. Global asthma guidance no longer recommends this for adults and teenagers, because it raises the risk of severe attacks. The fix is making generic inhaled steroids affordable, so the safe option is also the cheap one.

Statins. Generic atorvastatin is cheap and prevents heart attacks and strokes. Yet it is often not prescribed. Sometimes the most cost-effective step is simply following the guideline we already have.

Generics: our most practical tool

Generics contain the same active ingredient as the original brand, often at a fraction of the price. Kenya's HIV response shows what they can do at scale. Building them into the Kenya Essential Medicines List, KEMSA procurement and prescribing guidelines can widen access without lowering the standard.

But generics only work when five things are in place:

1. Quality. Strong regulation by the Pharmacy and Poisons Board, and action against substandard and fake products.

2. Fair prices. Cheaper procurement must reach the patient, not disappear into retail markups.

3. Biologics. Many newer cancer and autoimmune drugs are biologics. Their cheaper versions (biosimilars) are harder to make, approve and adopt.

4. Confidence. Clinicians and patients must trust that generics work just as well. That takes education.

5. Availability. A cheap drug that is out of stock helps no one.

A six-point checklist for hospitals and clinics

Use this to review how your facility handles NCD medicines.

1. Review your formulary every year. For each common NCD, stock at least one quality-assured generic first-line drug.

2. Set a clear substitution policy. Say when pharmacists may switch to a generic, how patients are told, and when a brand is clinically needed.

3. Vet your suppliers. Buy only PPB-registered products from licensed suppliers. Report quality problems and side effects to the PPB.

4. Show patients the prices. Let them compare brand and generic costs before they decide.

5. Make it easy to stay on treatment. Use combination pills, longer refills for stable patients and follow-up reminders.

6. Write down cost-based decisions. When cost leads to a lower-tier choice, record the reason and the talk with the patient. This protects everyone and builds evidence for better financing.

The takeaway

Affordability should inform guidelines. It should never quietly define them.

Be honest about what is best. Be practical about what is possible. Then use generics, pooled procurement and insurance reform to close the gap.

In NCD care, treatment lasts a lifetime. Getting this right is the difference between writing a prescription and keeping a patient well.

Your turn: Are you a clinician, pharmacist, facility manager or policymaker? Where do you feel this tension most in NCD care, and what would make you trust generics more? Share your experience below.

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LGM Health Advisory helps hospitals and clinics with clinical governance, formulary and quality systems, medicolegal risk and health financing. Talk to us about building NCD care that is practical, affordable and meets the standard.