“I cannot imagine going to a level two hospital”, says John Mwangome. “Even Coast General Hospital is struggling, so I just hope I don’t fall sick.”
Vincent Sande has made up his mind. The Kongowea resident will not visit a lower-level health facility, and past experience is the reason. “I don’t trust these smaller hospitals because I have never received good service there,” he says. Even at referral hospitals, he adds, long waiting hours remain a challenge.
Paul Barasa goes a step further. He is not just sceptical of primary healthcare facilities – he is largely unaware of how the system works. He has never encountered a Community Health Promoter (CHP), the frontline workers the government has deployed to provide basic health services and education at the household level. “I don’t know who they are or what they do. If I get sick, I just go to a pharmacy first,” he says.
John Mwangome is more fatalistic still. “I cannot imagine going to a level two hospital. Even Coast General is struggling, so I just hope I don’t fall sick,” he says.
These are not isolated sentiments. Across Mombasa, a quiet but consequential pattern is playing out daily. Residents are bypassing dispensaries and health centres close to their homes and heading instead to Coast General Teaching and Referral Hospital, the county’s only Level 5 facility. By seven o’clock in the morning, its benches are already full. Patients sit shoulder to shoulder clutching files, others lean against walls, waiting for hours, many of them seeking treatment for conditions that could have been handled at a dispensary, minutes from their front door.
Primary Health Care (PHC) refers to essential, first-contact services offered at dispensaries and health centres. According to Kenya’s Ministry of Health, up to 80 per cent of common illnesses can be treated at this level. Yet despite Kenya’s ongoing push for Universal Health Coverage (UHC), large numbers of patients continue to opt for higher-level hospitals, overwhelming facilities that were never designed to absorb that volume.
In urban areas like Mombasa the presence of Community Health Promoters is hardly felt on the ground
George Obonyo, a resident of Nyali, says he has heard of CHPs but has never actually encountered one. “I don’t really know what they do, and I prefer going to Coast General because I am sure I will get full medical attention,” he says.
His uncertainty reflects a structural visibility problem. The government’s Community Health Strategy targets one CHP per 100 households, but in urban areas like Mombasa, their presence on the ground remains low. Health experts have long warned that this gap in awareness, combined with low trust in lower-level facilities, is a significant driver of congestion at referral hospitals.
Salma Hemed, Executive Director of She Rises and a resident of Old Town, is not surprised by what Sande, Barasa and Obonyo describe, but she is troubled by it. “It is surprising that many residents living near level two facilities do not use them,” she says. “People don’t have faith in these facilities and instead rush to Coast General.”
The problem, she explains, is compounded by a basic misunderstanding of how the healthcare system is structured. “Most people don’t know who CHPs are or how to find them. Yet they can help with first aid and health education at the household level,” she says. Many patients, she adds, do not understand the referral system, which is designed to direct people to the appropriate level of care for their condition, ensuring efficiency across the entire health network.
The picture is not uniformly bleak. For some Mombasa residents, primary healthcare is functioning as intended.
Mombasa residents prefer private clinics over public primary facilities for better quality care, even at higher cost
Fredrick Nyalum, a resident of Majengo, says he actively prefers his local Majengo Dispensary. He has visited twice – once for malaria, once for an ear infection. “They may not have all the equipment like Coast General, but for a start, they are efficient,” he says. “The staff are friendly, and there is no congestion.” On his second visit, he was referred to a higher-level hospital for specialised care, a straightforward demonstration of the referral system working as designed.
Nyalum’s experience points to what is possible. But it also highlights how unevenly that possibility is distributed across the city.
Mombasa’s urban character adds a layer of complexity that rural counties do not face in the same way. The city has a significant private health sector, and many residents choose private clinics over public primary facilities, believing they offer better quality care even at higher cost. This further drains potential users away from the public PHC system, reducing its utilisation and, in some cases, its sustainability.
Public health guidelines are explicit that strengthening primary healthcare is essential to achieving Universal Health Coverage. When properly utilised, PHC can address most common health needs, relieving pressure on referral hospitals and enabling facilities like Coast General to focus on the complex cases they were built to handle.
Success of primary healthcare will depend on whether communities understand, trust and use the system
The referral system itself is sound in design. A patient presents at a dispensary or health centre, receives care for conditions that can be managed there, and is referred upwards only when the condition requires it. This tiered approach is central to Kenya’s UHC framework and mirrors health system architecture in countries that have achieved strong primary care outcomes. The breakdown in Mombasa is not in the design. It is in whether residents know about it, and whether they trust it.
Hemed is calling for the county government to treat public awareness as a health infrastructure investment in its own right. “The county government needs to invest in awareness, especially in urban areas,” she says. “If people understand how the system works, they will use it correctly.”
She also proposes a practical measure: deploying community health personnel within major hospitals to guide patients, identify those presenting with conditions manageable at lower levels, and redirect them appropriately. Done well, this could begin to ease congestion at Coast General while simultaneously connecting residents to the primary care facilities they have been bypassing.
As Kenya continues to pursue Universal Health Coverage, the success of primary healthcare will depend not only on policy implementation but on whether communities understand, trust and use the system. Until that gap is closed, referral hospitals like Coast General will continue to shoulder a burden that was never meant to be theirs.
