A call for more intersectionality analysis in studies of Kenyan health sector devolution

We are health systems researchers based in Kenya who are tracking the health sector implications of the on-going political devolution in the country. We attended an interesting meeting recently at the University of Oxford to discuss current and future research on devolution in Kenya, in which our plans to continue to follow this complex and contested process as it unfolds across several counties, and to incorporate an intersectional approach in our analyses, were reinforced.

The meeting was convened by Professor Nic Cheeseman (University of Oxford) and Professor Catherine Booth (London School of Economics), and attended by a small group of prominent political scientists and students from diverse contexts (including Kenya, UK, US and Finland). We were delighted to interact with experts from different disciplines with broader interests than the health system. We shared our findings on the implications of devolution for county health systems, focusing on three ‘tracers’: 1) health sector budgeting and planning; 2) essential medicines and supplies; and 3) human resources.

Several contextual factors stood out as particularly relevant to our health systems research.

• Kenya is an exciting country to study decentralization implementation and impact. The country is undergoing meaningful change, as opposed to the extension or replication of historical power structures at sub-national level as is the case with many countries in the region. This is related in part to the push for devolution in Kenya having come primarily from the public rather than the centre, culminating in the passing of a new constitution in 2010 through a national referendum. The 47 new ‘semi-autonomous’ counties also control significant funds: counties get allocated a minimum of 15% of the total government revenue as an equitable share (distributed according to set criteria), and an additional 0.5% (as an equalization fund targeted at marginalized counties). And governors are advocating for further funds and powers.
• The health sector is an important lens through which to study devolution. With health as the biggest, and most complex and visible sector to be devolved, health system devolution has important implications for broader devolution and vice versa.
• Devolution in Kenya is unfolding in unplanned and unexpected ways. The transfer of functions to counties post the 2013 elections happened at a much faster pace than many technocrats and observers had anticipated leading to some chaos and confusion, but also to diversity and creativity. Complex power battles over status and resources within counties, and between county and national political elites, are ongoing. While there is excitement among many Kenyans that development activities are reaching communities that were previously missed, there are also concerns that corruption may have been transferred downwards and become increasingly entrenched; that it has become ‘everybody’s turn to eat’.
• Many Kenyans are concerned that health care has deteriorated since devolution, but remain supportive of the broader principles and goals of devolution. Tracking of counties’ capacity to deliver health care and protect and improve public health and well-being will therefore be complex but essential.
• The importance of analysing the intersections between gender, ethnicity and class in the politics of inclusion and exclusion under devolution was highlighted. There is a notable absence of females in senior county government positions, and many of the women who are in government have been included to meet the 30% affirmative action legal requirements, and for political purposes, rather than out of a genuine interest to strengthen women’s rights and build civil society more broadly. In the health sector, which is highly gendered, exploring how different factors – including gender – intersect to impact on quality health care for everybody in need is critical.

In terms of research priorities that resonate with our own plans, there is a clear need to continue to follow this complex and contested process as it unfolds in the health sector. Longitudinal approaches that incorporate critical reflection from diverse social scientists is ideal, as is the incorporation of comparative studies across counties given significant differences across them in composition, history, and current implementation experiences. Incorporating an ‘intersectionality lens’ is long overdue. In the health system our priority remains understanding the implications of change for equitable access to quality care, and contributing to research and practice that challenges inequity.