Why it matters 

Since 2013, Kenya has embarked on a rapid process of devolution with the creation of 47 semi-autonomous county governments. In the health sector, county governments are now responsible for key management functions including: planning, budgeting and financial management, human resources and the provision of emergency medicines and medical supplies.

Devolution, in theory, is argued to promote community participation, accountability, technical efficiency and equity in the management of resources. Whilst the potential benefits of devolution in the health sector are well documented, it is important to monitor the actual implementation experiences of devolution and how it impacted on health service delivery in practice.

What we did 

Researchers from KEMRI-WT monitored the early experience and effects of devolution on the health sector in Kilifi County. Initial baseline data was collected prior to devolution being introduced in 2013, enabling researchers to compare data from before and after devolution. 

The research has focused on investigating the effects of devolution on several areas including: 

• Human resources for health 
• Budgeting and planning 
• Essential medicines and emergency medical supplies 
• Hospital autonomy 
• Experiences of sub-county health managers 

What we found 

• Devolution initially caused serious disruption to public health services. 
  Hospitals and primary health facilities  lost essential sources of revenue, many doctors and nurses faced  delays in salary payments and spending decisions were driven by political motivations. 
   
• Devolution reduced hospital autonomy over key management functions.  
  Public county hospitals lost control and flexibility over several sources of revenue and significant hospital management committee roles were transferred to County health departments, leaving hospital managers feeling powerless and demotivated.   
   
• Lack of capacity at the county level to undertake devolved tasks. 
  County level structures and institutions were not in place to manage the health sector effectively, and there were no guidelines about roles and responsibilities for both national and county actors. Lack of capacity was partly due to the rapid transfer of powers to county governments.  
   
• Sub-county managers were unprepared for the rapid pace of devolution. 
  They experienced loss of autonomy and resources in addition to confused lines of accountability within the health system. However, they harnessed individual, team and stakeholder resources to maintain their jobs, and continued to play a central role in supporting peripheral facility managers to cope with change.
   
• Improving picture. 
  Over time, the county governments have established structures and progressively built capacity, leading to an improvement in their ability to manage devolved functions. Counties have made deliberate efforts to find local-level solutions to emerging challenges and to work towards meeting the overall public goals and expectations of devolution. 

Implications for policy and practice

1. For countries with similar settings to Kenya, individual and institutional capacity considerations should always be taken into account when allocating functions between the centre and local levels. 
    
2. Policymakers should clarify roles and responsibilities of different actors at all levels of the system and build capacity of counties to undertake specific tasks. 
    
3. Policymakers should ensure that appropriate structures are already in place at county level to undertake decentralised functions. 

What we changed 

In Kilifi County,  researchers highlighted the consequences of sudden changes to health facility and hospital funding, partially brought about by devolution. Their efforts eventually led to new county government legislation aimed at ensuring facilities have access to, and decision-making powers over, much needed funds. 

At the national level, researchers from KEMRI-WT have been requested by the Senate Committee on Health to compile evidence and make recommendations for strengthening devolution efforts. Findings will shape the Senate's agenda and plans to strengthen devolution through either the refinement of county laws or provision of guidelines for policy implementation.