In March 2013, Kenya transitioned from a centralised to a devolved system of governance. Within the health sector, this entailed the transfer of service provision functions to 47 newly formed semi-autonomous counties, while policy and regulatory functions were retained at the national level. The devolution process was rapid rather than progressive.

This study conducted qualitative research within one county to examine the early experiences of devolution in the health sector. Specifically focusing on the experience of change from the perspective of sub-county managers, who form the link between county level managers and health facility managers. 

The findings reveal that sub county managers as with many other health system actors were anxious about and ill prepared for the unexpectedly rapid devolution of health functions to the newly created county government. 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.

The study illustrates the importance in accelerated devolution contexts for:

• mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system
• clear lines of communication during reforms to these actors
• anticipating and managing the effect of change on intangible software issues such as trust and motivation.

More broadly, the study shows the value of examining organisational change from the perspective of key actors within the system, and highlights the importance of drawing upon and working with those already in the system in times of rapid change. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained capacity building within the health system.