Primary Health Care (PHC) facility managers play a key role in the functioning of PHC facilities, in particular in implementing health sector reforms and facilitating initiatives that strengthen community involvement. This paper explores the roles and responsibilities of managers or ‘in-charges’ working in public PHC facilities in Kenya; as well as their challenges and coping strategies under accelerated devolution of health services.

The data presented in this paper is part of a wider set of activities aimed at understanding governance changes under devolution in Kenya through long-term collaboration between health managers and researchers. Research data was collected through seven formal in depth interviews and observations at four PHC facilities as well as eight in depth interviews and informal interactions with sub-county managers from June 2013 to July 2014.

The results show that PHC managers perform complex and diverse roles in a difficult environment with relatively little formal preparation. Their key concerns are:

• lack of job clarity and preparedness
• balancing multi-directional accountability responsibilities amidst significant resource shortages
• renumeration anxieties

Day-to-day management in an environment of resource constraints and uncertainty requires PHC in-charges who are resilient, reflective, and continuously able to learn and adapt. The paper highlights the importance of leadership development including developing critical soft skills such as relationship building.