Decentralisation has been a recurring theme in health system reforms for several decades. It is argued to promote community participation, accountability, technical efficiency and equity in the management of resources. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments and gave them responsibility for the management and delivery of health services.

Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, this study analysed the early implementation experiences of decentralisation at county level. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014.

As with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. In the case of HRH this led to:

• major disruptions in staff salary payments;
• political interference with HRH management functions;
• confusion over HRH management roles;
• lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level;
• health worker strikes;
• mass resignations were witnessed.

With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution.

The devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies.