Disruption, disillusion and contestations: the effects of rapid implementation of devolution on the health sector in Kenya
March 2018 marks five years since devolution in Kenya, implemented as part of government efforts to bring service delivery closer to its citizens. Described by the World Bank as ‘among the most rapid and ambitious devolution processes going on in the world’, researchers from KEMRI-WT have been monitoring the early experiences and effects of devolution on the health sector in Kilifi County.
Brief background on devolution in Kenya
- Devolution refers to the transfer of decision-making power, resources and representation from the centre (national) to local levels.
- Devolution was a central part of the Constitution of Kenya in 2010, leading to the creation of 47 county governments and associated structures and institutions including county assemblies and treasuries.
- In the health sector, County governments are now responsible for key management functions including: planning, budgeting and financial management, Human Resources for Health and Emergency Medicines and Medical Supplies.
The research found that 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 rather than technical priority needs. The multiple challenges and uncertainties faced by health workers, culminated in a protracted strike during which they called for health services to be re-centralised.
If devolution was intended to improve service delivery, why then did it lead to disruption in health services and disillusion among workers? The research identifies three interconnected reasons.
Rapid transfer of powers to County governments
Despite the new Constitution outlining a seven-year process of transferring functions from national to county governments beginning in August 2010, in 2013 the newly elected President, under political pressure from counties and the opposition, directed that devolution should occur immediately.
At this time, many new county governments had not fully established structures, such as County Treasuries, Assemblies and Sector departments, nor had they employed staff to manage them. Within the health sector, most County Departments of Health – which were now responsible for health care provisions, did not have an agreed standard organisational structure, and there were significant delays in the appointment of senior County Health Sector top managers.
Confusion and contestations over different management roles and responsibilities for the health sector
At early stages of devolution, there were no clear terms of reference or guidelines outlining the roles and responsibilities of the different health sector actors between county and national government and within county governments. On health workforce management roles for example; It was not clear who, between the County Department of Health as the County Public Services Boards and the National Ministry of Health, would take responsibilities over certain critical management responsibilities including Inter-County transfers, In-service training and health worker promotions. This created anxieties and uncertainties among health workers, leading to reported low staff morale, resignations and the health worker strikes .
Lack of capacity at county level to undertake devolved tasks
Also at the time of devolution, counties lacked the personnel with the skills and experiences necessary to undertake devolved key strategic management tasks such as developing strategic plans and budgets, including in the health sector.
“This is a primary school teacher who was picked from the classroom and made Chief Officer. She has no capacity to do any planning, and you’re telling them today – develop a strategic plan.”
When capacity gaps were identified, such as in procuring Emergency Medicines and Medical Supplies, interim action plans helped to lessen the negative impacts of devolution. In this instance, the national Ministry of Health procured a buffer-stock of six-months’ worth of medical supplies for all government health facilities to use while County level procurement structures were being set up. This example illustrates the importance of good communication between all parties involved in devolution during the planning phase to identify potential problems and find effective solutions.
Lessons for other countries considering devolution
The early implementation experiences in Kenya provide important lessons for other countries that are considering devolution, or are in the process of planning health sector decentralisation policies.
- Always consider individual and institutional capacity constraints when allocating functions between central and local levels
- Ensure appropriate structures are already in place at county level to undertake decentralised functions
- Pre-establish clear and distinct roles between central and local levels
Over time, the county governments have established structures and progressively built capacity, leading to a general improvement in their ability to manage devolved functions. Researchers have witnessed counties making deliberate efforts to find local level solutions to some emerging challenges, and to progressively work towards meeting the overall public goals and expectations of devolution.
Dr Tsofa is the Director of Kilifi Centre for KEMRI-Welcome Trust, Kenya. His research interests are in health systems governance, health financing and health policy analysis - with a special interest in health sector resource allocation, priority setting, planning and budgeting. His DrPH, from LSHTM focused on the effects of political decentralisation in Kenya on county level health sector planning and budgeting.