In 2013, Kenya transitioned into a devolved system of government with a central government and 47 semi-autonomous county governments. This paper reports on early experiences of devolution in the Kenyan health sector, with a focus on public county hospitals. Specifically, it examines changes in hospital autonomy as a result of devolution, and how these have affected hospital functioning.

Researchers at the KEMRI Wellcome Trust Research programme used a case study approach to examine the level of autonomy hopsital had over key management functions and how this had affected hospital functioning in three county hospitals in coastal Kenya. Data was collected  through in-depth interviews of county health managers and hospital managers in the case study hospitals. The autonomy of hospitals was examined over five management domains:

1. Strategic management
2. Finance
3. Procurement
4. Human resource
5. Administration

The findings reveal that devolution has resulted in a substantial reduction in the autonomy of county hospitals over the five key functions examined. This reduction in autonomy has led to:

• weakened hospital management and leadership
• reduced community participation in hospital affairs
• compromised quality of services
• reduced motivation among hospital staff
• non-alignment of county and hospital priorities
• staff insubordination
• compromised quality of care

The authors recommend that national and county decision makers should amend devolution laws to give hospitals autonomy over key functions. There is also a need to clarify and realign the roles of hospital management and leadership structures to the current institutional and organisational framework in the devolved system.