Examining the effects of political decentralisation in Kenya on health sector planning and budgeting: a case study of Kilifi County.

Abstract

Health sector decentralisation has been a recurring theme in health systems reform discourse for several decades, particularly in developing countries. Decentralisation is promoted for its ability to strengthen community participation and accountability, and to enhance technical efficiency in the management of limited health sector resources. However, most of the literature on health sector decentralisation has been descriptive, reporting outcomes of different decentralisation models, with minimal analysis of how contextual factors contribute to the observed outcomes. In 2010, Kenya passed a new constitution through a nationwide public referendum. A key feature of this constitution was the introduction of 47 semi-autonomous devolved county governments. This study aimed to describe and analyse the effects of this major political decentralization on planning and budgeting in the health sector at the sub-national level, including the goals and intended strategies for health sector operational planning and budgeting, and stakeholder expectations and experiences of decentralisation. I used a case study design, focusing on Kilifi County, guided by a conceptual framework which drew on decentralisation and policy analysis theories. I used three tracers: planning and budgeting for recurrent expenditures; Human Resources for Health (HRH); and Essential Medicines and Medical Supplies (EMMS) management. I collected qualitative data through document reviews, key informant interviews, and participant and non-participant observations. I found that the Kenyan devolution was largely driven by the need to address political rather that technical challenges in public sector management. To this effect, county level functions were rapidly transferred without proper structures and capacity to undertake these functions leading to major disruption of public services at county level. Within the health sector, the early days witnessed perverse re-centralisation of operational financial management roles from health facility level to the county level. On HRH, there were major disruptions in staff salary payments, political interference with HRH management functions and confusion over certain HRH management roles; leading to industrial strikes and mass resignations by health workers. On EMMS, there were significant delays in the procurement process leading to long periods of stock outs of essential drugs in health facilities. With time though, and with the county governments establishing their structures and progressively building their capacity, a general improvement in counties’ ability to manage devolved functions, including health sector functions has been witnessed and there are deliberate efforts to find local level solutions to some of the emerging challenges. In conclusion I argue that the political push for decentralisation is often stronger than the technical intentions and implementation processes. There is thus need for health sector policy actors to have a broader understanding of the countries’ political context whenever designing technical strategies for implementing health sector decentralisation. In addition, I propose that the allocation of functions between central level and decentralised units should always be guided by considerations around decision space, organisational structure and capacity, and accountability arrangements and practices within the health system.