Abstract
BackgroundPractices of power lie at the heart of policy processes. In both devolution and priority-setting, actors seek to exert power through influence and control over material, human, intellectual and financial resources. Priority-setting arises as a consequence of the needs and demand exceeding the resources available, requiring some means of choosing between competing demands. This paper examines the use of power within priority-setting processes for healthcare resources at sub-national level, following devolution in Kenya.MethodsWe interviewed 14 national level key informants and 255 purposively selected respondents from across the health system in ten counties. These qualitative data were supplemented by 14 focus group discussions (FGD) involving 146 community members in two counties. We conducted a power analysis using Gaventa’s power cube and Veneklasen’s expressions of power to interpret our findings.ResultsWe found Kenya’s transition towards devolution is transforming the former centralised balance of power, leading to greater ability for influence at the county level, reduced power at national and sub-county (district) levels, and limited change at community level. Within these changing power structures, politicians are felt to play a greater role in priority-setting for health. The interfaces and tensions between politicians, health service providers and the community has at times been felt to undermine health related technical priorities. Underlying social structures and discriminatory practices generally continue unchanged, leading to the continued exclusion of the most vulnerable from priority-setting processes.ConclusionsPower analysis of priority-setting at county level after devolution in Kenya highlights the need for stronger institutional structures, processes and norms to reduce the power imbalances between decision-making actors and to enable community participation.
Highlights
Practices of power lie at the heart of policy processes
Vary across counties? Who benefits from this re-distribution? How are the new powers used? Do new priorities lead to improved health equity? We aim to provide a power analysis of priority-setting at the new county level, to understand how power influences priority-setting in Kenya
Our results relating to power are presented in line with Gaventa’s power cube and Veneklassen’s expressions of power, as these are a natural fit according to the power-related findings arising from the data
Summary
Practices of power lie at the heart of policy processes [1] In both devolution and priority-setting, actors seek to exert power through influence and control over material, human, intellectual and financial resources [2, 3]. In both processes, a range of actors, each with their own values, needs and interests must make judgements and decisions about the selection of priorities contained within plans and budgets. While sometimes viewed as a purely technical process, priority setting is typically a complex, value laden process where actor’s values and interests are brought to bear, negotiating decisions about which values or principles should dominate as political, institutional and managerial factors come into play [9]
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