Abstract:
Background: In 2013, Kenya transitioned into a devolved system of government with a
central government and 47 semi-autonomous county governments. In this paper, we
report early experiences of devolution in the Kenyan health sector, with a focus on public
county hospitals. Specifically, we examine changes in hospital autonomy as a result of
devolution, and how these have affected hospital functioning.
Methods: We used a qualitative case study approach to examine the level of autonomy
that hospitals had over key management functions and how this had affected hospital
functioning in three county hospitals in coastal Kenya. We collected data by in-depth
interviews of county health managers and hospital managers in the case study hospitals
(n = 21). We adopted the framework proposed by Chawla et al (1995) to examine the
autonomy that hospitals had over five management domains (strategic management,
finance, procurement, human resource, and administration), and how these influenced
hospital functioning.
Findings: Devolution had resulted in a substantial reduction in the autonomy of county
hospitals over the five key functions examined. This resulted in weakened hospital
management and leadership, reduced community participation in hospital affairs,
compromised quality of services, reduced motivation among hospital staff, nonalignment of county and hospital priorities, staff insubordination, and compromised
quality of care.
Conclusion: Increasing the autonomy of county hospitals in Kenya will improve their
functioning. County governments should develop legislation that give hospitals greater
control over resources and key management functions.