Abstract:
Background: Practices 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.
Methods: We 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.
Results: We 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.
Conclusions: Power 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.