Abstract:
Devolution changes the locus of power within a country from central to sub-national
levels. In 2013, Kenya devolved health and other services from central government to 47
new sub-national governments (known as counties). This transition seeks to strengthen
democracy and accountability, increase community participation, improve efficiency and
reduce inequities. With changing responsibilities and power following devolution
reforms, comes the need for priority-setting at the new county level. Priority-setting
arises as a consequence of the needs and demand for healthcare resources exceeding the
resources available, resulting in the need for some means of choosing between competing
demands. We sought to explore the impact of devolution on priority-setting for health
equity and community health services. We conducted key informant and in-depth
interviews with health policymakers, health providers and politicians from 10 counties (n
= 269 individuals) and 14 focus group discussions with community members based in 2
counties (n = 146 individuals). Qualitative data were analysed using the framework
approach. We found Kenya's devolution reforms were driven by the need to demonstrate
responsiveness to county contexts, with positive ramifications for health equity in
previously neglected counties. The rapidity of the process, however, combined with
limited technical capacity and guidance has meant that decision-making and
prioritization have been captured and distorted for political and power interests. Less
visible community health services that focus on health promotion, disease prevention and
referral have been neglected within the prioritization process in favour of more tangible
curative health services. The rapid transition in power carries a degree of risk of not
meeting stated objectives. As Kenya moves forward, decision-makers need to address the
community health gap and lay down institutional structures, processes and norms which
promote health equity for all Kenyans.