Devolution of services is a broad continuum of events that culminates in transfer of power, authority and decision making powers to the local authorities (The Pan African Medical Journal, Henry Nyongesa)

The promulgation of the new constitution in Kenya in August 2010 effectively ushered in devolution as the latest and highest form of decentralization in Kenya. The health sector was the largest service sector to be devolved under this new governance arrangement. The rationale for devolving the sector was to allow the county governments to design innovative models and interventions that suited the unique health needs in their contexts, encourage effective citizen participation and make autonomous and quick decisions on resource mobilization and management possible issues ( Council for the Development of Social Science Research in Africa, Leah Kimathi)

The Kenya 2010 constitution provides a legal framework that guarantees an all-inclusive rights-based approach to health service delivery to Kenyans. It provides that Kenyans are entitled to the highest attainable standards of health, which includes the right to healthcare services including reproductive health care (Article 43). Article 53 provides for the right of every child to basic nutrition, shelter and healthcare. In Article 56, the constitution provides that the state shall put in place affirmative action designed to ensure that minorities and marginalized groups have reasonable access to water, health services and infrastructure.

To actualize these rights, the constitution has divided the healthcare responsibilities between the county and national governments. The Fourth Schedule of the constitution provides specific guidance on which services the county or national governments are to provide. In the health sector, essential health service delivery is assigned to county governments, while the national government retains health policy, technical assistance to counties, and management of national referral health facilities

In the Kenyan scenario, devolution of health care services to the 47 county governments is heavily driven by constitutional pressures. Whether devolution is the panacea to challenges facing public healthcare or not has not been described in any substantive paper. Yet, this represents one of the radical healthcare reforms in the post colonial period. In brief, health legislative process is within the domain of central government with ultimate decision making and implementation being vested upon counties. In principle, therefore, the ministry of health is comparatively weaker considering shared responsibilities with other ministries and decisive role of regional health ministries. In these initial stages, health services from the lowest delivery point (health centre) to provincial district referral hospitals have been put under the management of county governments. To expedite the process, county government health docket is run by county director of health. The county public service commission, on the other hand, is mandated to recruit, discipline and dismiss the personnel.

For health services to be all inclusive and rights-based, as envisaged in the constitution, four important inputs are required. First, there has to be the availability of a network of healthcare facilities; second, the facilities must be functional with competent and motivated staff; third, there needs to be supplies of essential medicines, and, finally, funds for the operation and maintenance of health facilities must reach the facilities on time. These four factors are primary to delivering the healthcare promise to the 62 per cent of Kenyans who primarily rely on the public healthcare system (Mwangi 2013).

Transition from national to county governments has been marred by inconsistency, poor understanding of the system, management issues and lack of coordination between the two levels of government. At the national level, challenges of devolution as depicted in the media have emerged in the form of poor management, resource distribution, ethnicity fears, poor working conditions and delayed salaries, among other factors. Reports of health workers resigning due to these issues have been rampantand so are strikes and strike threats. In Turkana West Sub-county for example, a survey conducted by the International Rescue Committee among twelve health facilities in the sub-county in 2015 indicated that over 92 per cent of the health officers (nurses and levels above) were occupied by members of the local Turkana community, yet in 2013 May, the local community held 56 per cent of the positions. This disparity can be explained by the massive exodus of staff from other communities from the area since devolution. This out-migration was partly supported by ethnic fears, general desertion of the health sector by professions due to frustrations experienced since devolution as well as subtle political statements made by leaders in the area to the effect that they were discouraging outsiders from employment in the county. As a result, almost all the new employees hail from the local community as leaders justify this as affirmative action due to their historical marginalization (International Rescue Committee 2015).

Challenges to the devolved healthcare systems

Lack of Availability of Health Care Facilities and Personnel, Health facilities must be physically available for the population to access healthcare services. Just 63 per cent of Kenyans have access to government health services located within an hour of their homes (International Rescue Committee 2015:12) and greater distance to a facility is a significant factor in decreased demand for healthcare in the country. Health facilities are unequally distributed across the forty-seven counties. In Turkana County for example, some residents in the far flung corners of the county have to travel for two days to access a health facility. As a result, health indicators are much below average, compared to other counties. In addition, there are only sixty-five public health facilities out of a total 4,929 in the country and twenty-one private facilities out of a total 3,794 in the country (Ministry of Health 2014). Further, only 18 per cent of births are delivered at a health facility against the national average of 61.2 per cent and an average of 23.9 per cent of persons experience stunted growth against the national average of 2.6 per cent.

Generally, half of the counties in Kenya have fewer than two health facilities per 10,000 people and fewer than 4.2 facilities per 100 square kilometers. Densely populated Mombasa and Nairobi have 134 and 124 health facilities per 100 square kilometers respectively, but far fewer facilities per 10,000 people (2.9 and 2.4 respectively). Marsabit, Tana River and Isiolo have the fewest health facilities per 100 square kilometers, but above-average numbers of health facilities per 10,000 people (Ministry of Health 2013:67). While these counties may have a sufficient number of facilities for the population, patients must travel long distances to reach them (Muoko and Baker 2014).

Beyond the number of health facilities, there are also great discrepancies between the numbers of health personnel per county offering services in these facilities. This is because healthcare personnel tend to concentrate in major urban areas hence denying services to far flung local authorities. However some Counties such as Nairobi and those of central Kenya are better resourced and therefore are not effected by some of this factors

The population densities of doctors and nurses are important indicators of a county’s capacity to provide adequate primary healthcare coverage. The proportion of doctors per 10,000 people in the forty-seven counties ranges from zero (Mandera) to two (Nairobi). These rates are below the national benchmark of three medical officers per 10,000 people (Ministry of Health 2013). Counties generally have higher population density rates for nurses, ranging from 0.9 per 10,000 people in Mandera to 11.8 per 10,000 people in Isiolo. However, just four counties in Kenya currently meet the country’s benchmark of 8.7 nurses per 10,000 people (Ministry of Health 2013). In general, counties with higher population densities of doctors tend to have higher population densities of nurses.

The lack of adequate personnel in most counties has been one of the biggest contributing factors to the current unrest in the health sector in several counties. Between January and August of 2015, more than twenty-two counties experienced strikes by health personnel, who cited understaffing as one of the critical causes (Kariuki 2014). The main reasons contributing to the critical staff shortage include high rates of desertion by medical personnel, lack of proper structures to determine the health personnel requirements and place them accordingly, high corruption rates at the counties and lack of adequate funds to employ health personnel, among other reasons.

The human resource challenge becomes more apparent when broken down by specialization. The sector faces a critical brain drain which was exacerbated by devolution and the arising conditions at the county level. Currently between 30 to 40 per cent of the estimated 600 doctors who graduate in Kenya annually move to other countries in search of greener pastures after completing internships for instance there is currently not a single general cancer doctor in government hospitals. This is alarming considering that an estimated 112 Kenyans are diagnosed with cancer every day (Ministry of Health 2013)

Lack of adequate Healthcare Financing, The government spending on healthcare is proximately 6% of GDP which is low compared to other countries in the region, Despite the Abuja declaration according to which African countries are committed to invest 14 per cent of the national budget in health. These drastic cuts in healthcare provision have led to poor services, lack of drugs and frequent strikes as well as increased mortality rates (KPMG Africa 2014).

Therefore, primary funding for healthcare comes from three sources: public, private (consumers) and donors. Consumers are the largest contributors, representing approximately 35.9 per cent, followed by the Government of Kenya and donors at around 30 per cent each (KPMG Africa 2014). Although the consumers are the largest contributors to the healthcare budget, the paradox is that the majority of those who opt for public health care are the poorest who cannot afford private care. This bracket of the population spends more than 40 per cent of non-food expenditure on healthcare (Government of Kenya 2014). Healthcare is thus a major source of financial distress for Kenyans.

As a devolved function, the major health financing at the county level comes through the county government, and beyond that is provided by consumers through cost-share. In the 2014/15 budget, counties received about 25 per cent of the total budget. However, at the level of individual county allocation, most counties allocated less than 5 per cent of the budget to health. A lot of this allocation went into remuneration of personnel, purchase and improvement of hospital equipment and infrastructure, and purchase of drugs. Because of the low allocation, however, the money is not enough, directly impacting on the quality of care

Availability of essential drugs is another key component of the health system and is closely related to financing. In Kenya, the government introduced the ‘pull system’ in 2010 to facilitate supply of relevant essential drugs to facilities throughout the country. The ‘pull system’ is a demand-based approach for ensuring the reliable availability of health commodities at all service delivery points within a health system. Under the National Health Sector Strategic Plan II (2005–2012) the government (Ministry of Health) established virtual ‘drawing rights’ for health facilities to move toward the ‘pull’ system of supply in which facilities order their required supplies and commodities based on actual need rather than receiving centrally determined numbers of medicine kits (referred to as the ‘push’ system of supply).

While this system was in place in most of the health facilities by 2013, the introduction of devolution has greatly disrupted it. This is because where it was previously facilitated by facilities drawing medicine from the Kenya Medical Supplies Authority (KEMSA), counties are no longer obliged to source from the government-run KEMSA and can source from other areas they deem better. This has opened an avenue for corruption, mismanagement and perennial scarcity of drugs at health facilities. This is because since procurement systems are still largely young and sub-optimal, unscrupulous personnel within the county governments are procuring drugs from unknown sources at great expense. This compromises not just the list of essential medicines, as provided by the Ministry of Health, but also the quality of the medication procured. Effective monitoring systems are urgently needed at county levels to address the question of drug supply and redress mechanisms put in place to curb the rampant corruption that is currently ongoing in relation to drugs.

Management of health facilities at county level is another big challenge. The county government, facing serious capacity challenges, has left the management of facilities in the hands of health personnel. While they have a lot of technical and professional expertise, the majorities lack adequate strategic management skills to access and make proper use of resources and militate against new devolution challenges. Furthermore, the procurement of goods and services at county level has been centralized at county headquarters. That has led to confusion and procurement challenges which affect quality of procured products and service delivery (Mamuye and Nyamu 2014). This over-centralization of procurement at the county level introduces the same hurdles that were experienced with the former system of centralization at the national level, and which necessitated devolution.
Conclusion
Healthcare in Kenya will remain a devolved function despite the many challenges the sector currently faces. These challenges are related to capacity gaps, lack of infrastructure and personnel, conflictual relationships with national government and a lack of understanding of devolution among citizens, which translates into little or no support from the same. To institutionalize devolution within the health sector, learning from other areas where devolution has worked and devising home grown solutions will help. Concerted efforts towards this from both governance institutions and ordinary citizens are needed to ensure that devolution delivers on its promises as enshrined in the constitution.

The government should also ensure that resources are equitably distributed, for instance let them ascertain the minimum number of health facilities or various levels of hospital per constituency based on the population.

Procument policy in all the counties should be regulated by the national government let them procure the systems for all the counties and proper training for all the procurement personnel.

Since Kenya is Kenya is one of 57 countries with critical shortage of healthcare workers, the government should have properly equipped institutions for training the medical personnel or even offer scholarships to its citizens in order to bridge this gap.

The government should also enhance the healthcare Infrastructure to enable healthcare workers to focus on service delivery, improve their work environment, as well as ensuring the availability of functioning medical equipment. In addition to improving work environment, improved social amenities at the county level to encourage health workers to stay near healthcare facilities in which they work, especially in hardship areas.

Rewards and Incentives participants proposed better remuneration packages for health workers. Example cited included reviewing hardship allowances and harmonizing all allowances. Conference participants noted that currently, housing allowances are greater for those in urban counties than for those in rural counties, yet those in rural counties may at times need better incentives than those in urban counties. An incentive proposed to address the distance barrier, was the provision of housing for healthcare workers at or near the healthcare facilities at which they are employed. And to develop/nurture cohesive healthcare worker teams that work well together

Counties should embrace innovations that are county specific. This can be read more as a challenge to the counties to think outside the proverbial box as they seek to address what were previously national challenges and that now residing at the county level. As is documented in the KPMG report, devolution was implemented as a way of addressing a legacy of inequity. This inequity manifested itself and still does to date in many ways, including the “quality” and the quantity of distributed healthcare workers across the country. To address the skills inequity and allow for knowledge sharing and the sharing of best practices. Opportunities to be created also for intercounty transfers of healthcare workers

Counties should enhance staff retention at healthcare facilities; there should be a signing of a memoranda of understanding (MOUs) between healthcare workers and facilities that endorse them for training. These MOUs should stipulate a length of time during which healthcare workers upon completion of their training, will provide services at the respective facilities

As per Kenya’s most recent human resources for health HRH strategic plan (National Human Resources for Health Strategic Plan, 2009 – 2012) that was formulated prior to devolution. It therefore logically follows that a revised HRH policy that is aligned to the new form of government should be implemented; One of the unintended consequences of the devolution of healthcare workers, as documented in the KPMG Devolution report is that “career structures can suffer”, that is, smaller administrative areas with fewer layers can reduce opportunities for talented people to progress up the career ladder. It is therefore important to create policies that facilitate/ enhance career progression. To keep healthcare workers in the workforce longer, and thus alleviate the shortage of healthcare workers, revision of the retirement age of healthcare workers from 60 to 70. In addition, to provide opportunities to especially those in marginalized areas,

And finally, to develop/nurture cohesive healthcare worker teams that work well together, a proposal is to have the inclusion of team building activities in the places of employment.

However despite all the above recommendations, it is important to note that healthcare is avery critical to each and every Kenya as part of the basic needs, its important we try to to form government and private sector partnership to ensure that devolution is a success.

We should also sensitize the society at large on the importance our taking up this jobs at the county level in order to have an impact in our society.

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