Process, power and politics: setting priorities for community health and equity in the recently devolved Kenyan health system

Devolution in Kenya was politically driven, motivated by the desire to share power and resources across regions, so as to remedy historical inequities. This led to transfer of planning, management and budgeting responsibilities for a range of services, including health, from central government to 47 new sub-national governments (known as counties), starting in 2013. This transition was driven by increasing frustration with inefficiencies and inequities associated with the former centralised government. Objectives for devolution are to strengthen democracy and accountability, increase community participation, improve efficiency and reduce inequities. However, global experiences have shown that transfer of powers does not always lead to achievement of these objectives. Rather, potential risks include that inefficiencies will multiply, inequities will widen and corruption will become more widespread. Health has been the most controversial of all devolved services in Kenya, contributing to recurring health worker strikes. Respondents described that ideally, priorities should be set following a series of consultations between local decision-making actors, guided by local evidence and community-generated priorities, bounded by available resources, using cost-effectiveness and equity principles to identify context-appropriate interventions which advance universal health coverage. This thesis which, to the best of our knowledge, is the first study of its kind, aims to explore priority-setting for community health and equity across counties and multiple health systems levels in Kenya post-devolution. It uses mixed qualitative approaches in ten counties including interviews, focus group discussions and participatory photography research conducted two to three years after devolution took place. It includes respondents from national to community level to analyse county health priority-setting processes, power dynamics and implications for health equity and community health services. This study shows that many respondents across health systems levels identify equity as a guiding principle, with devolution bringing positive ramifications for previously neglected counties, reducing inequities between counties. County decision-makers, who often hold greatest power compared with health workers and community members, perceive building health facilities as the most appropriate way to achieve health equity. Community members who have a more holistic understanding are not yet sufficiently empowered to understand the benefits and limitations of choices available to them or to reflect this within the priorities they identify. There is wide variation between counties, with emerging examples of stronger, more equitable health priority-setting, with inclusion of an illustrative case study. Overwhelmingly the findings from this study relate to power dynamics. We found a lack of clarity surrounding roles for decision-making actors, inadequate information, unclear criteria and processes for guiding priority-setting. Within the confusion created by the limited guidance and capacity, opportunistic actors have seized available power to manipulate priorities to align with personal objectives, such as political re-election. The resulting increase in complexity blurs lines of accountability creating a situation that makes progress beyond a single elected term challenging. This has led to increased focus on tangible curative services, stifling opportunities for strengthening quality and community-based primary health care. Devolution has brought a period of colossal upheaval with changes in roles and power locus within the health system. Clearer guidance, capacity building, stronger community empowerment, involving marginalised groups in priority-setting processes and accountability mechanisms are needed if devolution’s objectives are to be realised