By Rosalind McCollum

Universal Health Coverage (UHC) is one of the four pillars of the Kenyan president Uhuru Kenyatta's current term in office (2017 – 2022). This has attracted the attention of several international development organisations that are keen to support Kenya to achieve health for its most vulnerable and poorest populations, through community-based primary health care.

Decentralisation, including devolution, is increasingly being adopted by countries seeking to address health inequities. In Kenya, pre-existing historical inequities between regions, with wide variations in power, resources and levels of access to and use of essential health services were felt to have contributed to the demand for devolution.  This contributed to the devolution of administrative, political and fiscal responsibility for health care from the national level to 47 entirely new sub-national (county) levels in 2013. 

What were we trying to find out?

Given the short timeframe since devolution was introduced, little is known about how and why priorities for health are set and how this influences effective and equitable coverage of community-based primary health care at county level.  We carried out the first large-scale qualitative study of post-devolution priority-setting for community-based health services.  We sought opinions and experiences from 269 health workers, policy makers and politicians from across the health system in ten counties, and perspectives from 146 community members through focus group discussions.

What did we find?  

We found that devolution has great potential for increasing health equity and UHC.  Our study revealed a general perception of improving equity between counties, with health equity felt to have improved in some previously neglected counties.  The potential for deepening inequities within counties has not yet been adequately addressed, since any rapid transition in power carries with it a certain degree of risk that local elites may capture priority-setting processes.   

Devolution is transforming the balance of power in Kenya by reducing the role of national bureaucrats and sub-county health implementers and increasing the degree of decision-making power at the (new) county level.  Here multiple political, technical and community actors, each with their own values and motivations, must compete to influence the priority-setting process.  This changing balance of power has wide-reaching implications for community-based primary health care and for achieving UHC.  Politicians’ have greater influence and may be motivated to provide services which appeal to their electorate, consolidate political support and maximise their voter base in pursuit of re-election.   Given such political processes, lower profile community-based health services risk being neglected, in favour of more visible curative services.

Our own and others’ research has shown that the rapidity of devolution can be a threat to its success:  with limited time to build up technical expertise and processes at county level this can lead to further unintended consequences. This can be compounded by insufficient clarity surrounding roles and responsibilities for actors within priority-setting; limited understanding by technical actors about how to engage meaningfully with politicians; insufficient knowledge and understanding of holistic health care; limited scope for meaningful participation of marginalised groups; reduced opportunity for involvement of health workers and insufficient guidance and capacity building for priority-setting before the roll-out of devolution. 

What can we learn from this study?

Several counties in Kenya have stated UHC and community health services for all as priorities, but with different interpretations or adaptations of both. In contrast other counties do not yet have adequate focus or capacities to ensure vulnerable groups are not left behind, risking failure to realise UHC.  The tumultuous electoral events of 2017 and recurring health worker strikes have created uncertainty, further threatening progress towards UHC.  There is therefore a need to learn from current best practices (see box 2 in study) and to lay down institutional structures, processes and norms which promote health equity for all Kenyans. As the president and interested international development organisations discuss UHC with related media attention, there is a critical window of opportunity to build political backing at sub-national (county) levels for planning and investing in community-based primary health services. 

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