Fulfilling the promise of health for all

In 2013, Kenya ushered in a new chapter in history. Through a new constitution, Kenyans voted to decentralise government on the promise of a strengthened democracy and the fair distribution of resources. Eight established provinces dissolved to give way to 47 newly formed counties, and a raft of service delivery functions – from agriculture and transportation to health and sanitation – were passed from national to county control. Kenya had not seen such a major departure from its ingrained system of national government since its independence in 1963.

In the health sector, devolution brought an opportunity for more locally driven, responsive health systems and better health outcomes. Citizens wanted closer access to higher quality public services and a voice in the decisions that were affecting their lives.

Over these 8 years, Options has sought to support the promise – and to address the pitfalls – of devolution in Kenya’s health sector. Through our work engaging local leaders, civil society, the private sector and government in more than half of Kenya’s counties, we have learned valuable lessons on building a path to lasting change.

1. Governance is not only about government

Successful governance under Kenya’s devolved system requires an inclusive, whole of society approach. But bringing diverse voices around a table can be acrimonious, and many of Kenya’s newly formed governments have sought to avoid it. But the country’s health advocates have successfully managed to claim closed spaces and  proven themselves to be much more than ‘watu wa matawi’ [‘people of the twigs’ – who wave sticks at demonstrations] by working politically and using evidence to drive improvements to healthcare.

• Locally led advocacy models, like Steps to Change, provide coalitions with flexible tools for health advocacy to plan their own course of action. This approach has demonstrated the vital role that evidence plays in shaping dialogue, building credibility and mutual trust. When advocates speak with authority and knowledge, they are viewed as experts with value to add – rather than antagonists.
• Thinking and working politically is the cornerstone of successful advocacy. Political economy analysis looks at how power and resources are distributed and contested: that is, who makes the decisions, where the money goes and why. The delivery of health services in Kenya is not insulated from tribal or party politics. Supporting advocates to use a politically informed approach has enabled them to recognise both the written and unwritten rules of how decisions are made, and align advocacy efforts to what decision makers care about.
• Successful coalitions also take their engagement beyond invited spaces (like consultation forums and working groups) to identify and claim closed spaces. In Nairobi county, for example, a Maternal and Newborn Health coalition used their knowledge from political economy analysis to gain access to a previously closed meeting of the County Health Assembly. These breakthroughs gradually shift the landscape towards more inclusive and collaborative governance.
• Taking a long-term approach to collaboration can pay off. Development partners often work behind the scenes over many years to mobilise domestic resources for health – both at county and national levels. In Kenya we collaborated with family planning (FP) stakeholders to successfully advocate for policy makers to increase public investments in FP commodities. This helped reduce the country’s reliance on donor support for funding FP programmes.

2. Kenya’s counties are unique, and they are in charge

Kenya’s transition to devolved health services happened rapidly. Very little training was provided to hundreds of staff put in newly created leadership positions, and the boundaries of several functions remained unclear for many years. Kenya’s counties are also more diverse than most outsiders realise – each has its own unique culture, language and contextual history. With 47 county governments now in the driver’s seat of health, technical assistance approaches to build sustainable change from the grassroots up are most effective when they are locally based, flexible, adaptive and systems oriented.

• Each county’s health system functions as an organisation. Managers can work together to adapt existing tools that assess organisational capacity to their unique context, as we’ve done in Bungoma County. This tool enabled county and sub-country leaders to track their progress towards their goal of improving health system capacity by setting objectively verifiable criteria.
• Coaching is an effective way to support the development of local leaders. For example, we used a combination of group and individual coaching sessions to support the Bungoma County Health Management Team to improve its performance. This personalised approach is more effective and affordable than the traditionally available, classroom-based leadership courses often provided in Nairobi.
• County health systems are dynamic and constantly changing. But the development sector relies on the use of linear, predictable planning tools, such as logical frameworks, results matrices, and fixed targets. Timing is everything at the county level: when one door shuts due to unexpected external changes, another one often opens. We need to be ready to change gears to provide effective technical assistance regardless of what the log frame says. Our ‘pathways of change’ tool has shown that it is possible to ensure a programme approach can meet donor requirements and be adaptive and flexible at the same time.

3. Financial autonomy is the elephant in the room

Devolution promised to move decision making closer to local managers. But in many counties, the opposite happened because the autonomy to make planning and budgetary decisions that previously sat at health facility and district levels was actually moved up to the newly formed county governments – further away from the people. The motivations behind this power shift are complex. But any intervention that seeks to improve the performance of a county health system is incomplete until this elephant is addressed:

• In Bungoma county, an autonomy case study identified that misinterpretations of the Public Financial Management Act were playing a central role in this ‘recentralization’, which resulted in limiting facility level financial autonomy. This evidence created a basis to open dialogue with county leadership to release these controls from the county down to lower levels.
• Performance based financing (PBF) supports managers to focus on results by enhancing local autonomy and incentives. It can improve service quality by providing health workers with the power to decide what is needed to improve local health outcomes, and the resources to get there.

Devolution in Kenya has facilitated a new chapter of growth, with each county charting its own path towards a more responsive health system. At Options, we support Kenya’s health sector leaders to recognise the challenges and opportunities that devolution still presents, and to face them with a commitment to fulfilling devolution’s original promise of better health for all.

This blog was written by Options’ Strategic Advisor Nicole Sijenyi Fulton.