Devolution status: Why counties are struggling to run health systems

Devolution was a people-driven mandate enshrined in Kenya’s Constitution, which placed health among its flagship devolved functions. Yet, more than a decade later, doubts persist over whether the sector is firmly secured under county governments or gradually reverting to the national government control.

While some counties have built strong health systems, others still grapple with glaring gaps.

For instance, some facilities in respective counties have empty drug stores, overworked or absent health workers, and gleaming but underutilised buildings.

However, one of the most celebrated success stories in devolved healthcare comes from Makueni County under former Governor Kivutha Kibwana.

His flagship ‘MakueniCare’ initiative brought affordable, accessible healthcare to thousands of residents, making him one of the most beloved leaders in the region.

Under the scheme, residents paid a one-off annual fee of Sh500 to access a full range of services from X-rays to hospital admission and treatment, at no additional cost.

“I wish each county had such a universal healthcare system, implemented jointly by the two arms of government,” Prof Kibwana said in an interview with The Standard.

He envisioned a model where counties provide first-aid universal healthcare, while those requiring specialised treatment beyond county capacity are covered under the national Social Health Authority (SHA) scheme.

Devolution came with excitements and hope — hospitals were built, drugs supplied, with some counties in northern regions of the country reporting caesarian section for the first time.

The initial excitement over devolution has faded in a number of counties, while others like Murang’a have embraced innovations such as mobile dialysis to bring services closer to the people.

A visit by The Standard to Tana River County shows the visible impact of devolution.

Before devolution, most residents travelled to Garissa, Mombasa or Nairobi for healthcare.

Today, the number of health facilities has grown from 33 to 90, taking services closer to communities.

Bahati Mohamed, who recently delivered her seventh child at Hola Level Four Hospital, recalls a time when such services were unavailable.

“I delivered my first and second born at home, and the rest in hospital,” she says. “I am happy that whenever I come, there are health workers ready to serve me.”

Improved maternal care in the county has helped reduce deaths of mothers and newborns.

Hola Hospital now records about 174 deliveries a month, according to the medical superintendent, Dr Abbas Godana.

The facility also offers dialysis, blood transfusion and theatre services, with an oxygen plant under construction.

For kidney patient Ali Salah, the local dialysis unit has been life-changing.

“I undergo two sessions here every week. Having care nearby has spared me the cost of travelling to Garissa or Malindi,” says Salah.

Governors say the promise of devolution is being undermined by unpredictable and insufficient national government funding. They say delayed disbursements by the National Treasury have slowed procurement of medicines, halted construction projects and disrupted service delivery in counties.

Council of Governors vice chairperson Mutahi Kahiga notes that although health has been prioritised with at least 30 per cent of county budgets allocated to the sector, “health under devolved units is under threat.”

“National government should wake up and realise health is a fully devolved function. The only areas left for the national function are pandemics and referral hospitals,” says Kahiga, also Nyeri Governor.

He adds that inadequate budgetary allocations hinder the hiring of health workers and the provision of essential drugs and equipment.

His sentiments are echoed by CoG Health Committee chairperson Muthomi Njuki and former Makueni Governor, Kivutha Kibwana, who argue that much of the allocation remains with the national government while counties shoulder the implementation burden.

Njuki calls for a change in how the legislative arm relates to counties, saying competition for resources is undermining service delivery.

“When the legislative arm of government realises they are not in competition with counties, we will have better opportunities to deliver our mandate because counties will get the resources they deserve,” he says.

He blames stalled county funding on stalemates between the Senate and

Governors have also accused the national government of infringing on county roles — enrolment of Community Health Promoters (CHPs) and establishment of the Social Health Authority (SHA).

“We agreed with President William Ruto to jointly hire CHPs and split their pay. But to date, we still share the cost, yet supervision is a county function,” says Kahiga.

“How do you know if a CHP responsible for 100 households in Karachuonyo actually reported to work, yet their pay comes from Nairobi? Why not give the money to counties to pay, since they supervise them?”

The Sh5,000 monthly stipend for CHPs has also been inconsistent, with some counties failing to remit the funds.

Kenya Union of Clinical Officers Secretary General George Gibore says health workers are unevenly distributed across counties.

“Some hospitals remain non-functional due to staff shortages, while others lack specialised professionals, especially in counties such as Mandera, Turkana, and Wajir,” says Gibore.

“In Tharaka Nithi, we once had only 47 clinical officers, but the number has grown to 200. On the other hand, Kirinyaga has never employed or promoted clinical officers,” says Gibbore.

Kirinyaga, he adds, is also embroiled in multiple court cases involving health workers.

In Isiolo, CHPs are on strike over delayed payments.

Kibwana adds that governors have been excluded from SHA policy decisions, leaving its implementation to the Ministry of Health.

MES programme was among the most hotly debated initiatives between the two arms of government when it was launched in 2016.

The programme has since been rebranded as the National Equipment Service Programme (NESP), set to run for seven years under a fee-for-service model for both national and county hospitals.

Suppliers will provide the equipment, with the SHA paying per service rendered.

President William Ruto unveiled the details last week at State House, noting that 45 counties have signed the Intergovernmental Participatory Agreement (IPA).

So far, over 60,000 pieces of advanced medical equipment, including CT scanners, ultrasound machines, dialysis units and digital X-rays have been delivered to 29 facilities in 18 counties.

President Ruto describes NESP as “a good example of what can be achieved through collaboration between national and county governments.”

Still, questions remain over the division of healthcare roles.

“The national government should focus on health standards, capacity-building and main referral hospitals,” says former Makueni Governor Kivutha Kibwana.

Njuki adds that the Ministry of Health should focus on policies, standards, and training — not on implementing projects meant for counties.

“Why do we still have hospitals being built in counties from Ministry of Health? Why do we still have equipment and ambulances delivered from MoH to counties? Can’t county governments procure an ambulance?” poses Njuki.

Human resource remains the biggest bottleneck in devolved health units, according to the Kenya Union of Clinical Officers (KUCO).

KUCO Secretary General George Gibore says health workers are unevenly distributed across counties.

“Some hospitals remain non-functional due to staff shortages, while others lack specialised professionals, especially in counties such as Mandera, Turkana, and Wajir,” says Gibore.

He notes that while some counties have made progress, disparities remain glaring.

“In Tharaka Nithi, we once had only 47 clinical officers, but the number has grown to 200. On the other hand, Kirinyaga has never employed or promoted clinical officers,” adds Gibbore.

Kirinyaga, he adds, is also embroiled in multiple court cases involving health workers.

Gibore acknowledges that the national government also struggled to manage healthcare staff effectively before devolution, but argues that disparities have worsened under counties.

“Previously, it wasn’t working well, but at least there were no huge inequalities. To actualise UHC, we must invest in health workers,” he says.

Other challenges facing healthcare workers in counties include persistent salary delays, stalled promotions, lack of medical insurance, poor job placement, and limited career progression.

Despite health being a fully devolved function, KUCO is calling for a centralised human resource management system for healthcare workers.

“We don’t see professionals running the health system. It’s politically run between the President and governors. They do what they want. During Covid-19, we centralised health. Fragmentation is not good; we need to fix it. Right now, the system is still shambolic,” says Gibore.

Nyeri Governor Mutahi Kahiga warns that devolution is under threat, urging Kenyans to stop viewing governors as inherently corrupt.

“Why can’t we ask ourselves how much money actually goes to counties? It’s only 15 percent. Where does the other 85 percent go? We are obsessed with 15 percent but ignore 85 percent.

We must ask these questions. The fact is, devolution is under threat — it must be protected. We must tell the President the truth-devolution is here to stay. It was a decision by Kenyans, not leaders,” he says.

Despite wrangles in managing the health sector, Kahiga insists governors will defend devolution.