1. Examining the Effects of Political Decentralization on Sub-National Health Sector Governance in Kenya B Tsofa DrPH Candidate – LSH&TM

2. Background  Decentralization: Transfer of power and authority over public affairs from central level government to sub- national levels (Rondinelli 1981)  Decentralization is thought to enhance ‘good governance’ through community participation and enhanced accountability in decision making  It takes many different forms and modes – and its highly context specific  Has been a recurring theme in health sector reforms over the past three decades

3. Kenya and the 2010 Constitution  New constitution passed in August 2010 47 semi-autonomous counties County governments since March 2013; accountable to the electorate Minimal control by central government An ideal ‘natural experiment’ to study decentralization

4. Study Objectives 1.To describe and analyze the goals and intended strategies of political decentralization on health sector operational planning and budgeting 2.To describe and analyze stakeholder expectations and experiences of political decentralization on health sector operational planning and budgeting 3.To identify strategies for enhancing achievement of decentralisation goals within the health sector in Kenya

5. Broader Context Content, Actors, Process and Contextual Factors Sub-national health sector operational planning and budgeting Organizational structure and capacity Accountability Decision space Conceptual framework Adapted from Bossert and Mitchell, 2011

6. Study Design  Case study design, with Kilifi County as the study case.  Three study tracers namely 1.HRH Management 2.EMMS Management 3.Planning and Budgeting for Recurrent Operational Expenses  Study case is part of and on-going long-term health systems governance studies using a “learning site’ approach Map of Kilifi County

7. Study Methods  Document Reviews – On the design and implementation of the decentralization in Kenya – On health sector sub-national operational planning and budgeting  Participant and Non-participant Observations – Participating in meetings and activities for planning and implementation of the decentralization at national and county levels – Observing the 2013/14 FY planning and budgeting activities in Kilifi County – Observing the country and county level political activities and context  Key informant Interviews – Selected participants at district/sub-county level (n=9), county level(n=9), and national level (n = 10)  Reflective Practice Monthly reflective practice session with the research team involved in the governance research work at the “learning site’

8. Key Findings

9. Broader Context The Constitution envisaged a three year transition period for transfer of functions from national to county level A Transition Authority was established in 2012 to prepare for; and oversee the transfer of functions to county governments MoH formed a Functional Analysis and Competency Team (FACT) to “unbundle” the functions of the MoH and prepare a transfer process schedule

10. Broader Context (Cont)  Election outcome of March 2013 – Winning party portrayed as anti-devolution – Majority of National Assembly Members are in ruling party – Majority of Governors in opposition party  “Power” and Control – Control of resources: - Counties vs National government – Symbols of Power : - Titles, Pecking order, Flags  Effects of power & control battles – Hurried transfer of functions to counties – Delayed setting up of county structures and capacity building – Disruption of health services

11. Planning and Budgeting  Resource allocation – Counties receive ‘block grants’ from central government – Different county departments bid for funding during county – County budget approved by county assembly  Planning and budgeting process – County Health Strategic Plan should guide Annual Work Plans and then resource allocation – County Health SP yet to be concluded and No 2013/14 Annual Work Plans – No systems and mechanism guiding utilization of different sources of funds – User fees, Maternity reimbursements, etc..  How planning units are coping? – PHC Facilities – Business as usual – Hospitals and DHMTs/Sub-County Management Teams  Sending their requirements needs to county level  Hospitals have not been able to use the facility ‘collected user fees’

12. HRH Management  Two phased transfer of HR management functions March – Dec 2013 : – Salaries payment undertaken by central MoH and invoice counties Jan 2014 – Salary payments undertaken by counties  Functions transferred to counties before county structures were fully functioning  Effects of hurried transfer of HR function Disruptions in salary payments for health workers Confusion/Lack of clarity on certain categories of staff leading to lay-offs Fear and anxiety by many frontline health workers leading to many seeking for transfers to their “home” counties and resignations

13. EMMS Management  Buffer supplies provided to all health facilities unto Dec 2013  Counties to begin buying their own supplies from Jan 2014  Process in Kilifi county: – County began commodity quantification and procurement process in Sept 2013 based on actual facility needs – Procurement orders made in December 2013 – Process focusing on one person undertaking the commodity quantification and ordering function  Outcome: – Supplies were delivered between January and March 2014 – Facility managers report a better order – fill rate for commodities ordered compared to previous centralized system – County managed to buy supplies for all operating facilities

14. Conclusion The boarder political context has had a significant effect on the implementation of decentralization in the health sector Decentralization has potential for improving efficiency; and community participation and accountability in management of health sector resources There is need for fast tracking establishment of county structures; and strengthening their capacity to enhance the ‘benefits’ of decentralization Need for health sector to be more responsive and adaptive to rapidly changing socio-political environments

15. Acknowledgements  DrPH Supervisors Dr. Catherine Goodman – LSH&TM Dr. Sassy Molyneux - KEMRI-WTRP  Student Advisory Committee – Prof. Lucy Gilson -UCT/LSH&TM  Learning Site Colleagues Sassy Molyneux Edwine Barasa Mary Nyikuri  Funders The Wellcome Trust :– Through KEMRI-WTRP UKaid :– Through RESYT  MoH National MoH Kilifi County Health Managers Kilifi, Malindi and Kaloleni Sub-Counties Health Managers