Recentralization within decentralization: County hospital autonomy under devolution in Kenya

• Published in: PloS one 2017-08, Vol.12 (8), p.e0182440-e0182440
• Main Authors: Barasa, Edwine W, Manyara, Anthony M, Molyneux, Sassy, Tsofa, Benjamin
• Format: Article
• Language: English
• Subjects: Alignment; Autonomy; Biology and Life Sciences; Case depth; Case studies; Child, Preschool; Coastal environments; Community involvement; Community participation; Decentralization; Delivery of Health Care - organization & administration; Demographic aspects; Developing countries; Devolution; Employee motivation; Engineering and Technology; Female; Finance; Financial management; Government procurement; Health services; Hospital Administration; Hospitals; Hospitals, County - organization & administration; Humans; Infant; Kenya; LDCs; Leadership; Legislation; Local Government; Male; Management; Medical care quality; Medical personnel; Medicine; Medicine and Health Sciences; Motivation; Ownership changes; Physical Sciences; Politics; Practice Management, Medical; Priorities; Procurement management; Qualitative Research; Reforms; Resource management; Social Sciences; Strategic management
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0182440

In 2013, Kenya transitioned into a devolved system of government with a central government and 47 semi-autonomous county governments. In this paper, we report early experiences of devolution in the Kenyan health sector, with a focus on public county hospitals. Specifically, we examine changes in hospital autonomy as a result of devolution, and how these have affected hospital functioning. We used a qualitative case study approach to examine the level of autonomy that hospitals had over key management functions and how this had affected hospital functioning in three county hospitals in coastal Kenya. We collected data by in-depth interviews of county health managers and hospital managers in the case study hospitals (n = 21). We adopted the framework proposed by Chawla et al (1995) to examine the autonomy that hospitals had over five management domains (strategic management, finance, procurement, human resource, and administration), and how these influenced hospital functioning. Devolution had resulted in a substantial reduction in the autonomy of county hospitals over the five key functions examined. This resulted in weakened hospital management and leadership, reduced community participation in hospital affairs, compromised quality of services, reduced motivation among hospital staff, non-alignment of county and hospital priorities, staff insubordination, and compromised quality of care. Increasing the autonomy of county hospitals in Kenya will improve their functioning. County governments should develop legislation that give hospitals greater control over resources and key management functions.