Health

How Kenya’s devolution hobbled healthcare

Earlier this year, two girls died of dog-transmitted rabies in western Kenya. The deaths incensed veterinarians who had been struggling to obtain rabies vaccines from the local government for years. By all accounts, the veterinarians should have been able to source the vaccines. In 2014, Kenya’s national government had embarked on a drive to eliminate rabies by 2030, starting with vaccinating 70% of the country’s dogs. Local governments were tasked with procuring the vaccines, which cost a dollar a dose.

A rapid increase in the area’s dog population had made vaccination scale-up a priority, the veterinarians argued. But local health officials disagreed. “The local governor did not see rabies as a serious problem,” says one of the veterinarians, all of whom spoke to Scientific African Magazine on condition of anonymity. Moreover, local health officials told him the area where the girls lived had not voted for the governor anyway. That throwaway comment fuelled a concern the veterinarians had been harbouring for years: that local politics was influencing the distribution of health resources, entrenching health inequalities, and possibly causing avoidable deaths. 

The veterinarians’ worry is not new. For decades, political commentators and political science researchers in Kenya have noted that regions that harbour supporters of the political opposition remain poor and sidelined. In 2009, World Bank economist Raymond Muhula wrote that many Kenyans say they are being treated unfairly in areas that don’t align politically with the central government. And, he wrote, this sentiment was reflected in the “availability of social services, such as water”. [1]

But in recent years critics’ focus has changed from national to local politics. Scientists and healthcare experts say that a process known as ‘devolution’—which has moved political control of a number of policy areas, including healthcare, to Kenya’s 47 self-governing counties—is making things worse.

That is the opposite of what the architects of devolution intended when the process began in 2013—the year when Kenya transitioned from a centralised to a devolved system of governance. This new system transferred the provision of services like health, transport, and public works to the newly formed semi-autonomous counties. Devolution, the architects said, would tackle disparities between regions, improve service delivery, and engage citizens by bringing local decision-making closer to affected communities. In many instances, it has worked: Some counties have new health centres, roads, and street lights that wouldn’t be there without devolution.

But for certain areas of healthcare, it has been a disaster. Decentralising disease control was not a good idea, says Kariuki Njenga, an infectious disease expert at the Kenya Medical Research Institute (KEMRI) in Nairobi. Njenga, who has worked on national disease outbreaks for decades, says he has personally witnessed healthcare workers and scientists being delayed in their response because governors or other senior county officials would expect to be paid courtesy calls, asked to officiate openings, or be included in press statements—all of which would take time. He has also experienced officials insisting that they be left to handle the disease without the national government’s help, even when they lacked the necessary resources and skills. 

It’s not just disease control that has suffered, according to Kenneth Wameyo, a veterinarian who until his death in early November was based in Nairobi and part of the Kenya Veterinary Association. He said that, since devolution, the management of health interventions across the country has lost its uniformity. 

For example, there are counties such as Nyandarua in the centre of the country, which organises vaccinations for livestock to prevent Rift Valley Fever—an acute viral disease that affects domesticated animals but can also cause illness in humans when they come into contact with a carcass or infected animal. Other counties in the north do not have the same plans. In counties that vaccinate, only about 70% of livestock receive the vaccine. This has been enough to keep the disease out of central Kenya. However, in February this year an outbreak of Rift Valley Fever occurred in Nyandarua, infecting hundreds of cattle and sheep and at least two people. Local veterinarians and healthcare staff believe the outbreak was a result of unvaccinated livestock from the north moving into Nyandarua. Had vaccination been governed at national level, this might have been avoided, they say.

Wameyo said county governments lack the technical skills needed to plan and implement health interventions. And, as illustrated by the example of rabies in western Kenya, what drives action is not always what is best for patients. “Every governor wants to outshine the other, or make this or that section of their county happy,” said Wameyo. 

Scientific African Magazine asked the central Ministry of Health to respond to the issues raised in this article, including the concern that devolution has empowered local policymakers without putting in place safeguards to assure the quality and fairness of healthcare distribution. The ministry did not respond. 

Not just a rural issue

The problems are not limited to rural areas. During a cholera outbreak that centred on a popular Nairobi hotel in June 2017, Ben Muia, then county executive in charge of health, would not allow the national government to intervene and help Nairobi County contain the disease. At the time, Jackson Kioko, then national director of Kenya’s medical services, said that the central government’s hands were tied because, constitutionally, Nairobi County had jurisdiction over health services. 

A contributing factor is the way in which devolution has changed the allocation and spending of health budgets. Before devolution, clinics and other health providers’ budget requests—whether for routine work or emergencies—would go to the provincial director of medical services. There were then eight provinces: Nairobi, Central, Rift Valley, Eastern, Coast, Western, Nyanza, and North Eastern. As long as the requests were in line with national policies, health providers say the money would usually materialise, since the provincial managers had no discretion to decide how money should be spent. 

However, under the current system, the county manages the funds for public health facilities, and county officials have full autonomy over how to spend it. Thus, critics say, county-level officials are able to reject requests for funding, even when those requests are in line with national healthcare guidelines. This is what the veterinarians in western Kenya believe happened when they asked their local health officials for rabies vaccines. 

Some of the challenges blamed on devolution have their roots in nepotism and bad governance, says Edwine Barasa, director of the KEMRI-Wellcome Trust Nairobi programme in Kenya, who also heads its Health Economics Research Unit. He says the people appointed to look after health at county level are often selected for reasons other than being suitable for the job—their appointment might be a personal reward from the governor, or they might belong to a community that voted for him. This erodes accountability, he says, and leads to poor resource allocation. “To be seen as doing their work, politicians would build hospitals and not know which healthcare workers would see patients there, or what medical equipment or supplies [the hospital would need],” he says. Under these circumstances, disease control and preventive medicine suffer, he adds. 

Barasa’s own research bears this out. In a 2018 paper, he and colleagues from the United Kingdom investigated the effects of power on priority-setting for healthcare resources in post-devolution Kenya.[2] From interviews with more than 300 policymakers and community representatives from 10 counties, they concluded that devolution increased local politicians’ power to make healthcare decisions without addressing underlying social structures and discriminatory practices that had historically skewed healthcare resource allocation. This, they wrote, has “led to the continued exclusion of the most vulnerable from priority-setting processes”. 

The solution, for Barasa, is two-fold: Put in place mechanisms that ensure counties use their money prudently, and teach communities about their rights to healthcare so they in turn can agitate for better disease management. But Ouma Oluga, a medical doctor and the secretary-general of the Kenya Medical Practitioners Pharmacists and Dentists’ Union, says things will only change when the central government realises the damage that devolving healthcare has done—a process that he believes could take many years, and cost many more lives. Oluga, who says he has endured strikes and disease outbreaks since devolution, has reached a point of fatalism: “Let the government smell its mistakes.”

Verah Vashti Okeyo is a global health reporter and development communications researcher in Kenya. Email her on info@verahokeyo.com or tweet @BeyondaHeadline 

References

[1] Muhula, Raymond, Horizontal Inequalities and Ethno-regional politics in Kenya. Kenya Studies Review: 1, 1, 85-105. (2009)

[2] McCollum et al. “Sometimes it is difficult for us to stand up and change this”: an analysis of power within priority-setting for health following devolution in Kenya, BMC Health Services Research (2018) 18:90

This article is dedicated to the memory of Kenneth Wameyo.

Image credit: U.S. Air Force photo by Senior Airman Brittany E. N. Murphy

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