CASESTUDIESFOR

HEALTHSYSTEMSANDPOLICYANALYSIS

CASESTUDYOFGOVERNANCECHANGEHealthsystemdecentralisationinKenya

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TABLEOFCONTENTSABOUTTHISCASE 4

CASESTUDY:HEALTHSYSTEMDECENTRALISATIONINKENYA(2013-2015) 5

CASESTUDYFOCUS 5THEORGANISATIONOFTHECOUNTYDEPARTMENTOFHEALTHAFTERDEVOLUTION 7UNPREPAREDNESS,UNCLEARROLESANDBRIDGINGARRANGEMENTS 8HUMANRESOURCESFORHEALTH 8FINANCINGPRIMARYHEALTHCAREFACILITIES 9THESUPPLYOFMEDICINEANDMEDICALEQUIPMENT 10THEPLACEOFTHECOUNTYDEPARTMENTOFHEALTHINOVERALLPROCESSESOFPLANNING,BUDGETINGANDPRIORITISATION 11WHATWASSUPPOSEDTOHAPPEN? 11WHATHAPPENEDINPRACTICE? 12NEWFINANCIALPROCEDURESANDACCESSINGFUNDINGFORHEALTHSERVICEDELIVERY 13HOSPITALS 14SUB-COUNTYHEALTHMANAGEMENTTEAMS 15PRIMARYHEALTHCAREFACILITIESANDMANAGERS 16CONCLUSION 17

SAMPLESTUDENTTASKS/ASSESSMENTS 19

TAKE-HOME,OPENBOOKEXAMINATION 19

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AboutthiscaseThis case study focuses on the decentralisation of government functions in Kenya thatoccurred after the adoption of the 2010 constitution, in particular how these changesaffectedthelocal-levelhealthsystemandservicedeliverytocommunities.The case study was written for use with CHEPSAA’s open access course Introduction toComplexHealthSystems.Assuch,itisusefulforstimulatingstudents’thinkingabouttopicssuchas:

• Theinfluenceofthebroaderpoliticalsystemonthehealthsystem;• Theroleoftimeandtiminginhealthsystemchange;• The(changing)relationshipsbetweenactorsandthesoftwareandhardwareofthe

organisationalcontextswithinwhichreformscometolife;• Thesometimescounter-intuitiveimpactsofreforms;and• Theimpactthatchangesinoneaspectofthebroadergovernmentorhealthsystem

canhaveonotheraspectsofthatsamesystem.However, thiscasestudy isalso relevant toahealthpolicyanalysiscourse,especiallyonethatiscentredonconceptssuchaspolicyactors,context,policycontent,policyprocessandstrategies,policycontentanalysisandstakeholderanalysis.ItcanthereforealsobeusedinconjunctionwithCHEPSAA’scourseHealthPolicyandPolicyAnalysisandcasestudiessuchtheoneonthemarketingofalcoholicbeveragesinSouthAfrica,whichispartofthesameseriesasthisdecentralisationcase.

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Case study: health system decentralisation in Kenya (2013-2015)

CasestudyfocusIn June 2013, the entire governmental systemof Kenya, and thus also the health system,underwent a profound change when the longstanding centralised system of national,provincialanddistrict levelwasreplacedbyonethatcentredonnationalgovernmentand47semi-autonomouscounties.

Thisnewsystem,which isoutlined inKenya’snewconstitutionof2010,was tocome intoeffectaftertheMarch2013generalelection,subjecttoathree-yeartransitionperiodthatwould see the progressive transfer of functions. After the election, however, CountyGovernors increasingly pressurised the national government to have all functionstransferredtocountiesimmediately.Followingthispoliticalpressure,thePresident,inJune2013,orderedthisimmediatetransfer.Thenewsystemcameaboutforanumberofreasons,including:

• Widespread frustrationwith the perceived inefficiency of the previous centralisedgovernment. The goalwas therefore to shift power away from the strong centralgovernmentandtomakegovernmentmoreresponsivetocitizens;

• Concernsaboutresourceallocationinequitiesassociatedwiththeprevioussystem.Theseinequitiescan,inpart,betracedbacktocolonialismandisreflectedinwidelydifferent levels of poverty, education, development, resources and investment indifferentareas. Thenewarrangementswere therefore intended toalleviate thesedisparities;and

• Local and international political pressure after the violence following thepresidentialelectionin2007.Thisviolencehadpartypoliticalandethnicdimensionsand was also intertwined with longstanding grievances about issues such asresourcesandinequality.The2013changeswerethereforealsointendedtocreatemoreautonomyfordifferentregionsandgroups.

In practice, the reforms meant that each county was required to establish a semi-autonomous executive and legislative arm of government. County governments were

Kenya has a long history of decentralisation. In 1983, the government published astrategy that identified the district as the basic unit for planning and public servicedelivery. Under this policy, districts carried out operational tasks on behalf of higherlevelsof government,butdidnot havemany strategic functions. In thehealth system,the key decentralised structure was the District Health Management Team, whichoversaw all health sector activities and managed health facilities up to the level ofdistrict hospitals. The 2013 reforms did away with these de-concentrated structures,mostnotablytheDistrictHealthManagementTeam.

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directly accountable to the electorate, but had no direct accountability to the nationalgovernment.The legislature is referred to as the County Assembly and is comprised of Members ofCountyAssembly,whoareelectedfromeachelectoralwardinthecounty,andnominatedmemberswhorepresentspecialinterestgroups.Theexecutive armof government ismadeupof an electedCountyGovernor andDeputyGovernor,aswellasaCountyExecutiveCommittee,the10membersofwhichareappointedby the Governor. Themembers of this County Executive Committee shoulder the overallpoliticalandpolicyresponsibilityforthecounty’s10servicedeliverydepartments,ofwhichthe County Department of Health is one. Within each department, the Governor alsoappoints a Chief Officer. The Chief Officer reports to the relevant County ExecutiveCommitteememberandhasoverallaccountingresponsibilityforthedepartment.Countygovernmentshavefourmajorsourcesofincome:

• Unconditional funds from national government. At least 15% of nationalgovernmentrevenuemustbeputtowardsthis;

• Equalisation funds allocated to marginalised counties for the delivery of socialservices.Atleast0,5%ofnationalgovernmentrevenuemustbeusedforthis;

• Self-generatedrevenuethroughcounty-leveltaxes;and• Conditionalgrantstoaddressspecificnationalpriorities.

Thiscasestudyexplorestheimplementationofthisnewsystemintheperiod2013/2015–the early days of transition. It focuses on the implications for the County Department ofHealthandhealth systemandon theprogressandchallenges inone specific county:KilifiCounty,intheformerCoastProvince.Whydecentralise?Proponents of decentralisation often hope to achieve both political and technical /managerial objectives. The idea is that decentralisation will give the local level moreautonomy over decision-making and that this autonomy will combine with greatercommunityparticipationorcommunityvoiceto:

• Ensurethatgovernmentwillbemoreresponsivetotheneedsofcitizens,i.e.itwillbe more effective in delivering services and it will work to reduce inequitiesbetweenpeople;and

• Increase the accountability of the health system to citizens, so that citizens areempoweredandthehealthsystemworkefficientlywith theavailable resources topromotegoalssuchasequity.

The theory is that autonomy, community participation, responsiveness and accountabilitywillcombinetoimprovethequalityofthehealthcaredelivered.Source: Atkinson S, Medeiros RLR, Oliveira, PHL, de Almeida, RD. (2000). Going down to the local: incorporating socialorganisationandpoliticalcultureintoassessmentsofdecentralisedhealthcare.SocialScienceandMedicine,51:619-636.

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Whatarethetypesofdecentralisation?Theliteraturecommonlydistinguishesbetweenfourtypesofdecentralisation:

• De-concentration: Handing over some administrative authority to locally basedofficesofcentralgovernmentministries.

• Devolution: Creating or strengthening sub-national levels of government that aresubstantiallyindependentofthenationallevelwithrespecttocertainfunctions.

• Delegation: The transfer of managerial responsibility for certain functions toorganisationsoutsideofcentralgovernmentandonlyindirectlycontrolledbycentralgovernment.Theagenthasbroaddiscretion,butultimatelyresponsibilitystillrestswithcentralgovernment.

• Privatisation: The transfer of government functions to voluntary organisations,profit-making companies or non-profit organisations, often with continuedgovernmentregulation.

Source: Mills A, Vaughan JP, Smith DL, Tabibzadeh I. (1990). Health system decentralisation: concepts, issues and countryexperience.WorldHealthOrganisation:Geneva.(http://apps.who.int/iris/handle/10665/39053)

TheorganisationoftheCountyDepartmentofHealthafterdevolutionWith the advent of the new system, the national Ministry of Health retained certainresponsibilities relating to health policy and regulatorymatters such as quality assuranceand standards. The national level is also responsible for the provision of national referralservices (the fourth tier of the public healthcare delivery system),which refers to formerprovincialandnational-levelfacilities,wherethemostspecialisedcareisavailable.However, ahostof responsibilities and functionsnowshiftedtotheshouldersofthecounty.Theseincludedbudgeting and allocating resources, the managementofhumanresources,theprocurementofmedicineandmedical supplies, as well as the delivery of servicesrelated to health promotion and disease prevention,primary health, county hospitals and ambulances.Ownershipof thephysical facilities - countyhospitals,health centres and dispensaries – also rests with thecounty government. The devolution was a deeplypolitical reform that shifted significant power anddecision-makingawayfromcentralgovernment.Overall,thedeliveryofhealthservicesinthecountyismanaged by the County Director of Health and theCountyHealthManagement Team,who report to theChief Officer of Health regarding financial issues and

TheCountyTreasury,whichcountswiththeCountyDepartmentofHealthasoneofthe10departmentsinthecounty,andthefinancialrulesassociatedwithit,hadamajorimpactonthehealthsystem’sexperienceofdevolution.TheroleoftheCountyTreasuryistodirectplanningandbudgeting,aswellastomanagepublicfinances.EachcountyestablishedaConsolidateRevenueAccount,toholdalltherevenuereceivedfromthenationalgovernmentandcollectedwithinthecounty.

Whattypeofdecentralisationdothe2013reformsrepresent?

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thememberoftheCountyExecutiveCommitteeresponsibleforhealthonpolicyissues.First-levelreferralhospitals (countyreferralservices,thethirdtierofthepublichealthcaredelivery system) are the highest-level facilities in the county and these facilities’ HospitalManagementTeamsreporttotheCountyHealthManagementTeam.HospitalManagementTeamsareheadedbytheMedicalSuperintendentandincludethehospital’sadministrator,headsofdepartment,andnursingofficer-in-charge.Alongside the Hospital Management Teams, the Sub-County Health Management TeamsalsoreporttotheCountyHealthManagementTeam.Thesub-countylevelisverysimilartothe former district level,which had its ownDistrict HealthManagement Teams. Kilifi hadsevensub-counties,whichweremanagedbythreeSub-CountyHealthManagementTeams.Sub-CountyHealthManagement Teams include thosewhodirect health programmes anddepartmentsinthesub-countyandarechairedbySub-CountyMedicalOfficersofHealth.Inthehierarchy,theSub-CountyHealthManagementTeamsarejustabovethePrimaryCareHealth Management Teams; nursing officers-in-charge and clinical officers-in-charge whomanagetheprimaryhealthcare facilities.Primaryhealthcare (thesecondtierof thepublichealthcare delivery system) includes dispensaries, health centres, and public and privatematernity homes. Finally, community health services constitute the first tier of the publichealthcare delivery system. This includes creating demand for services, health promotionanddiseasepreventionthroughcommunityhealthworkers.

Unpreparedness,unclearrolesandbridgingarrangementsThe fast-paced transfer of functions occurred despite the absence of guidelines andcertainty on all the roles of the national and county governments. Like most counties inKenya, Kilifi was caught without the full complement of structures, staff and capacitiesrequired for the new county-level system. Early on in the devolution process, this had agreat impact on processes of budgeting and priority-setting, as outlined in the followingsection.However,thisissuewasmuchbroader.

HumanresourcesforhealthUnderthenewsystem,theCountyPublicServiceBoardbecametheoverallemployerofallgovernment employees in the county, replacing the national-level Public ServicesCommission,whichwouldcontinuetooverseetheemployeesofthenationalgovernment.When thedevolutionoccurred therewas, in the relationshipbetween thecountyand thenational government, a lackof clarity aboutwhichorganisationswouldbe responsible forhuman resource management issues that was relevant beyond individual counties, forexample the in-service training of healthworkers, the steps and processes in their careerprogression, and managing the transfer of health workers between counties. In therelationshipbetweentheCountyPublicServiceBoardandtheCountyDepartmentofHealth,itwasalsounclearwhowouldtakecareofwhichday-to-daytaskswhenitcametomatterssuchasrecruitment,appraisals,promotionsanddiscipline.

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The confusion was not limited to the relationships between the national and countygovernment,ortheCountyPublicServiceBoardandtheCountyDepartmentofHealth,butalso extended to the internal workings of the County Department of Health where sub-county managers in Kilifi complained, for example, about a lack of a clear organogram,unclearrolesandlinesofaccountabilitybetweentheCountyHealthManagementTeamandtheSub-CountyHealthManagementTeam,andcoordinationdifficultiesbetweenthesetwolayersofmanagement.Inthemonthsbeforeandafterthesuddentransferofpowers,thesemanagers felt starved of information (their prior provincial managers would only makevague statements about what would happen in future; once the devolution process wasunderway,theyoftenlearntaboutnewdevelopmentsfromthemedia),whichcausedmuchanxiety and stoked their fears that theywould lose their jobs. These dynamics negativelyaffectedthemotivationofsomeofthesemanagers.Thenewhumanresourcesarrangementsalsohadaparticularsignificanceforthehospitalsin Kilifi. Hospitals had previously managed their own support staff, who were now alsotransferredtotheCountyPublicServiceBoard,leavingthehospitalswithnoautonomyoveranyoftheirstaff.Thishadcertainpositiveeffects–reducedpressureonhospitalmanagerstorecruitandpaytheseworkers,andbetterbenefits for theworkers–butwenthand-in-handwith a perceived increase in indiscipline by theseworkers, aswell as appointmentsbasedonnepotismandtribalism.Finally, the county’s new role in human resourcesmanagementwas not only amatter ofrecruitment,performanceormotivation,butalso intersectedwith the financialdomainasthere was initially, given the rushed nature of the process, concern that counties hadinsufficientcapacityinpayrollmanagementandthattheywouldthereforefailtopayhealthworkers’salaries.ItwasthereforeagreedthatthenationalMinistryofHealthwould,foraninterimperiodofsixmonths,continuetopaythesalariesofallhealthworkersonbehalfofthecounties.AttheverystartofthisprocessinJuly2013,healthworkersexperiencedsalarydelays.AfterKilifiCountytookoverthetaskinJanuary2014,thefirstmonthssawproblemssuch as general delays in payment, the non-payment of certain allowances, and thedisappearanceofsomehealthworkersfromthepayroll.Inanefforttoironoutsomeoftheproblems, all staff had to report for a headcount over two days in February 2014. Thisheadcount included questions about staff’s county of birth and ethnicity, which createdconcernthatsome“outsider”staffwouldlosetheir jobsandonlyfuelledexistingtensions,anxietiesandfearsrelatedtothehumanresourcesandpayrollprocesses.

FinancingprimaryhealthcarefacilitiesIn2009,theKenyangovernmentintroducedtheHealthSectorServicesFund,throughwhichpayments were made directly from National Treasury to the bank accounts of primaryhealthcare facilities, thus bypassing the normal multi-level bureaucracy. The money wasprovidedbythenationalgovernment,thedonoragencyDANIDAandtheWorldBank;wasdistributed quarterly; supported recurrent expenditure; and was a small (US$ 340 – US$1200)butusefulandimportantsourceoffinancing.

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For the first six months of devolution, this funding came to an abrupt halt due tocontestation between the main actors. First, county governments argued that themanagement of primary healthcare facilities fell within their ambit and that they shouldtherefore select and officially gazette the Facility Management Committees (made up ofcommunitymembersandhealthworkers),whichwereinvolvedinmanagingandexercisingoversight over the direct facility funding. Second, the county governments and DANIDAwantedtochangetheflowofthemoneysothatitcametothecounties,whilethenationalgovernmentandWorldBankwereinfavourofmaintainingthedirectchanneltofacilities.In the end, it was agreed that the counties could gazette the Facility ManagementCommittees, but that the funds would go directly to the facilities. DANIDA, however,disagreedandwithhelditsfunding,soreducingthetotaldisbursementstofacilities.

ThesupplyofmedicineandmedicalequipmentUnderthedevolvedprocessofprocuringmedicinesandmedicalsupplies facilitymanagersprovidetheirestimatedneedstotheCountyPharmacist,whoprovidestechnicalassistancetothefacilitymanagersifrequired.TheCountyPharmacistlaterconsolidatesallthefacilityestimates,beforepreparingpurchaseordersandsubmittingthesetotheCountyTreasury.The supplies are then bought mostly from the Kenya Medical Supplies Agency, a statecorporationworkingunderthenationalMinistryofHealth.Countymanagers were in favour of this new system as they thought it would give themmore bargaining power relative to the Kenya Medical Supplies Agency to demand moreefficientserviceandtheoptiontouseothersuppliers,shouldtheybedissatisfiedwiththeKenya Medical Supplies Agency. Under the previous procurement system, the nationalMinistry of Health paid money to the Kenya Medical Supplies Agency, who essentiallycreated an account for all formally gazetted health facilities, againstwhich facilities couldthenordermedicinesandsupplieseveryquarter.In the early days of the devolved system, there was contestation around the role of theKenyaMedicalSuppliesAgency,although itwaseventuallyagreedthat theKenyaMedicalSuppliesAgencywouldbethecounties’firstoptionforprocurement,toachieveeconomiesofscaleandqualityassurance.Atthesametime,publichealthfacilitiesacrossthecountrywereexperiencingadrugshortagecrisis,whichwasamelioratedbythenationalMinistryofHealthanddevelopmentpartnersmakingavailablemoneyfora“starterpack”of6months’suppliesforallcounties,givingthemtimetoget inplacethenecessaryprocurementstaff,structuresandprocesses.InKilifi,theCountyDepartmentofHealthbegantheneedsestimationandorderingprocessattheendof2013,withthefirstsuppliestohospitalsdeliveredinFebruary2014.Althoughthe supplies to other, lower level, facilitieswere slightly delayed, the systemwas seen ashavingcertainbenefits,forexampletheKenyaMedicalSuppliesAgencysupplyingahigherproportionoftheorderedproductsthanbeforeandthefactthatthecountyboughtsupplies

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forallpublichealthfacilities,notjusttheformallygazettedones,thusreachingawidersetoffacilitiesandsupportingfacilitiesthatoftenwaitedforyearsaftertheirestablishmenttobegazettedbythenationalgovernment.

However, the new system did not affect all stakeholders equally and not all were alwaysequallypositiveaboutitseffects.SomeKilifihospitalmanagerscomplainedof,forexample,lengthy authorisation processes at the county level (previously, such approvals occurredmoreswiftlyatthedistrictoffices,whichwereclosertothehospitalsandlessbusy),delayedpaymentsduetofactorssuchastheperceivedpriorityoftheorderbycountyofficials,andconsequentdelaysindeliveries,whichaffectsservicedelivery.Asaconsequenceofthenewdevolved system, hospitals also lostmuch of their autonomy over the strategic planning:theycouldnolongerdeveloptheirownstrategicplans(allhealthfacilitieswerecoveredbytheCountyDepartmentofHealth’sstrategicplan)andwhiletheycouldstilldevelopannualworkplans,theiractivitieswereoftenunfundedbecausethebudgetingoccurredatcountylevel,outsideoftheircontrol.Hospitals’prioritieswerethereforeoftenatoddswiththoseof the county, for example when the county built what they felt were unnecessarystructuresorprocuredmanyambulances,insteadofpayingformorestafforrespondingtootherfeltprioritiessuchasadditionalwards.

The place of the County Department of Health in overall processes ofplanning,budgetingandprioritisation

Whatwassupposedtohappen?The fiscal yearof theKenyangovernment runs from July to June.At the county level, theannualplanningandbudgetingprocessstartsinSeptemberwhentheCountyDepartmentofHealth reviews itspreviousannualworkplanand identifies itspriorities for theupcomingyear.

In an attempt to secure votes and bolster their power, politicians often favouredvisible interventions. In the early phase of devolution,many counties opted to buyambulances. Moreover, County Governors, also in Kilifi, increasingly organisedpoliticalrallieswhenthetrucksarrivedtodeliverdrugsandmedicalsupplies.Devolutionalsocreatedspacesforpoliticianstoattempttoassertthemselvesinotherwaysinrelationtothehealthsystem:

• Insomecounties,therewereattemptstoensurethatnewlyqualifieddoctorswhoweredeployedtherecamefromthesamecountiesorthesametribesasthemajorityofpeoplelivingthere.

• InKilifi,afacilitywasclosedbecausetheMemberoftheCountyassemblyandthe community demanded to transfer out theonly nurse,whichwas from adifferenttribe.

• SomeMembersofCountyAssemblyhavesupportedfacilitymanagersintheirinitiatives. However, there has alsobeen conflict in some cases, for exampleregardingfacilitiesnotadheringtofreecarepolicies(seebelow).

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Also in September, the County Treasury publishes its Budget Review and Outlook Paper,whichoutlinesexpenditureagainst theprior year’sbudget, estimates the total amountofavailable resources thatwill be received from national government and generatedwithinthecounty,andallocatesanindicativeamounttoeachofthe10administrativedepartmentswithinthecounty.In December, there is then a resource bidding process in terms of which the countyadministrative departments, infomed by their annual work plans and identified priorities,lobbyfortheresourcesallocatedtothemtobemaintainedorincreased.FebruarythenseesthereleaseofbudgetceilingsandtheCountyFiscalStrategyPaper,whichcontainscounty-wide strategic fiscal goals that adminisrative departments should align their budgets andannualworkplansto.In the period from February toApril, the CountyDepartment ofHealth adjusts its annualwork plan and budget to fall within the budget ceilings and county priorites, and thensubmits a consolidated annual work plan and budget to the County Treasury, whichcombines itwith theworkplans andbudgets of theother departments to form thedraftcountybudget.FromApriltoJune,thisdraftbudgetthenhastobeapprovedbytheCountyExecutiveCommittee,thebudgetcommitteeoftheCountyAssemblyandultimatelythefullCountyAssembly,intimeforthestartofthenewfiscalyearinJuly.Atvariouspointsintime,thisannualprocessallowsforpublicparticipation,forexamplebyCounty Treasury after the release of the Budget Review and Outlook Paper and FiscalStrategy Paper; by the County Department of Health around the time of consilidating itsannualworkplanandbudget;andbythebudgetcommitteeoftheCountyAssemblywhenitscrutinisesthebudgettowardstheendoftheprocess.

Whathappenedinpractice?InpartduetotherapidtransferofpowerandfunctionsfromnationaltocountylevelinJune2013, Kilifi did not have all theorganisational structures and staff in place for this annualbudgetingandplanningprocess.WhileaChiefOfficerofTreasurywasappointedinMay2013,politicallobbyingforpositionsmeant that the posts of all the other departmental heads, including the Chief Officer ofHealth,remainedvacantuntilApril2014whentheGovernorfinallyappointedthem.FromMay2013toApril2014,theChiefOfficerofTreasurywasthereforetheaccountingofficerfor all the county departments. Weeks before the election of March 2013, the nationalMinistry of Health seconded interim county health coordinators to the county, whoestablished interim County Health Management Teams, who, in turn, designated formerDistrictHealthManagementTeamsas interimSub-CountyHealthManagementTeamsandformerHospitalManagementTeamsasinterimHospitalManagementTeams.Theproblemwasthatallthesestructureshadnoclearguidelines,rolesormandates.

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The upshot of this was that the County Department of Health abandoned the 2013/14planning and budgeting process (it did not develop an annual work plan or participateactivelyintheoverallprocess),asithadnoChiefOfficerofHealthtoleadtheprocess.Inthemeantime, the County Treasury, who was bound by legal deadlines around budgeting,developedandhadapprovedgenericbudgetsforallthedepartments,includingtheCountyDepartmentofHealth,toavoidtheprocessbeingstalled.In addition to the absence of key structures and personnel, this early period ofdecentralisationraisedconcernsaboutthecapacityofkeyofficeholderstoeffectively fulfiltheir roles in theseplanningandbudgetingprocesses.Therewas, forexample,aquestionmarkoverthequalificationsandpreviousworkexperienceofsomemembersoftheCountyExecutive Committee and whether this was suitable for their new strategic planning andoversight roles. In addition, some stakeholders at the county and sub-county levels wereconcerned that the new Members of County Assembly did not have the necessaryknowledge and understanding to hold officials and members of the County ExecutiveCommitteetoaccount,andthatthelatterwouldbeabletousefinancialincentivessuchasallowancestoenticeMembersofCountyAssemblytobe lessthorough intheirscrutinyoflegislationandpolicy.SomealsoexpressedthisconcernaboutthecapacityofMembersofCountyAssemblyinrelationtotheirroleinvettingtheappointmentofseniorofficialssuchofmembersoftheCountyExecutiveCommitteeortheChiefOfficerofHealth.Inthe2013/2014planningandbudgetingprocess,theCountyTreasurydidmakethebudgetavailableforpubliccomment,oncetheconsolidatedbudgethadbeenfinalised,butbeforeitwas sent to the County Assembly for approval. This limited public participationwas evenmore limited from the perspective of the health system, with the County Department ofHealth’s lack of active participation resulting in virtually no health-specific community orstakeholderinput.

NewfinancialproceduresandaccessingfundingforhealthservicedeliveryWiththenewcountygovernmentandtheestablishmentoftheCountyTreasurycamenewfinancial procedures and funding flows. In the weeks and months after the transfer ofpower,beforetheappointmentoftheChiefOfficerofHealth,longdelaysinaccessingfundsfor service deliverywas an immediate reality. Thiswas because all requests, including forroutineexpenditureonrecurrentservicedelivery,hadtobeapprovedbytheChiefOfficerofTreasury,whichcausedmajorbottlenecks.However, thenew financial procedures and funding flowshadmuchwider consequences,whichrippledthroughallthelevelsoftheservicedeliveryandmanagementhierarchy,andacrossdifferentdimensionsofthehealthsystem.

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HospitalsHospitalsexperiencedsomeofthebiggestchanges.First,beforedevolution,oneofthehospitals’sourcesoffinancingwasadirecttransferfromthenational government to thehospitals’bankaccounts.Afterdevolution,hospitalswererequired to request the goods and services required for service delivery with the countygovernment,whowouldorderandpayforitdirectly.Hospitalsthereforestoppedreceivingabudgetallocationfromeitherthenationalorcountygovernment.Second,thehospitalsinKilifilostaccesstotheirbankaccountsafterdevolution.Inthepast,all the hospitals’ fundingwent into their bank accounts, fromwhere they could access itwith co-signatories from the former district treasury. After devolution, the accountsignatories from the hospitals remained, but twomandatory signatories from the countyreplaced the former district treasury signatories. The effect was that hospitals could nolongerwithdrawmoneyfromtheiraccounts.Third, countyhospitals, including those in Kilifi, used to collect user fees,whichwouldbedeposited into their bank accounts, and then used at the hospital to meet the runningrequirements of the hospitals, subject to the development of budgets and the necessaryapprovals from the provincial level. Under the new dispensation, however, the countydirected the hospitals to bank their user fees into the county’s Consolidated RevenueAccount,whichwasinaccessibletothehospitals,unlesstheywentthroughthecounty-levelcentralised order placement and payment system. The CountyDepartment of Healthwasextremely dissatisfiedwith this directive and for a year hospitals continued to bank theiruser fees in theiroldaccounts,althoughtheycouldnotwithdraw itbecausetheyhad lostsignatory controlof theseaccounts. Somehospitalmanagerswentas far as to collect theuser fees and spend the cash, without banking any of themoney, on the needs of theirfacilities, bypassing the county-wide ordering and approval processes. Kilifi County laterdevelopedadraftlawtoenablehospitalstoretainandspenduserfeerevenue,butdespitethetwo-yearprocess,thelawisyettobeimplemented.Thenewfinancialarrangementsaffectedservicedeliveryinthathospitalslosttheflexibilitytorespondtoday-to-dayemergenciessuchasdrugstock-outsorfuelshortagesforvehicles,andexperiencedlongdelays intheprocurementofessentialsupplies. Itwasalso linkedtolowerstaffmotivation,becausemanagerscouldno longer try toensure thatstaffhad thebasics that theyneeded todo their jobs, and reduced support fromexternaldonors,whonow had to work through the county government, instead of being able to approachhospitalsdirectly,andwerefacedwithasituationwherehospitalscouldnolongerusesomeoftheirownfundstoco-contributetoagreedprojects.

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Sub-CountyHealthManagementTeamsThe new financial systems and procedures left the Kilifi Sub-County HealthManagementTeams starved of money for implementing their activities. With all the money held byCountyTreasury,thelatterlackedtechnicalcapacitytodealwithfundrequestsfromallthedifferent servicedelivery andmanagerial units.Anaddeddifficultywas that therewasnolegalframeworkforrecognisingSub-CountyHealthManagementTeamsasaccountingunits.The Sub-County Health Management Teams could approach the County HealthManagementTeamwithfundingproposals,butmanyofthesewereignoredoronlypartiallypaid.Thisunderfundingcontributedto:

• The cancellation of the private practitioners meeting, which the former DistrictHealthManagement Teams had used to convey guidelines and policy updates toprivatesectorfacilities;

• The abandonment of quarterlymeetings to review the performance indicators ofsub-counties;

• A meeting of all health-related stakeholders, previously used for planning andresourcesharing,beinglimitedtotheoccurrenceofemergenciessuchasoutbreaks;and

• Supportivesupervisiontohealthfacilitiesbecomingmuchmore irregular,changingfromatleastonceaquartertoafocusononlythosefacilitieswithknownproblems.

Drivenbyasenseofdutyandadesireforuncompromisedservicestopatients,somesub-countymanagersfundedtheiractivitieswiththeirownmoney,bycoveringcostsfor itemssuch as transport, mobile phones and internet access. Drawing on longstanding workingrelationships and a sense of team spirit, sub-countymanagersmetweekly to assess eachother’sperformanceandtoproblemsolvetogetherandsharedresourcestoenablethemtofulfil some of their roles, for example doubling up by using the resources of specific

Various hospital managers in Kilifi perceived a reduction in their autonomy withrespect to strategic planning, financial management, procurement, and humanresourcesmanagement. This reduced autonomy did not only affect these functionalareas, but had wider effects, including: (i) the weakening of hospital managementcommittees (why keep these committees going if they don’t have much power orresources?); and (ii) lessening the attractiveness of the position of medicalsuperintendent(whytakeupthisjob,whichnowhasreducedpowerandcontroloverresources?).Reduced autonomy also impacted community participation. Hospital ManagementCommittees,which included community representatives, had someproblems beforedevolution, but were now completely absent because there was not yet a legalframework for theirestablishmentand appointment. Thisaffectedcommunity inputintohospitaldecisions,butalsohospitals’abilitytocommunicatewiththecommunity.

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programmes to monitor those programmes, with officers from those programmes alsoreportingbackonanybroaderproblemsinfacilities.Using their networks, sub-countymanagerswere also to someextent able to get fundingfromdonorsandnon-governmentorganisationsworkingintheirareasforgeneralactivitiessuchassupportivesupervisionandspecificproblems,suchaswhentwonon-governmentalorganisationsmade it possible formanagers to travel to a cholera outbreak area, collectsamples,sendthemtoalaboratory,andtransportsuffererstohospital.

PrimaryHealthcareFacilitiesandManagersIn theearlydaysofdevolution,primaryhealthcare facilitiesreceivedfinancialshocks fromallsides. InJune2013,thePresidentofKenyaannouncedthatprimaryhealthcarefacilitieswouldnolongerchargeuserandmaternityfees.Theplanwasforthenationalgovernmentto compensate primary healthcare facilities for the lost revenue through direct paymentsintotheirbankaccounts,but formonthsafter theannouncementnosuchpaymentswereforthcoming.Overlappingwith theuser fee removalwas thedisputeover thepaymentofthe Health Sector Services Fundmoneys to primary healthcare facilities;money that wasalso intended to go directly into the bank accounts of facilities. Funding to facilities onlystartedflowingsixmonthsafterthePresident’sannouncement.In the absence of their national government and user fee funding, primary healthcarefacilities in Kilifi faced a severe cash crunch that affected, among other things, the basicinfrastructure of facilities (water and electricity accounts piled up; one facility wasdisconnected), human resources (facilities were unable to pay casual workers such ascleanersandsecurityguards;someofthemstoppedworkingandleftfilthyfacilitiesintheirwake), and service delivery (someoutreach serviceswere cancelled). In an effort to copewiththecrisis,someprimaryhealthcarefacilitymanagersworkedwithsub-countymanagersandmembersof the community to re-introduceuser fees. Theprimaryhealthcare facilitymanagers went about this in different ways, adhering to the previous user fee policy todifferentextentsandsettingthefeesatdifferentlevels.Liketheircounterpartsinhospitals,themanagersofprimaryhealthcarefacilitieswerenow,afterdevolution,bound to thenewsystemofprocuringdrugsandothermedical suppliesthatrequiredthemtoplacetheirordersthroughthecountyandintermsofwhichdeliveryisdependent on timeous payments. Late payments by the county resulted in regular drugstock-outs,and so therewas initiallyoftena feeling thathadexacerbateddrug shortages,whichhave alwaysbeen a featureof life in primaryhealthcare clinics. Primaryhealthcarefacilitymanagers and staff copedwith these stock-outs in variousways, includingwritingprescriptions so thatpatients couldpurchasedrugs in theprivate sector,borrowingdrugsfromotherfacilities,andusingtheirownmoneytobuydrugs,whichsomesoldtopatientsatmarketprices,whileotherswereallegedtochargemuchmore.

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ConclusionInKilifi,the2013/2015periodwasthereforecharacterisedbyfast-pacedchange; immensestructural change within and beyond the health system; changing roles and powerrelationships between actors; profound changes within functional areas such as finances,human resource management or medicine procurement; and impacts across functionalareas as governance changes affected staffmotivation, financial changes affectedmedicalproducts, governance and service delivery, and so on. Many of these changes impactedquite directly, whether positively or negatively, on the decentralisation objectives ofefficiency,effectiveness,equity,andresponsiveness.Beyondtheperiodthatisthefocusofthiscasestudy,furtherresearchhasyieldedadditionalinformationaboutKilifiandothercountiesthatcanbeusedtoformajudgementaboutthesuccessesandchallengesofdecentralisationinthehealthsectorinparticular.

A study (May– September 2017) that evaluatedplanning andbudgeting processes intwocountiesfound,withrespecttoKilifi,that:

• The budgeting process and the development of annual work plans had not beensynchronised. The latter were at least one quarter late, so that budgets did notnecessarilyreflecttheprioritiesintheannualworkplans.TheChiefOfficerofHealthled the budgeting process, while the County Director of Health led the planning.Managers’ perceptions that the budget was a legal requirement, and the annualworkplansnot,alsoensuredtimeousprogressinthebudgetprocess.

Thissamestudyreported:• Theinfluenceofpoliticalinterests,donorsandotherpartnersonresourceallocation

decisions.Thishasthepotentialtopromoteinequity,forexamplebyfavouringsub-countieswiththemostvocalrepresentationorregionsthathavesupportedcurrentpoliticalleaders.

• Criteriarelatedtoefficiencyandequitywasnotincorporatedintodecision-making.• The planning process came to involve non-governmental organisationsworking in

health,HospitalManagement Teams, Sub-CountyHealthManagement Teams andtheCountyHealthManagementTeam.PrimaryHealthcareManagementTeamsandthepublicwerenotinvolved.

• With respect to budgeting, seniormanagers invited participation from the public,HospitalManagementTeamsandSub-CountyHealthManagementTeams,but thelattertwogroupsweredissatisfiedbecausetheyfeltdisempoweredintheprocess.Primary Healthcare Management Teams did not participate in budgeting. Publicparticipationwasalso limited inscope.Thebudgetdoesnotcontainthedetailsofthe recurrent activities, which are usually in the annual work plans, so thatdiscussion focuses mainly on development / investment expenditure, which onlyrepresentsabout30%ofthebudget.

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Anotherstudy(March2015–April2016),conductedin10counties,toexplorepriority-settingforhealthequityandhealthservicesatthecommunitylevel,highlightedissuessuchas:• Limited capacity building and guidance for county-level decision-makers, which

created spaces for actors to promote their own interests, for example politicians’frequentpreferencesforveryvisiblecurativeinterventionsthathadthepotentialtogarnervotes.

• Limited action by county governments to address barriers to communityparticipation,informcitizensoftheirrightsandexplaintheirrolesinthebudgetingandplanningprocesses,causingcommunityconfusionandincreasingthechancesofdominationbythelocaleliteandthemanipulationofcommunitymembers.

• Thefeelingthathealthequitybetweencountieshad improvedduetofactorssuchas pro-poor funding flows from the national government, but that there is lessclarityonequitywithincountiesbecauseofcomplicationssuchasthe influenceofpowerfulpoliticiansandvariedsystemsof resourcedistribution,whichrange fromattempts to favour poorer and disadvantaged areas to the provision of equalfundingtodifferentlocalareas,regardlessofneed.

Thiscasestudyisbasedon:

1. TsofaB,MolyneuxS,GilsonL,GoodmanC.(2017).Howdoesdecentralisationaffecthealth sectorplanningand financialmanagement?Acase studyofearlyeffectsofdevolutioninKilifiCounty,Kenya.InternationalJournalforEquityinHealth,16:151.DOI10.1186/s12939-017-0649-0.

2. Tsofa B, Goodman C, Gilson L, Molyneux S. (2017). Devolution and its effects onhealth workforce and commodities management – early implementationexperiencesinKilifiCounty,Kenya.InternationalJournalforEquityinHealth,16:169.DOI10.1186/s12939-017-0663-2.

3. Barasa EW, Manyara AM, Molyneux S, Tsofa B. ((2017) Recentralization withindecentralization:Countyhospital autonomyunderdevolution inKenya.PLoSONE,12(8):e0182440.https://doi.org/10.1371/journal.pone.0182440.

4. NyikuriM,TsofaB,BarasaE,OkothP,MolyneuxS. (2015)CrisesandResilienceattheFrontline—PublicHealthFacilityManagersunderDevolutioninaSub-CountyontheKenyanCoast.PLoSONE,10(12):e0144768.doi:10.1371/journal.pone.0144768.

5. NyikuriMM,TsofaB,OkothP, Barasa EW,Molyneux S. (2017). “Weare toothlessandhanging,butoptimistic”:subcountymanagers’experiencesofrapiddevolutionin coastal Kenya. International Journal for Equity in Health, 16:113. DOI10.1186/s12939-017-0607-x.

6. WaithakaD,TsofaB,KabiaE,BarasaE.(2018).DescribingandevaluatinghealthcareprioritysettingpracticesatthecountylevelinKenya.InternationalJournalofHealthPlanningandManagement,1–18.DOI:10.1002/hpm.2527.

7. McCollum R, Theobald S, Otiso L, Martineau T, Karuga R, Barasa E, Molyneux S,Taegtmeyer M. (2018). Health Policy and Planning, 1–14. doi:10.1093/heapol/czy043.

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Samplestudenttasks/assessmentsThissectioncontainsanexampleofanexaminationthatcandrawonthiscasestudy.Thisisby no means the only way of structuring student engagement and this example can, ofcourse,beadaptedtosuitdifferentcoursesandcontexts,forexamplebychangingitsform(e.g.intoanassignment)ortheinstructionsandquestionsitcontains.

Take-home,openbookexaminationSource: This example is adapted from Introduction to Health Systems, a course in thecurriculumoftheMastersinPublicHealthoftheUniversityofCapeTown,SouthAfrica.Submissionandformattingguidelines

• Becausethisisatake-homeexam,properacademicwritingstyle,andaccurateandconsistentacademicreferencingwillbeexpected.

• Thewritingshouldbepredominantlynarrativeinstyle,althoughtablesordiagramsmayalsobeused.

• The entire typed exam response is expected to require between 10-12 pages ofresponse,excludingthereferencelistandadditionalappendices.

• Inwritingupyouranalysis,please structureyoursubmissionaround the followingheadings:

1) Initialdescriptionofthecaseexperience2) Explainingthefactorsinfluencingthehealthsysteminterventionconsidered

inthecaseexperience3) Systemlessonsandpolicyrecommendations4) References5) Appendices

Part1:Initialbriefdescriptionofthecaseexperience(‘Whathappened’)In this section, draw on the case report that was provided, the discussion in class, andsecondaryliterature,to:

• Describe the health system intervention considered in this case experience, andwhat effects the intervention had on other dimensions of the health system,consideringbothintendedandunintendedeffects;and

• Discussthelikelyimplicationsoftheinterventionforthepublicvaluegeneratedbythehealthsystem.

Note: includeatimeline identifyingthecriticalevents in thecaseexperiencesomewhere inthissection

Toprepareforthisanalysis:Reviewandreviseyourcourseworkandreadaroundthecaseoffocus. Inparticular,youmightwanttoreferbacktothesessionsonhealthsystemframeworksandexperiencesofhealthsystemdevelopmentincountriessuchasThailand.

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Part2:Explainingthefactorsinfluencingthecaseexperience(‘Whyithappenedthatway’)Inthissection,presentananalysisofhowtheexperienceunfoldedovertime,andhowitsintended and unintended effects were generated. In this analysis, show how differentinfluencingfactorsinteractwitheachotherwithintheexperience,includingingeneratingitseffects,asrelevant.Inwritingthissection,considerallofthefollowingissues:• Howagents,theirmindsetsandtheirrelationshipsinfluencedtheexperience,including

the intervention effects (and include at least 1 diagram showing agents and theirrelationships);

• What critical hardware and software issues in the organizational context of theinterventioninteractedandinfluencedthiscaseexperience,andhowtheyinfluencedit;

• Whatwidercontextualfactorshelpexplainhowtheexperienceunfolded;and• Any other critical factors that you have identified as explaining how the experience

unfolded over time and the intervention effects (justify their selection by discussingtheirinfluenceoverthisexperience).

Part3:Systemlessonsandpolicyrecommendations(“LessonsfromthecaseforHSS”)Fromyouranalysisof thiscaseexperience, identify threekey lessonsabouthealthsystemstrengthening in general. Justify and explain each of these lessons by reference to your

Toprepareforthisanalysis,reviewyourcourseworkandconductthefollowinganalyses:Contextual analysis: Think more broadly about the hardware/software of the organizationalcontext into which the intervention was introduced, drawing on the Aragon framework. Alsothink about the wider overarching context of the health system as a whole. Consider howhardwareandsoftwarefactors,aswellaswidercontextualfactors,influencehowtheexperienceunfolded over time – how they influenced agents, their responses to it and how theirrelationshipsplayedoutinthisexperience;andhowtheymighthaveinfluencedtheinterventionseffectsandlikelyimpactonpublicvalue.Agent mapping and analysis: Identify the key agents who had some influence over, orengagementwith,thesituationdescribedatthestartoftheperiodexamined.

• Drawadiagramtomaptherelevantagentsandtherelationshipsamongthem.• Use linestoconnectagentstoshowthe inter-relationshipsamongthem,withdifferent

lines (e.g. dotted vs. solid lines or different colours) showing different types ofrelationships(e.g.relationshipbasedonresourcesvs.basedoninformationvs.basedonjob position vs. based on informal support etc.). Try not to have too many differentcategoriesofrelationshiptoavoidgettingtoocomplex.

• On the same diagram, if possible, or in a linked but separate diagram, represent anychange over time in who the key agents were and the relationships among them(consideringatleast2criticaltimepointsintheexperience).

• Consider how these agents and the relationships among them influenced theinterventionovertime,andidentifythefactorsthatallowedthemtohaveinfluence.

• Alsoconsiderwhetheranyadditionalagentscametohaveinfluenceovertime(andwhatinfluence),aswellaswhethertheinfluenceofanyagentslessenedovertime(andhow).

Finally,considerhowthinkingaboutagentsandrelationshipsprovidesinsightson‘organisationalsoftware’,andhowthissoftwareinfluencedthecaseexperience.

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analysis of this particular experience and wider literature about health systemstrengthening.

ReferencesList all the sources of information/papers reviewed that you have drawn on towrite thisresponse.Useonereferencingconventiononly.Donotincludereferencestomaterialsthathavenotbeenused.AppendicesWhilst youshoulduse some illustrations (diagrams, tables) in the text itself, youmayalsoinclude additional diagrams ormaterials not included in the text of your narrative in theappendices.However,anythingintheappendicesshouldbeactivelyreferencedinthetextitself.Assessmentcriteria MarkClear identification and description of the case (the intervention),includingtheintendedandunintendedeffectsoftheinterventionoffocuson other health system dimensions, and its likely implications for thepublicvaluegeneratedbythehealthsystem.Includetimelineofcriticalevents.

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Fullandclearanalysisofthefactorsinfluencingthisexperience–includingappropriate consideration of agents, their mindsets and relationships,hardware/software organizational dimensions and wider contextualfactors;andtheinteractionsamongthesefactors.Shouldincludediagrams(e.g.agentmap,intextorinappendix)andshowuseoftheoreticalframeworksdiscussedinclass.

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Threelessonsabouthealthsystemstrengtheningareprovidedandeachiswell justified and explained – using broader literature to make yourargument.

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GeneralYoupresentaclearargumentbridgingacrossallpartsoftheanalysis–andprovidingsupportiveevidenceforyourargument.Originality and thoughtfulness (reflexivity) – youpresent yourown ideasabout the case, and also show awareness of the strengths and limits oftheseideasAppropriate style, adequate reading and references are used to makeconclusions(10refsminimum),spellingandgrammarmostlycorrect,usesappropriatereferencingconventions

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Total 100

Toprepareforthisanalysis:readaroundotherexperiencesofthistypeofinterventionandhealthsystemstrengtheningmoregenerally,aswellasclassnotesfromacrossthecourse).