Master’s Thesis 2019 30 ECTS

Faculty of Landscape and Society

The Impact of Devolution of Health

Care Systems In Kenya-A Case
Study Of Meru County Health
Facilities

Ntongai , Job Kubai

Master of Science in International Relations
THE IMPACT OF DEVOLUTION OF HEALTH CARE SYSTEMS IN KENYA- A CASE
STUDY OF MERU COUNTY HEALTH FACILITIES

MASTER OF SCIENCE (INTERNATIONAL RELATIONS)

By

JOB KUBAI NTONGAI

Email: jokubai15@gmail.com

Telephone No: +47 939 46 748

Thesis submitted to the Department of International Environment and Development Studies

,Faculty of Landsam, in partial fulfillment of the requirements for the award of a Master of Science
degree (International Relations)

Norwegian University of Life Sciences

P.O Box 5003 N-1432 ÅS

Tel: +47 64 96 52 00

Fax +47 64 96 52 01

Website: http;//www.nmbu.no/noragric

May 2019
 Declaration

I declare that this is my original work and that it has not been presented for a degree at this or any
other University. Work of others used in this study has been duly acknowledged. Any errors
contained herein are entirely mine.

JOB KUBAI NTONGAI

REG. NO:

Signed ………………………………………………… Date……………………………….

This research project has been submitted for examination with my approval as the University

Supervisor.

PROF.OBA GUFU

Department of International Environment and Development Studies

Signed ……………………………. Date…………………………………….

 Acknowledgement

This thesis would not be complete without offering my sincere gratitude to everyone who shared
their valuable time and insights with me. I owe a great deal of gratitude to my supervisor, Prof
Gufu Oba, for the suggestions, encouragement and feedback throughout this process.

Am deeply indebted to my big brother Dr Isaac Kaberia and Dr Andrew Ratanya for their insight
that helped mould my thesis and I fear I would not have survived this process without their
assistance. To NMBU Writing Centre, my friends, Martin Karanja thank you for your support,
early morning wake up calls, the love and laughter.

To the Meru County health CES and the entire Meru County health fraternity for your help during
data collection. To everyone working to improve health standards around Meru County, Kenya
and the World receive my heartfelt gratitude.

My special thanks go to my parents and siblings for their prayers for without the gifts of life, love
and support, none of this would have come to be.
 TABLE OF CONTENTS
Declaration ...................................................................................................................................... 2

Acknowledgement .......................................................................................................................... 3

List of Figures ................................................................................................................................ iv

List of Tables .................................................................................................................................. v

List of Abbreviations and Acronyms ............................................................................................. vi

Operational Definition .................................................................................................................. vii

Abstract ........................................................................................................................................ viii

Chapter 1 ......................................................................................................................................... 1

Introduction ..................................................................................................................................... 1

1.1 Devolution around the world ................................................................................................ 2

1.2 Devolution in Kenya ............................................................................................................. 4

1.3 Problem Statement ................................................................................................................ 6

1.4. The impact of devolution on health? ................................................................................ 6

1.5. Research Objectives. ............................................................................................................ 8

1.6. Justification of the study ...................................................................................................... 9

1.7. Organization of Thesis ..................................................................................................... 9

Chapter 2 ....................................................................................................................................... 10

Literature Review.......................................................................................................................... 10

2.1 Overview of health sector in Kenya.................................................................................... 10

2.2 Health Devolution in Kenya ............................................................................................... 14

2.3 Theoretical Literature Review ............................................................................................ 19

2.3.1. Theory of Balanced Growth................................................................................................ 20

2.3.2. The Theory of Unbalanced Growth .................................................................................... 21

2.4 Health State in counties ...................................................................................................... 22

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 2.5 Critique of existing literature .............................................................................................. 25

2.6 Summary ............................................................................................................................. 27

Chapter 3 ....................................................................................................................................... 28

Methodology ................................................................................................................................. 28

3.1 Research Design.................................................................................................................. 28

3.2 Sampling Frame, Technique and Size ................................................................................ 30

3.3 Data Collection and Analysis.............................................................................................. 31

Chapter Four ................................................................................................................................. 34

Data presentation and results ........................................................................................................ 34

4.1 General Respondents Information ...................................................................................... 34

4.2 Impact of health devolution in Meru County...................................................................... 37

4.4 Conclusion .......................................................................................................................... 43

Chapter 5 ....................................................................................................................................... 45

Discussion and Conclusion ........................................................................................................... 45

5.1 Summarized Study Findings ............................................................................................... 45

5.2 Contribution to knowledge ................................................................................................. 46

5.3 Recommendations ............................................................................................................... 47

5.4 Limitations of the study ...................................................................................................... 47

References ..................................................................................................................................... 48

Appendices .................................................................................................................................... 52

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iii
 List of Figures

Figure 2. 1: Map of Kenya and 47 Counties ................................................................................. 15

Figure 2. 2: Vicious Cycle of Poverty .......................................................................................... 20

Figure 3 1: Meru County............................................................................................................... 29

Figure 4. 1: Respondents’ Location .............................................................................................. 35

Figure 4. 2: Respondents Level of Education ............................................................................... 36

Figure 4. 3: Respondents Gender .................................................................................................. 37

Figure 4. 4: Respondents perception of whether devolution influences Health Systems ............. 38

Figure 4. 5: Respondents Views whether devolution is implemented right way in Meru County 41

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 List of Tables

Table 4. 1: Implementation of Devolution .................................................................................... 40

Table 4. 2: Devolution of Health Finance ..................................................................................... 42

Table 4. 3: Respondents Perception on Hospital Leadership ....................................................... 43

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 List of Abbreviations and Acronyms

GOK- Government of Kenya

GDP-Gross Domestic Product

MOH – Ministry of Health

MTEF-Medium Term Expenditure Framework

SPSS- Statistical Package for Social Sciences

UHC- Universal Health Care

WHO- World Health Organization

HRH- Human Resource for Health

TA- Transition Authority

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 Operational Definition

Devolution refers to the statutory delegation of authority from the central authority of a sovereign
nation to government at local level. It is a type of administrative decentralization.

Primary health care refers to the basic health care that every citizen should be able to access

Delegation refers to the transfer of managerial roles to a specific unit which operates outside the
usual government structure.

Health infrastructure is all the physical infrastructure, transport, technology infrastructure, as

well as non-medical equipment which is essential to ensure effective delivery of health services.

Health care services are services which help to prevent and manage diseases, illness, and injuries,
physical and mental problems.

Healthcare workforce includes all the individuals whose responsibility is to provide health care
services whether in the public or private sector.

Health care system is the mechanism for delivery of high-quality healthcare services to all people
when and where they need them

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 Abstract

The Kenyan constitution was promulgated on August 27, 2010, created a major shift from a central
mode of governance to a devolved mode of governance. It created 47 county governments that are
led by governors and Members of County Assembly and this created a platform to devolve
functions of central government such as administrative, financial and political roles. The study
purpose was to evaluate the impact of devolution in Meru County health systems. The following
specific objectives were pursued: assessing the impact of devolution on health workforce, to
examine the impact of devolution on health infrastructure and to assess the impact of devolution
on health services provision. A descriptive design was used to collect information. Meru county
health workers and patients were the study’s unit of research. Fisher’s formula was used in the
determination of sample size of 385 respondents. Collection of data was done through close ended
and open-ended questionnaires.

The study found that devolution has yielded several benefits in Meru County health sector.
Devolution had brought health services closer to the common mwananchi at affordable rates
through an increase in health facilities and rise in the number of medical personnel in the county.
However delayed financial disbursement from the national government, nepotism, corruption, and
delayed promotions negatively affected implementation in Meru County health sector.

The study recommends the national governments should come up with appropriate mechanisms
that will help prevent delay of funds to the counties. The county government should put up
measures in place to counter corruption by reporting corrupt individuals to the relevant authorities
such as to the Ethics and Anti-Corruption Commission.

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 Chapter 1

Introduction

Decentralization is divided into four distinct forms which are: devolution, delegation, privatization
and deconcentration. Devolution refers to a system of governance which involves the partial
decentralization of power from central mode of governance to regional governments which by law
they are instituted via a majority vote. Devolution is a decentralization method, whereby, an
authority is re-organized so that there exists responsibility sharing between the national/central
authority and the regional authorities. It aims to encourage the participation by members of the
public as well as promoting freedom of individuals. Units created through devolution are outside
direct national government control and federalism represents the strongest form through which
devolution is exercised. Privatization occurs when the management and ownership of a public
entity is transferred to a private or a non-governmental organization.

Deconcentrating involves shifting of administrative roles for particular decision making, financial
and management roles by administrative ways to various levels under the same authority of the
national government. Power is shifted from the core to periphery offices. In Kenya deconcentration
was manifested through the 8 provinces. Thirdly, delegation is whereby decision making and
administrative powers are transferred from one entity to another maybe from a government office
to an organization that is semi-independent of government or it is under the government. Example
of entities that exercise delegated roles are parastatals and corporate organizations such a city
municipality.

Devolution was motivated by the need to have a new constitution that ensures equality in the
distribution of wealth across the country. Devolution history in Kenya is quite long since 1963
when the colonial government suggested formational of regional units depending on ethnicity
although it never saw light of the day. Between 1970 and 1990 several decentralization units were
formed through funding by World Bank and International monetary fund as part of the structural
adjustment reforms, which carried on with deco centration promotion.

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After a lengthy period of fighting for a new constitution in order to reduce presidential powers,
67% of Kenyans by vote on August 2010 confirmed a new constitution through referendum that
marked the beginning of devolution. The new constitution brought devolved units the government
of Kenya confirmed a devolved governance mode of authority in the year 2013. This system of
government comprised of 47 counties which were granted partial autonomy from the central
government (Kibua & Mwabu, 2008)

The devolved units have been given significant decision-making mandate with minimal
interference from the central government. One of the major factors for the push of devolution was
real and perceived political challenges that had affected the country since independence. Some of
those challenges were inequitable resource distribution and marginalization. The new constitution
provided that critical sectors such as health and education be under both national and county
governments (Kibua & Mwabu, 2008).

Some of the important arguments put forward on devolution is that it facilitates economic
efficiency through the optimization of information flow, public services are brought closer to the
common mwananchi and to a greater extent reduces cost of development. Additionally, devolved
unit’s forms democratic space that allows units of authority to thrive (Dewees, Lobao, & Swanson,
2003).

The main difference between the 2010 constitution and the Lancaster House one is on the size of
participation by the people. The new constitution advocates a bigger participation level by the
people who live at the grassroots and they are counted when significant decisions are being made.
Such type of participation is promised via devolved governance. Article 174 of the 2010
constitution stipulates that the main roles for devolution are: accountable and democratic power
exercise promotion, extend self-governance powers to the citizens, promote the participation of
people in making decisions on challenges affecting them and promote national unity and cohesion
via diversity recognition.

1.1 Devolution around the world

Internationally, bodies such as Word bank and International monetary fund, implemented
devolution through adoption of structural adjustment programs that promoted deregulation and

2
decentralization. They began supporting local governments financially directly under the Local
Government Reform Program according to (Linda, 2018). Also, several nations in the world are
run through devolution and level of success differs across. For instance, in the United Kingdom
(UK) concept of devolution didn’t involve the community, it reduced access to funds by local
authority and changed the emphasis on governance (Willet & Giovannini, 2014). Further, there
has been considerable success of devolution in the United States of America with about 200 years
and India with about 60 years of experience.

Thailand implemented local administration units Act in the year 1999 with an aim of allocating at
least 25 per cent of national budget to local authoritative units. Primary health facilities and
ownership was transferred from the health ministry to the local authorities. In Thailand health
facilities were only devolved upon meeting two conditions: good governance capable of being in
charge of health facilities and secondly 50 % of the staff should be willing to shift from national
to local authorities’ recruitment. The devolution of health in Thailand allowed local authorities to
be responsible for delivery of the primary medical care and in management of staff as well as
finances. But the health ministry still is in charge of policy, training and technical aspects of health
(Hawkins, 2009). In the Philippines devolution in the first year recorded lower occupancy in the
health facilities, a decrease in drugs and medical supplies procurement, there was loss of fiscal and
management control in the running of hospital administration, there was low morale recorded
among the health workers and in some instances very crucial health personnel resigned from their
work stations. All these indicators show that in the Philippines devolution brought more problems
than the ones it solved, and it can be attributed to a lack of political will.

At the Regional level, Africa context, post-independence period many nations were governed by
one party system which was later opposed as people were oppressed by powerful governments. In
addition, most African leaders also realized they had different ideologies and this coupled with
other reasons was the basis for multi-party democracy in several nations (Haughton, Counsell, &
Vigar, 2008)

Devolution was started in 1996 in Ethiopia as plan to improve health care provision across the
country. Reginal levels are where the first devolution recipients and later it was extended to the
district levels in year 2002.Devolution created a four-tier system comprising national, regional,

3
referral and primary health facilities. Districts received grants from regional level authorities. As
such district units they exercise the roles of hiring and firing of medical workers, building and
maintenance of health facilities (Dubusho, 2009). The country recorded great improvements in
health services delivery although there were challenges during the first phases.

In Ghana devolution facilitated government policies implementation since independence. In the

year 1993 the local government Act was enacted, and it outlined responsibilities of district
assemblies. Health ministry delegated its authority of managing health centers to Ghana Health
Service, responsible for operating and managing offices and health centers across the country.
With time Ghana Health Facilities devolved into district and regional offices.

Devolution started in 1997 in Uganda under the local government act focused on health, education,
agriculture and natural resources management. In Uganda various scholars found out that there is
zero health improvement as shown by various health indicators. Devolution did not achieve the set
objectives of ensuring greater participation by people in health and education matters. This can be
attributed to insufficient capital and staff, lack of participation by the community, weak civil
society and a very narrow tax base. Ugandan case shows us that devolution can improve state
institutions if the local people are made a part of the decision making process as this will make it
possible to hold civil servants accountable (Patrick, 2013).

1.2 Devolution in Kenya

At national level, in Kenya, the idea of devolving certain functions has been in play since
independence. In August 2010 the new constitution was passed , it created 47 county governments
that are led by governors and Members of County Assembly and this created a platform to devolve
functions of central government such as administrative, financial and political roles (Khaunya,
Wawire, & Chepng'eno, 2015) . In Kenya a cooperative system of devolution was adopted whereby
the national and county governments consult and cooperate on various matters in their operations.
Devolution in Kenya is guided by three distinct principles which are: the principle of oversight,
this principle deals with the supervision of how the devolved units are run and manage resources
and it is carried out by independent institutions such as senate and office of auditor general,
secondly the principle of interdependence, this principle emphasizes the interdependence that
exists between the national and county governments since they both serve same people, and some

4
of their roles overlap since the national government normally does policy formulation work while
county governments are ones that are involved with implementation part. Thirdly, is the principle
of being distinct, by this, it means that every government level such as national and county have
distinct boundaries, resource and roles.

To ensure an efficient transition from the national system to the county governance, the new
constitution laid out several bodies with the mandate to oversight counties to enhance
accountability such as the auditor general’s office and the Senate (Ndung'u, 2014).Devolution in
Kenya have several objectives such as promotion of equality in the allocation of local and natural
resources, ensure that the rights of the minority and marginalized groups are upheld and
acknowledge communities rights in the management of their own affairs to promote local
development, guarantee that services are easily accessible throughout the country in order to
facilitate economic and social development and lastly ensure balances and checks and separating
powers. Devolution extended the following powers to county governments such as power to form
agencies, power to enter into public and private partnerships to allow service delivery, power to
contract, power to delegate some of its roles to officers and other units and power to accomplish
various roles.

Article 53 of the new constitution provides the right to basic nutrition, healthcare and shelter to
every Kenyan and Article 56 provides that, the state should formulate and put in place frameworks
that will make sure that the marginalized and minorities can be able to access to health services,
infrastructure and water. In order to meet these rights, devolution divided health provision
responsibilities between county and national government and it provided particular guidelines on
which services national and county government are to offer. Primary health care provision was the
role of the county administrations while national government retained management of national
referrals and health policy formulation. In order to allow smooth transition and provision of
primary health services to more than 62% Kenyans four main inputs are needed: to start with a
well-developed network of health centers are needed, trained and motivated staff are required,
supply of necessary medicines and adequate finances to allow the maintenance and operation of
health facilities (Mwangi, 2013).

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1.3 Problem Statement

The Kenyan constitution promulgation was done on August 27, 2010, and it created a major shift
from a central unit of authority to devolved system of governance. As the country embarked on
devolution, there were fears of disruption of services which were majorly attributed to the capacity
of county governments to deliver services (Timothy, 2017). To ensure the smooth and efficient
transition, the transition authority developed several timelines and criteria to assess the
preparedness of county governments in taking up devolved functions. However, this criterion was
considered to be generic, and as such, it created some challenges in the capability of counties to
provide health services. Besides, the newly elected county governments exerted too much pressure
on the national government, and consequently, there was a lot of transferred functions without due
consideration of how well the county governments are prepared (Linda, 2018).

This paper looks into the gap that exists concerning the health infrastructure in the country as well
as access and healthcare workforce and the several methods through which these factors affect
health service delivery in devolved systems. This paper aims to achieve this objective by putting
into consideration the critical pillars for realizing universal health coverage which include an
efficiently operating health system and run by a professionally trained workforce who are properly
motivated.

Studies done on devolution in Meru County, such as (Ayub & Keiyoro, 2017) analyzed the impact
of devolution on individual health facility ,the Meru referral hospital, such a study therefore cannot
be used to examine how devolution affects health in Meru County as its results may not be trusted
as a representation of health situation in Meru County. This study comes in and analyses the impact
of devolution on the entire health sector case of Meru County.

1.4.The impact of devolution on health?

For Kenyans to be able to access health services it is important that health facilities be physically
accessible across the 47 counties. According to a report by (International Rescue, 2015) about 63
percent of citizens have access to health care in government facilities located an hour from their
places of residence as distance plays a critical role in determining health demand, the further a
facility is from the people the low the health demand and vice versa. It is worth noting that medical

6
facilities are not equally allocated in the 47 counties. For example, counties in northern Kenya
such as Turkana the residents travel long distances for 2 or more days in order to access a health
facility which makes their health indicators low below the required level in comparison with other
counties. Generally in Kenya, one can note that 50 per cent of the counties have less than 2 health
facilities per 10,000 people and less than 4.2 health centers per 100 square kilometers (Ministry of
Health, 2015).

There are great differences between one county to the other in terms of the number of medical care
workforce. In the country the ratio of medical care personnel to the total population is way beneath
WHO recommended ratio of 230 per 100,000 people but it stand at 169 per 100,000 people but it
is better compared to other African nations such as Tanzania, Malawi and Uganda (Government
of Kenya, 2015).Some counties such as Nairobi and those within central province are more
endowed and resourced and hence have a better ratio than those in rural set up. Devolution outlined
each county should be responsible for the recruitment and hiring of health workers. And in some
counties insufficient manpower have caused industrial unrest, for instance, between January and
August 2015 more than half of the counties had strikes by health workers and understaffing was
among the main reason for that (International Rescue, 2015).The health sector faces brain drain
which was even made more by devolution as it stands between 30 to 40 percent of approximately
600 doctors move abroad in search of better pay and working conditions (Magokha, 2015).The
study also found that Kenya lacks a general cancer physician in public hospitals, this is worrying
considering the fact that today in Kenya, about 112 people are diagnosed with cancer on daily
basis. Specialists such as gynecologists, kidney doctors, engineering technologists in most public
hospitals are extremely lower in number against the required number of them and most of them
are found only in national referral hospitals and level 5 county hospitals and this leaves the rest
particularly in rural areas without those critical personnel.

Some of the reasons why health was devolved are: to ensure that citizens across the country have
access to basic health care, to curb discrimination experienced in rural and low potential areas that
are less privileged compared to urban areas in terms of health provision, to discourse problems
associated with low quality of health care provision, to discourse challenges that come with
bureaucracy especially when procuring in order to facilitate better health services provision and

7
lastly devolution was implemented in order to make it more efficient in delivery of medical care
services.

1.5.Research Objectives.

The main objective of the study is analyzing impact of devolution on health care systems in Meru
County health facilities. To achieve this objective, the study will examine and answer the following
research questions:

1. What is the impact of devolution on healthcare infrastructure?

2. What is the impact of devolution on access to health services?
3. What is the effect of devolution on health care workforce?

Kenya has set an objective of achieving universal health care by 2030. The increased need to
achieve these objective means that the study will assist various health sector stakeholders. The
main beneficiaries of this study include: National government, it will play a critical role in
measuring the goal and assessing how national health policies can be improved. It will benefit
county government by pointing out the achievements as well as identify areas that may need
improvements in the county health facilities. It will help the community to hold civil servants and
elected leaders into account. It will assist the staff and management of health services since part
of the objective is to identify areas that need improvements in delivery of health care and ensure
improvement of primary and basic medical care. Lastly, the study will add immensely to the
growing unit of research regarding devolution and how it is affecting certain areas of governance.

Geographical area under research is Meru County. The sample population used in the study
includes patients, clinicians, pharmacists, nurses, doctors, technical hospital staff, and hospital
managers. The study began in May 2018 with the introduction, literature review, research design,
and methodology. The second part of the study which includes data collection, analysis of data,
discussion findings, conclusion and recommendations.

8
1.6.Justification of the study

The study will be of great significance to several groups in the society, which includes researchers,
academicians, county government and the national government where it will greatly help in policy
formulations.

County government, central government and policy analysts could utilize the results of the study
and examine effectiveness of devolution on health which could aid in the improvement of service
delivery to the people.

To the Kenyan citizens the finding of this study will offer important information on their function
in the implementation of devolution in their respective counties. The study will also offer insight
to the people on the strengths and weaknesses of devolving health.

In future the study will act as a source of literature on health devolution to academicians, while at
the same time adding knowledge to the existing body of knowledge by offering information on
devolution issues in Kenya, Africa and the world at large.

1.7.Organization of Thesis

The thesis has been arranged as follows: Chapter one: Introduction, Chapter two covers devolution
background in Kenya and health devolution theories, Chapter three outlines methodology adopted
for the study, Chapter four outlines results and findings and Chapter five highlights Discussion of
results and proposed recommendations.

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 Chapter 2

Literature Review

The chapter outlines briefly an introduction about Meru county, a detailed overview of the
available literature on the devolution of health care and an empirical literature reviewing
devolution of health care at local and international level. Lastly, it outlines theoretical literature.

2.1 Overview of health sector in Kenya

Kenya gained its independence in 1963 after several years of being a colony of the Britain and
became a republic in 1964 with Jomo Kenyatta becoming first Prime minister. Since then several
reformations, targets and policies have been pursued aimed at achieving free health provision to
the citizens in order to batten productivity, welfare and lower the poverty levels.

In the year 1965 the government did away with user charges for all citizens looking for health
services in local public clinics and by the year 1970 a healthcare that is free was introduced in
every public health services across the country. But the economy stagnated around the year 1975
following the free medical services introduced and this forced the government to re-introduce the
user fees in the year 1989 in order to allow operation of the public health centers to continue. In
order to guarantee cost-sharing and financial assistance availability for the medical facilities
offering services within the periphery regions, the government came up with District health
management boards in 1992.

A health provision framework which will be affordable, acceptable and accessible to all was
introduced through a government publication, the Kenya medical policy framework (Ministry of
Health, 2015) and its implementation was to be executed via a two 5 year laid down plans which
are: National health sector strategic plan 1, that was to be implemented from 1999 to 2004 and
National health sector strategic plan 2 which was to be implemented from year 2005 to year
2010.These two frameworks set the public health in a hierarchical order in form of a pyramid with

10
health facilities in the rural areas at the bottom, the second ones are district and provisional
hospitals. At the top of the pyramid there are national referrals such as Kenyatta national and
referral hospital, which is currently the biggest referral hospital in Kenya and Moi teaching and
referral hospital located at Eldoret.

The government made a commitment to increase health facilities within the county with an aim to
make health services closer to the people and reduce disease outbreak and spreading. The national
government provided medical services at national, regional and district levels while the
missionaries provided services at sub-district levels such as dispensaries and local government
offered their services in urban areas. This pattern continued until late 70s when the government
abolished it and came up with a more comprehensive system that covered medical facilities in the
rural areas which provided preventive and curative health care services. By 2018 health facilities
had evolved and there were three main classes of health facilities which are: hospitals, health sub
centers such as dispensaries and mobile clinics and health centers. Hospitals included facilities
such as Kenyatta national hospital and Moi referral hospital and these two were the tertiary levels
with the mandate to handle referral and delicate cases and they get their financing from the national
government.

The second category is composed of the health centers such as district hospitals and they are the
secondary tier responsible for treating injury cases and offering treatment to medical services that
do not need specialized care. Clinics and health sub-centers are managed and controlled by the
local authorities and they treat certain part of the populace and they act as the first points of contact
between the patient and medical facility. Health sector in Kenya is broadly categorized into three
classes: To begin with is the public health sector which comprises of all government health
providers such as referral hospitals, provincial and district hospitals and dispensaries. Second
category is made up of private health sector that is non-commercial such as NGOs run hospitals,
faith-based organizations and the mission health facilities run by churches. The third category is
the private for-profit health sector, it comprises of medical supplies manufacturers and distributors
as well as private hospitals such as Nairobi hospital, Coptic, Nairobi women’s hospital among
others.

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Currently there are about 9,696 medical facilities in Kenya that are legally registered out of this,
about 4,616 are operated and owned by the government which accounts for 48 percent,3.696 are
operated by the private sector which accounts for 38 percent and 1,384 are owned by NGOs or
community based organizations which accounts for 14 percent.

In 2006 the ministry of health in Kenya came up with norms to regulate human resources charged
with the responsibility to ensure that adequate and qualified personnel for the task and their
distribution across the county are adhered to. (Ministry of Health, 2015).Therefore, medical
facilities workers are distributed depending on the number of health facilities across the country.
At level 4 district hospitals there are specialized clinics that are run by specialized physicians,
specialist doctors run provincial hospitals while a majority of the level 2 dispensaries across the
country are run by nurses who provide first care services. Because of this the national government
invested a lot towards the training of health workers and expanding health structures, by the year
2010 the number of medical workers had increased to 7,129 doctors,3,097 pharmacists and 898
dentists with majority of them work in private sector because of higher pay and better terms of
work.

The health sector in Kenya is financed by 3 main methods which are: public financing accounts
for 29 percent, household accounts at 37 percent, private funding accounts for 3 percent and donors
stands at 29 percent according to (Government , 2008). The health ministry is the largest medical
services provider in the nation via health centers, provisional, district and referral hospitals. An
analysis of poverty socio-economic shown that the main problem facing the poor people is
affordability of health care services and this called on the government to intervene in offering
quality, sufficient and better health services to the populace (Government of Kenya, 2015). Kenya
integrated and pursued features of primary medical care services all was aimed at slowing down
morbidity and mortality causes, this has made it attract donor financing to ease the implementation
process. However, recurrent financial distribution still finances more of curative at 70 percent than
preventive at 19 percent measures and this has made the pattern of poor quality medical care
services, insufficient inputs such as drugs and this has made the medical facilities at place have no
capacity to treat even small and simple health ailments.

12
A report by (Government , 2008) indicated that some of the health challenges facing the health
sector in Kenya includes expensive medical resources such as equipment’s and insufficient
medical facilities. That is one of the reasons that necessitated devolution in 2013, but health sector
in the counties have been experiencing health challenges since the counties were given the
autonomy to come up with different ways of raising revenues to supplement budget allocations
from the national government, and in some poor counties such as Baringo, Turkana the amount
collected is never enough to cater for health personnel salaries and this has led to boycotts which
have made citizens from such counties when sick to seek medical assistance from private health
facilities which are expensive.

In the year 2001 African heads of state met at Abuja and came up with the Abuja declaration that
required every nation to allocate a minimum of 15% of its total GDP but Kenya health allocation
stands at 6% of the GDP which falls short of the declaration. The Kenyan government has various
ways through which the country can raise funds to cater for medical services, but it faces the
challenge of ineffectiveness of some methods to meet the set targets.

After the 2010 new constitution was passed and implemented in 2013 during the first term of
President Uhuru Kenyatta, the power to make decisions was delegated and exercised by the
regional administrative units called the counties headed by a governor. Offering of basic as well
as secondary health care service were delegated to the county governments in order to promote
allocation of resources, ameliorate health services delivery to the populace in the long-run and
draw decision making powers closer to the local authorities. Periodically the central government
discharges funds to the county governments taking into considerations each county’s integrated
development plans. The Kenya health policy plan of 2012-2013 required every county come up
with a health department in order to coordinate and run health services provision for the county
and it also developed a framework of health management teams for the county whose mandate is
to offer professional and standard technical assistance in order to facilitate the coordination and
running of health delivery programs via medical care centers per county.

Devolution separated the roles the national government had to perform and retained and the ones
that is responsibility of the county governments. National government was in charge of following
functions: financing of the county health programs, in charge and coordinating running of the

13
national referral hospitals, management of laboratories in all public health facilities, carries out
major diseases control programs such as leprosy, malaria and TB formulation of health policies,
engaging in public and private partnerships, In charge of all services offered by Kenya health
supplies agencies like the National Hospital Insurance Fund, Kenya medical training college and
the Kenya medicines and supplies agency. National government also plans and allocates funds for
all health services at national level, communication of vital medical information and technological
changes and lastly quality assurance and standards. The county governments were charged with:
controlling abuse of drugs through campaigns and control of pornography, offering veterinary
services except in cases where veterinary professional regulation is required, provision of public
health and sanitation services, carrying out disaster management such as during floods, carrying
out disease surveillance and offering responses, equipping hospitals with ambulances and lastly
the management of health facilities and pharmacies within the county by recruiting qualified staff
and stocking the pharmacies with medicines.

2.2 Health Devolution in Kenya

Kenya is one of the six nations that compose the East Africa Community (EAC) whose head office
is in Arusha, Tanzania. Kenya estimated population as at March 2019 stands at 51 million with a
population growth of 2.48% with urban population of 44.6 % of the total population with an area
of approximately 582,000 km2.

As at 2018, Kenya had a GDP of $85.980 billion, Inflation stood at 5.04% with 42% population
living below poverty line. The major economic sectors in Kenya is agriculture which stands at
75% while service and industry accounts for 25%.

The major element towards achievement of universal health care is a strong, efficient and
efficiently managed health system. Robust health infrastructure is essential to compliment these
elements. (Kilonzo, Kamaara, & Magak, 2017) defines health infrastructure as medical apparatus,
buildings, transportation, communication and ICT facilities. Other essential infrastructure in the
Kenyan health system includes national and referral hospitals in the counties, regional, sub-
regional and sub-district hospitals, dispensaries, individuals in the private sector, Non-
Governmental Organizations and traditional sectors that are informal (Timothy, 2017). Over years,

14
there has been deficit budgetary allocations for the health ministry. This has contributed to
inefficiencies in operating most of these facilities Government of Kenya (2008).

The figure below shows the map of Kenya and its counties headed by a governor.

Figure 2. 1: Map of Kenya and 47 Counties

Source: Google (2019

Hence, most of these facilities require renovations before institutions of maintenance programs.
There are also insufficient premises for priority interventions such as laboratories, theaters and
delivery rooms in most health facilities. The most effective way to achieving delivery of quality
care would be maintaining health infrastructure in working condition. This in turns led to more
people utilizing available health care facilities and services (Munge & Briggs, 2013).

15
With the establishment of county governments the National government was able to prioritize the
presence of a specific number of health facilities in every county by considering what services
should be delivered at the primary health facilities (Munge & Briggs, 2013). According to
available data on health information management system (HMIS), there are more than 5000
medical structures and equipment in Kenya. Kenyan government runs over 43% of these facilities
while individuals operate 41% in the private sector, and non- governmental organizations run the
rest 14%. While the government runs and owns a large number of the medical facilities, private
individuals operates most of the clinics and nursing homes. The data also indicate that there is an
uneven allocation of these medical facilities across the several regions, Government of Kenya
(2008)

Lack of sufficient infrastructure has adversely affected the delivery of healthcare and maintenance
of health professionals in the public service. These are many cases of specialized doctors
complaining of underutilization of their skills, and in most cases, they opt to resign and join the
private sector. As a result, patients are forced to seek the services of less qualified healthcare
personnel. Others will opt for the private sector which is more expensive. As such, it is impossible
to realize the gains that should be provided by the financial risk protection program provided by
the government (Barnes , et al., 2010)

But currently most health facilities cannot provide a comprehensive package of primary health
care services. This is because there had been low investment in health care facilities as compared
to investments in other areas, and it has adversely affected the functionality upon the completion
of the investments (Barnes , et al., 2010).

Most investments in health care infrastructure focus on the establishment of modern health centers
under the economic stimulus program, Government of Kenya (2008). Besides, there are more than
80 hospital projections under construction. In spite of all these there are some challenges which
are affecting the equity in the distribution of infrastructure.

Hospitals ICT sector are well equipped in most public facilities, notably communication gadgets
have been adequately provided inorder to ease communication within hospitals. In addition most
health facilities in arid and semi-arid areas have been provided with radio equipment for effective

16
communication. Despite all these efforts, there is insufficient investment in the maintenance of
these ICT facilities thus some of them are dilapidated (Barnes , et al., 2010).

The national government in collaboration with the county government have put up mechanisms in
place to ensure specific hospitals especially Level 5’s have been installed with medical equipment.
However, there are several challenges that have prevented the realization of such efforts according
to (Zulu, et al., 2014). The main challenge being lack of comprehensive and coordinated
investments and limited investment in the maintenance of medical equipment.

On the issue of transport, the county governments have purchased ambulances for their hospitals
and health centers. But there are significant gaps in the availability of utility vehicles. To
supplement these efforts, it is imperative for the government to invest in maintenance of these
investment (Zulu, et al., 2014).

In Kenya, health funding consists of four major sources, namely: public, private, donor household
and insurance schemes financing. Households are the biggest source of funding accounting about
35.9%, the government and donors accounts for 30% each. In 2001, African governments passed
the Abuja declaration which requires African Nations to set aside a minimum of 15% of GDP
towards funding health provision (Kibua & Mwabu, 2008)

However, in Kenya, government funding has consistently remained just above 4% of the GDP
falling short of the Abuja target of 15%. Additionally, there is also an uneven distribution of funds
to public facilities. According to (Barnes , et al., 2010) report conducted in 2011 by Health Action,
over 70% of funds from government funding goes to secondary and tertiary facilities. Further the
report indicated that although primary infrastructure is significant in the offering of basic
healthcare services, they are poorly funded. Regardless of the numerous efforts made by the donors
to bridge the gap of funding in public health facilities, there is a general ten of underfinancing in
the health sector (Ndetei & Gitonga, 2011).

The Health Financing Strategy of 2010 was implemented by the government to ensure provision
of quality health care to all.This strategy brought about a social solidarity mechanisms whose main
purpose was to cushion the poor and the vulnerable (Government of Kenya, 2015). On top of that
the Kenyan government proved their commitment to this agenda by reviewing the NHIF act that

17
enhanced access and benefit to its users. The new constitution provided a legal framework with
the aim of making sure that the provision of comprehensive medical care services which is people
oriented.

It is important for any plans to recognize the need to incorporate more input from other players in
the health sector to reverse the trends in health provision (Munge & Briggs, 2013). Therefore, there
is need for active participation of all stakeholders in the provision of healthcare and their efforts
should be aimed at providing an efficient health system and lastly the system should include a
sector-wide approach and emphasized flexibility for rapid disbursement and constant monitoring
of budgetary resources.

For effective & quality health care service to be realized, well trained and well supported health
care workforce is mandatory. Health care workforce includes all the personnel involved in
enhancing health services. These professionals include technicians, management personnel,
doctors, nurses, laboratory specialists among others who even though they do not engage directly
with the patients, their services are crucial for the smooth functionality of the health sector.

The healthcare personnel are responsible for the offering of health care services. They comprise a
crucial part of the healthcare system,Government of Kenya (2008) .Human Resource for Health
(HRH) it’s comprised of two major parts: Huma Resource Development(HRD) and Human
Resource Management (HRM) .The two form a lifetime pathway for all health workers from
training, employment until they exit the health workforce. The coordination among the two
determines the success level of a country’s health sector (Kumar , 2014)

To effectively assess the health market, it is crucial to study demand and supply sides of the health
labor market and examine the difference (Kumar, 2014) .The supply side is made up of trained
and qualified healthcare workforce such as nurses, physicians among other care givers who
willingly work at a given wage rate in the health sector.

The demand for healthcare providers is closely linked with the demand for healthcare services. It
is measured by the rate at which both the public and private health facilities hire professional health
care providers.

18
According to the 2012-2030 report, Kenyan government made a commitment towards improving
accessibility of quality medical services to the citizens through providing affordable, equitable and
quality services (Linda, 2018). The policy covers major health guidelines for both National and
County government’s health sector.

Since Independence, the government has made significant investments in health sector, however
there are still a myriad challenge facing health workforce. The situation has mainly been
contributed by the consistent population growth over the years. This has put a lot of pressure on
the available workforce. It is therefore important for the government to increase financial
allocations for human resource in the health sector as well as provide incentives and better working
conditions that will foster retention and motivation among the available workforce (Blaise &
Kegels, 2004)

Another health sector challenge in Kenya is the shortage of health workers just like most countries
in Africa. According to WHO, Kenya has a significant shortage of healthcare workers. Currently
the ratio of doctors to population is 13:10,000 which is low compared to the minimum threshold
of the WHO which requires 23 healthcare professionals per 10,000 individuals. In rural areas this
condition is even worse (Timothy, 2017).

Health sector in Kenya has experienced a massive loss of qualified health workers mainly caused
by poor working conditions and inadequate remunerations. According to various reports, over
5000 Kenyan trained doctors have emigrated while over 3000 have left health sector to join other
sectors. Due to this only about 3440 doctors take care of the huge population. Some of the
challenges facing the health sector currently have been attributed to devolution (Linda, 2018).

2.3 Theoretical Literature Review

The study was based on two theories, which are: Theory of balanced growth and theory of
unbalanced growth.

19
2.3.1. Theory of Balanced Growth

This theory was formulated by Prof Nurkse (1907-1959). The major tenet of the theory is that it
emphasizes the need to make simultaneous investments in several industries as this will lead to
bigger markets and lead to an increase in the need to invest.

He postulated that the main impediment of development in Underdeveloped countries is the

vicious circle of poverty. The theory shows income is low in underdeveloped countries, which leds
to low savings. Low saving will automatically lead to low investment which will consequently
lead to low production. The low production will generate low income which will make the demand
for goods by consumers low as shown in Figure 2.3 below.

Figure 2. 2: Vicious Cycle of Poverty

Low
Low Income
Demand

Low Low
Productivity Investment

Low Capital
Formation

Source: Author’s Summary

This theory emphasizes that the major hindrance to development is limited market opportunities
and narrow markets. As a result of these only complementary investments are capable of creating
mutual demand. And thus, for any government to achieve balance it must plan for investment
(Merrifield, 2010).

20
According to (Fernando, 2009) who supported the theory of balanced growth, the study argued
that because of low demand for goods, it leads to a low propensity to invest which consequently
leads to low capital. And due to low per capita, productivity per worker will be low which in
extension leads to poverty.

This study borrows heavily from this theory as it provides insight on how the county governments
can improve the welfare of the common mwananchi through investing. The counties should invest
in sectors that have higher relation between demand, supply and purchasing power in consumer
goods industry and in the production of food (Whitworth & Whitworth, 2010).

2.3.2. The Theory of Unbalanced Growth

This theory was propounded by Hirschman, Rostow, Fleming and Singer as a development
strategy to be adopted by those nations that are underdeveloped. The theory emphasizes on the
importance of investments in strategic sectors of the economy rather than investing in all economic
sectors simultaneously.

This is because all economic sectors are linked together and hence the other sectors where
investments are not done will also grow this is because of the linkage effect and thus all sectors
will develop. Prof Hirschman asserts that to accelerate the rate of economic growth there is need
to create imbalances deliberately. As in underdeveloped countries resources are not enough and
the little available should be efficiently utilized. And thus, those strategic sectors should be
prioritized. And this is the best strategy for underdeveloped countries to grow.

According to Prof Hirschman, the real challenge towards development of underdeveloped

countries is not capital shortage but rather the lack of entrepreneurial skills, and this is a complete
contrast to the balanced growth according to (Gardiner, Martin, Sunley, & Tyler, 2013).

This study finds this theory of interest as it provides a totally different perspective on how to
achieve balanced growth in the counties. As it emphasizes that the most significant and influential
factor for development it’s the existence of entrepreneurship ability.

21
2.4 Health State in counties

Devolution introduced 47 counties in Kenya and they were mandated with the responsibility to
oversee: fisheries, agriculture, cultural activities, entertainment of the public and public social
amenities, transport system within the county, carrying out of trade and development such as
construction of open markets, offering pre-primary education, oversight of public works such as
roads construction and offering health services in terms of building hospitals and recruitment of
hospital staff.

Kenyan government will ensure that counties have access to sufficient funding in order to allow
the counties offer services to the people. Health is one of the sectors that was devolved from the
national level to county level. Some counties have recorded success in the implementation of
health devolution whilst others are still dragging along, and some have still terribly failed.
Devolution implementation led to the introduction of new health care facilities and medical
supplies such as medical equipment in al the 47 counties. But most health personnel in majority of
the counties are not satisfied with how the hospitals are run in terms of recruitment, enumeration
and the working conditions.

There have been several instances whereby the union of doctors and those of nurses have called
upon their members to go on strike due to delayed salaries and promotions and some even claim
that health should not be a devolved function as the national government managed it better. A
report by (KPMG, 2013) which explored the state of health before devolution and after devolution,
it investigates whether other nations recorded any gains or experienced losses upon implementing
devolution and some of the lessons Kenya as a country can learn from such countries experiences.
The report notes that health sector has been greatly centralized since independence with authority
concentrated in the capital but after devolution the national government is only mandated with
policy and management of only the two referral hospitals while other health related functions were
devolved to the counties.

Data has shown that under the national government health sector have been run wrongly and
review by the ministry of health revealed that improvements geared towards the health sector have
been minimal over the years with some health indicators having been worsened, for instance,
neonatal and maternal mortality rates have been on the rise until around 2008 which made

22
devolution as a cure especially in the marginalized areas in Kenya. A report by the World Bank
about access index to medical services indicated that some parts of the nation were completely
neglected and forgotten during the centralized system of governance. For example, 8 out of 10
newborns in central Kenya are born in the hospital while the report shown that in northern Kenya
only 2 out of 10 newborns were born in a hospital and this led to higher neonatal mortality in such
places and therefore need for devolution.

With devolution, it helped in making access to health facilities easier and better though the sector
has been facing numerous strikes from the health workers through their union representatives. The
World health organization identified Kenya as one country that is critically understaffed in terms
of health personnel due to reasons such as brain drain among others. World Health Organization
minimum ratio of physicians, midwives and nurses is at 23 per 10,000 while in Kenya the ratio
stands at 13 physicians, midwives and nurses per 10.000.

According to a report by (KPMG, 2013) Kenya can learn valuable lessons from nations such as
Thailand, Ghana and Ethiopia that greatly benefited from devolved health services, with Ethiopia
having devolved it medical sector in 1996 and its system reaped great benefits such as a decrease
in the number of under-five mortality rates from 123/1,000 live births to 88/1,000 live births in
2011.These benefits were achieved via a rapid implementation of health extension initiatives in
which more than 35,000 health workers were deployed in remote areas to offer medical services.
The districts received grants from the regional authorities which they used to come up with their
own goals and priorities and also formulate budget distributions depending on the needs of their
locality.

This district units were mandated with provision of human resources, setting up of new health
facilities and procurement process especially in the purchase of medical supplies such as drugs. In
Ghana health was devolved and it is under Ghana Health Service, a body that operates and runs
majority of the health facilities, centers and offices in the country. Ghana health service with time
it evolved and formed more deconcentrated units with district and regional medical offices. In
Thailand the situation has also improved.

The report by (KPMG, 2013) indicated that what has been observed in the 3 nations in the
formation of the correct administration and accountability system is very crucial in ensuring that

23
devolution is successful. In Wajir County health services have greatly improved, since before
devolution the residents would travel distances of more than 100 kilometers in order to access a
health center, but today more health centers have been put up near the people. New recruitment of
doctors which increased their number from 230 to 501 and the building of new maternity wings in
hospitals in order to reduce maternal mortality rates.

In most health facilities patients would get prescriptions and then told there are no drugs which
they would go and buy at privately owned pharmacies such cases with devolution have greatly
reduced as most hospitals are currently well stocked with drugs. The number of health workers
employed also increased by 34 percent since devolution came into practice. Since the year 2013,
health centers have increased in numbers across the country by 12 per cent as counties can now be
able to put up their new hospitals with some like Nandi and Kisii counties being on the process of
constructing referral hospitals.

The new health centers put up have increased the number of dispensaries by 12%, maternity
theatres increased by 142%, incubators increased by 43%, laboratories increased by 34 per cent
while beds increased by a whole 21 per cent. There have also been recorded improvements in
imaging facilities across the counties, and thus citizens no longer seek medical attention from the
expensive private facilities. Intensive care units have been opened up in Meru, Bomet and Kericho
counties.

Before devolution most hospitals did not have emergency services, but today most hospitals in the
counties have ambulances which have greatly contributed in saving lives. Many counties now are
stocked with drugs and hence patients are not asked to go and buy medicine from outside this is
attributed by the fact that before devolution the national government would spend sh.12.9 billion
on medicine while today with the county governments the spending on medicine have risen to 19.2
billion shillings showing an increase by 42 per cent. But, majority of the county’s defaults paying
the medical suppliers such as in Nairobi County, there are lack of drugs since the Kenya Medical
Supplies Agency is owed debt to the tune of sh.120 million by the county.

Majority of the county governments spends more than 30 per cent of their budgets on health while
national government used to spend only 6 per cent. There has also been an increment in doctors
and nurses number in the counties, although a section of them have raised complains over delayed

24
salaries and promotions, and the county governments have blamed the national government in
delaying funds disbursement to the counties.

There has been issues with devolution implementation especially in health matters, but also
significant improvements have been recorded and with time the country will reap heavily from
devolution.

2.5 Critique of existing literature

A lot of papers have been written about devolution and its impact on various on sectors such as
health and on education. This section analyses what various scholars wrote on the subject and
identifies gaps that the paper will fill. There are papers that show a positive relationship between
devolution and health, others show a negative relationship between devolution and health while
some of the scholars found there is no impact of devolution in health.

Some scholars found there is a negative relationship between devolution and health such as
(Hawkins, 2009) and (Willet & Giovannini, 2014). According to (Hawkins, 2009),the study found
out that in Philippines within one year of implementation of devolution in 1991 , the country
recorded lower occupancy in the health facilities, a decrease in drugs and medical equipment
procurement, there was loss of fiscal and management control in the running of hospital
administration opposite of what was expected. The country as a result of devolved health it also
recorded low motivation among the health care personnel and in some cases critical health workers
resigned from their workstations. All these indicators show that in the Philippines devolution
brought more problems than the ones it solved, and it can be attributed to a lack of political will.
Also a study by (Willet & Giovannini, 2014) he found out that in the United Kingdom (UK)
concept of devolution lacked a crucial factor of community participation and in turn it did not meet
the set targets as it has made accessibility of funds by the local governments to significantly reduce
and this changed the emphasis on governance.

On the same note other scholars found out that, devolution lead to an improvement in health.
According to (Anit, 2016), Brazil introduced a new constitution in 1988 that made access to health
a basic right and also introduced a unified health system for all. Devolution changed health model
from a privatized system to a state system with the private sector only supplementing the

25
government service delivery. States and municipal authorities were mandated with health delivery
and they were to ensure that health was accessible to all. Primary and secondary health care were
provided by state through public and private health facilities. By year 2012, 54.8 % of the
population were covered which was a manifestation of health care coverage. Devolution lead
expansion of community and public health centers which greatly improved health outcomes across
the country.

According to (Anit, 2016) China introduced reforms in sectors such as health in 1994 which were
designed to cure the inequality that exists between urban and rural dwellers. This is because the
urban and rural dwellers have different social, fiscal and economic conditions. Community health
workers were then promoted to private medical personnel mandated with the responsibility of
providing health to the rural people. This led to an improvement in coverage and quality of health
care in rural areas. This decreased infant mortality from 58 to 17 newborns and also it led to a
decrease in maternal mortality rates. Another study by (Dubusho, 2009) , found that in Ethiopia
introduced the concept of devolution in 1996 as plan to improve the provision of medical care in
the nation. Reginal levels are where the first devolution recipients and later it was extended to the
district levels in year 2002.Devolution created a four-tier system comprising national, regional,
referral and primary health facilities. Districts received grants from regional level authorities. As
such district units are solely mandated with the role of hiring and firing of health workforce,
building and maintenance of health facilities .The country recorded great improvements in health
services delivery although there were challenges during the first phases. (Dubusho, 2009). Another
case of devolution success is in Mexico where, according to (Anit, 2016), the country achieved a
decade success in achieving universal health coverage following the decentralization in 1985 of
health from the ministry to the states. There was an increase in private insurance by 4% and more
than 50 per cent of the population who did not have health insurance and could only afford public
health services they were funded by the states.

Other scholars also found that devolution did not have any impact on health. A study by (Patrick,
2013) he found out that in Uganda there was zero health improvement as shown by various health
indicators when devolution was implemented in 1997. He argued that devolution did not achieve
the set objectives of ensuring greater participation by people in health and education because of
insufficient capital and staff, lack of participation by the community, weak civil society and a very

26
narrow tax base. Ugandan case shows us that devolution can improve state institutions if the local
people are made a part of the decision-making process as this will make it possible to hold civil
servants accountable.

Conceptual framework, in this study, the researcher focused on health as the subject to facilitation
by devolution. The independent variables include health infrastructure, health funding, hospital
leadership, and health care access and hospital human resources.

2.6 Summary

Most of the previous literature reviewed in this section have not clearly shown the trends between
devolution and health. The studies have revealed mixed outcomes of devolution on health and
hence there is no specific direction in which impact of devolution has on health. Hence there is
need for a specific county or county to be individually investigated through empirical data.

Most of the literature reviewed analyzed impact of devolution on health at national levels such as
studies by (Anit, 2016) and (Willet & Giovannini, 2014) and their results may not necessarily be
trusted as a representative of the impact of devolution. Also, a study by (Patrick, 2013) focused on
the impact of devolution on national level and there is need to analyze individual county impacts.

27
 Chapter 3

Methodology

The chapter addresses methodology used in the study. It specifically outlines: Site Description,
Research design, population under consideration as well as the sample size, research procedures,
the methods of data collection and analysis used in the study.

3.1 Research Design

The study research design was comprised of a description of the site, unit of analysis and the target
population. Meru County will be our study site for this Research. Meru County is among the 47
Kenyan counties. By 2018 population of Meru County was projected to be 1.356 million, with an
area of 6,936 square kilometers. In addition, the County has 9 constituencies namely: Buuri,
Igembe South, Tigania West, Igembe Central, Central Imenti, South Imenti, Igembe North,
Tigania East and North Imenti.Meru County is well known for agriculture specifically Miraa
Farming.

Meru County is located in the Eastern province, as County 012, located 225 kilometers from
Nairobi. The county is bordered by Isiolo County on the northern side, on the southwest side it
borders Nyeri County, Tharaka nithi on the southwestern side and Laikipia County on the west. It
is believed that the word ‘meru’ came from the Maasai ethnic group who used to refer to Imenti
forests with the Maasai title ‘mieru’ forests. Current governor of Meru county is Hon.Kiratu
Murungi, and Titus Ntuchiu is the deputy governor while Hon Mithika Linturi is the Senator,
Wilfred Nyagwanga is the county commissioner and lastly Kawira Mwangaza is the Meru county
women representative. The main towns in Meru County are: Timau, which is about 55 kilometers
from Meru town and located along Meru-Nanyuki highway and hosts one of the county assembly
wards in Buuri constituency. The town is well known for horticultural produce such as roses and
ranches. Meru town, it serves as both the administrative and commercial town for Meru County.
River Kathita passes across the town and it is mostly known as a business and agriculture hub and
has the biggest open-air market in the county. Maua town is about 60 kilometers away from Meru

28
town and it is one of the most economical driven town as a result of an existing Miraa business. It
is home of Meru national park the biggest tourist attraction in the county. Maua town also hosts
significant institutions such as soldat teachers college, Methodist nursing home and Ikweta county
inn.Nkubu town is another major town in Meru County located next to Thingithu river banks along
the busy Nairobi-Meru highway.Nkubu is an administrative, agricultural and trade center with
major banks such as Kenya Commercial Bank, Equity Bank Limited, Cooperative Bank of Kenya,
Mount Kenya University Nkubu campus among other institutions. The other major town in Meru
County is Laare, and it is renowned as an agricultural town. It is located just 45 minutes’ drive
from Meru town and about 200 miles north of the capital city, Nairobi. Laare town is the largest
Miraa producer in the world and also hosts several administration units. See the figure below.

Figure 3 1: Meru County (Source: Google-2019)

29
A descriptive research design was used by the study in order to be able to illustrate the manner in
which the various elements of the study are coordinated to address the key research questions, and
because it makes it possible to collect data from respondents in natural settings.

To find out the influence of devolution on health infrastructure the respondents will be asked to
explain what their perception on devolution influences health care systems. To answer research
question 2, on whether devolution influences access of health services, the respondents will be
asked whether health services have moved to people since implementation of devolution. To
answer research question 3, respondents will be asked whether financing in health care has been
timey and sufficient.

In this study, the unit of analysis is the impact of devolution in Meru County health care systems
while unit of research comprised of Meru County health workers and patients. In this study, the
population target is the 216 health facilities in Meru County. The study utilized a stratified
sampling procedure in order to be able to choose sample populations. A study by (Cooper &
Schindler, 2006) defines target population as a group of interest from which the individual objects
or participants measurements are taken. The population of a study refers to all the objects that the
study seeks to investigate. Population is a large set of observations while a sample is a smaller set.
Samples are normally used to make observations in instances where the area or population that is
under investigation is very big.

In order to achieve the objectives, set the study settled on the impact of devolution on health
systems in Meru County as the unit of analysis and Meru county health workers and patients as
the unit of observation for the study.

3.2 Sampling Frame, Technique and Size

A sampling frame refers to a list of all the items that compose the population where a sample is
obtained (Fram, 2014). It mainly focuses on the population of the study where sampling is done
and from where generalizations regarding sample data are made. In this study, the sampling frame
is selected health facilities and satellite clinics within Meru County.

Sampling technique refers to the process by which the entities of the sample have been selected.
This study applied a stratified and cluster sampling techniques. In these two techniques, the

30
chances of each case being selected are unknown. Evaluating the characteristics of the population
using a representative sample is critical since in cases where the population is large, this process
may be costly and time-consuming (Fram, 2014).

According to (Fram, 2014) a sample size refers to a count of individual samples under observation.
To achieve a representative sample of the population, it is important to apply sampling techniques
which are relevant to the study that you are conducting. A bigger sample size increases the level
of accuracy in the results of the data under study (Fram, 2014) .This study used a total of 385
respondents selected from various health facilities across the county. The selection of the sample
was random and unbiased. The study used (Fisher, Laing, & Strocker, 1998) sample size
determination formula, with a confidence interval of 95 percent, this means there is a 5% chance
sample results will diverge from the true population average. Margin of error at ±5%, therefore

with confidence interval at 95%, Z score value will be 1.96, the margin of error will be, ε=0.05,

Standard deviation will be p=0.5, q= (1-std dev) =1-0.5=0.5, therefore sample size (n) will be
given by the formula:

n=z2pq

e2

n = (1.96 x 1.96) x 0.5 x 0.5

0.05 x 0.05

n = 384.16

Hence n=385

Stratified sampling technique was therefore applied to select 385 respondents in Meru County
health facilities

3.3 Data Collection and Analysis

This research utilized primary data. According to a study by (Creswell, 2008), he defines primary
data as data collected for the first time. Data collection methods refer to the mechanisms of used

31
to gather and measure information on targeted variables in a certain fashion that is systematic and
which helps address the research questions and evaluate outcomes (Mitchell & Jolley, 2013) . In
collecting primary data, the study utilized closed-ended questionnaires. Closed-ended
questionnaires are preferred to ensure uniformity in response to the predetermined questions. The
researcher developed these questions and structured as per the research questions of the study.
After physically delivering the questionnaires, the respondents were allowed sufficient time to
complete the questions. For follow-ups, the study used specific contact persons in each health
facility.

Prior to data collection, an introduction letter was obtained from Norwegian University of Life
Sciences in the Department of International Environment and Development Studies which was
later certified, stamped and approved by the Meru County Chief Health Officer which was
transmitted to the respondents to communicate identity of the researcher. Further, the duration,
purpose and intended use of the results were communicated to the respondents. During the
fieldwork interviews were only carried out on respondents who agreed to be interviewed. The
information was treated with confidentiality and names of the respondents were not mentioned.

To verify the validity of the items in the closed questionnaire, a pilot test comprising of 30
respondents from health facilities in South Imenti Sub County was conducted. It helps researcher
asses the suitability of the data collection instrument as well as identify challenges that may be
encountred during the interviews. Proper adjustments were made to the questions on the basis of
responses from our pilot test. Then final questionnaire was reviewed before sending it to the
respondents. This questionnaire was supplemented by a letter of introduction that explained
interview importance.

To answer the study’s research questions on the impact of devolution on healthcare infrastructure,
on access to medical care and on health care workforce, data was collected by using both open and
close-ended questionnaires that were administered during interviews in various health facilities
within Meru County

Qualitative analysis is normally used in examining non-measurable data. To ease referencing the
questionnaires were numbered before data collection. After data collection, it was cleaned, sorted
and coded for analysis. After verifying all the data entered was correct, descriptive statistics were

32
generated. According to (Mugenda & Mugenda, 2003) descriptive statistics assists in describing
the distribution of measurements, summarizing and organizing the data. The results from the data
were presented using figures and tables (Fram, 2014) in order to give a more appealing impression.

In order to achieve content validity, the researcher sought expert opinion from the supervisor and
face validity was obtained through carrying out a pilot test which allowed the researcher to edit
and correct research questions that seemed like ambiguous. According to a study by (Creswell,
2008) validity of any research instruments is the range by which the outcomes from a study through
analysis will show the phenomena under study. Validity is of two types, content validity which
deals with the probability a question set will be either misunderstood or misinterpreted. The second
type of validity is face validity which is the validity that shows all types of a social set up.

The researcher carried out a reliability test in order to ascertain whether the questionnaire formed
were able to give consistent outcomes. This was done through measuring internal consistency.
According to (Creswell, 2008), reliability can be defined as the degree through which a research
instrument such as questionnaire, interviews produce stable and consistent results.

33
 Chapter Four

Data presentation and results

Chapter four outlined data analysis methods, results and discussion of results. Main objective of
research was to examine devolution impact on health care systems in Kenya focusing in Meru
County. The study also focused to investigate impact of devolution on health workforce and how
devolution influenced the health care infrastructure. It also sought to analyze the impact of
devolution on access of health care services by the common citizens.

Sample size of the study was 385 respondents (health workers and patients), out of which 335
respondents filled and returned their questionnaires. 50 respondents refused to be interviewed and
consequently 50 questionnaires were not filled. The response rate was about 87.01% and according
to (Barberia & Biderman, 2005) any response rate above 50% is sufficient for analysis hence
87.01% response rate is very significant for analysis.

4.1 General Respondents Information

Respondents Location

The general information of respondents is location, highest level of education and gender. During
interviews respondents were requested to fill their location. The findings shown that 17.9% of the
respondents came from Buuri constituency, 40.3% came from Tigania East constituency, 12.0%
came from Imenti North Constituency, 5.9% came from Igembe South Constituency, 9.6% of the
respondents came from Tigania West constituency while 14.3% of the respondents came from
Imenti South constituency all within Meru County as depicted in Figure 4.1 below

34
Figure 4. 1: Respondents’ Location

The findings show that, most respondents came from Tigania East Constituency.

Respondent’s education levels.

The researcher requested respondents to fill highest educational level obtained .From the findings
34.3% had degrees, 44.8% of the respondents had College education, 20.9% of the respondents
had secondary school certificates while none of the respondents never attended school or just had
primary school certificate as shown in Figure 4.2 below. The findings indicated that most of the
respondents had college education.

The more educated the respondent is, the more he/she will be conversant with what devolution
means, its impact and gaps that needs to be filled as compared to the less educated members. From
the sample, we can conclude that in Meru County the literacy levels are higher.

35
Figure 4. 2: Respondents Level of Education

Respondents’ gender

The researcher also requested the respondents to indicate their gender. The findings indicated that
47.8% were male while 52.2% of the respondents were female as illustrated in Figure 4.3 below.
This demonstrated that majority of the people involved in study were female. According to
(Bardhan & Mookherjee, 2006) the study found out that both men and women view matters of
development under different perspectives.

Men will view development in terms of infrastructural developments in terms of electricity supply
and coverage, road network coverage and the growth of businesses. While on the other hand,
women being homemakers will view development in matters of increased accessibility to basic
commodities and services such as water provision, health services accessibility as well as
education accessibility in terms of schools.

36
Figure 4. 3: Respondents Gender

4.2 Impact of health devolution in Meru County

The interviewer requested respondents to indicate their perspective on whether devolution

influences health care systems. The study set out interviews, to find out whether devolution
influences health care systems (infrastructure, health workers and health services). From the
findings 79.7% of the respondents were positive while only 20.3% of the respondents thought
otherwise as shown in Figure 4.4 below.

For those who agreed they supported their position by indicating that since devolution was passed
and implemented, health services have moved closer to common mwananchi, this was due to an
increase in hospital staff. Some respondents indicated that previously medical services were only
accessible in Meru Level 5 Referral Hospital but currently they can be able to access the services
in the grassroots health facilities such as dispensaries that have been equipped by the County
government and also there has been an increase in public participation on matters health.

37
Figure 4. 4: Respondents perception of whether devolution influences Health Systems

In order to answer research question 2, on what is the impact of devolution on access to health
services. The researcher requested the respondents to indicate whether healthcare has improved
since implementation of devolution. Respondent was requested to fill his/her level of agreement
or disagreement on implementation of devolution. Where SA stood for strongly agree, A was
agreeing, N was neutral, and D was disagreeing while SD strongly disagreed. From the findings,
majority agreed at 53.9% health provision had improved since the implementation of devolution,
14.7% strongly agreed,9.8% were both neutral and strongly disagreed while 11.8% disagreed
among the respondents.

Secondly, 48.0% respondents agreed that devolution had led to an increase in healthcare workforce
in Meru County, 25.5% strongly agreed, 12.7% were neutral and 6.9% both strongly disagreed and
disagreed that number of health workers had increased since implementation of devolution. Some
respondents reported that ,there was overworking especially in Meru Level 5 hospital which lead
to inefficiency, this was in line with a report by (Ministry of Health, 2015) that indicated that the
health sector in Kenya still faced major human resource deficiency notwithstanding massive
funding injected into the sector since independence and also after devolution. This can be ascribed
by the increase in population which persistently exerts pressure on health demand.

38
Additionally, the findings shown that 17.6% strongly agreed devolution had led to an increase of
hospital infrastructure, 42.2% agreed respectively, 21.6% were neutral. Some respondents
indicated that they can now access health services in newly constructed health centers such as
Miathene and Ikaiga dispensaries. However, among the respondents 13.7% disagreed while 4.9%
strongly disagreed that health infrastructure had increased with devolution.

Further, 24.5% of the respondents strongly agreed that since devolution was implemented health
services had moved closer to the common mwananchi, 50.1% agreed while 12.7% were both
neutral and disagreed that since devolution implementation health care has moved closer to the
common mwananchi this was attributed to the fact that more health centers have been constructed
in the Sub-Counties and none of respondents strongly disagreed on the issue.

Lastly, majority of respondents agreed at 42.2% that medical supplies and financial allocations to
the health sector had improved since the onset of devolution while 9.8% strongly agreed. Out of
this 23.5% of the respondents were neutral as to whether financial allocations had improved with
devolution. Findings further revealed that 12.7% disagreed and 11.8% strongly disagreed that
health sector has improved since devolution started being implement in Meru county.

Table 4.1 shows agreement levels among respondents on various statements asked during the
interview

39
Table 4. 1: Implementation of Devolution

Implementation of devolution Level of Agreement Total

(Percent)

STATEMENTS SA A N D SD % N

Healthcare provision has improved since 14.7 53.9 9.8 11.8 9.8 100 335
implementation of devolution

Devolution led to health care workforce increase in 25.5 48.0 12.7 6.9 6.9 100 335
Meru County health facilities

Devolution has led to an additional and improvement 17.6 42.2 21.6 13.7 4.9 100 335
of hospital infrastructure

As a result of devolution, health care has been moved 24.5 50.1 12.7 12.7 0.0 100 335
closer to the common mwananchi in the grassroots

Medical supplies and financial allocations to health 9.8 42.2 23.5 12.7 11.8 100 335
sector have improved with devolution

To get more insight on devolution the respondents were asked to indicate whether devolution
implementation process was being made in the right way in Meru county. The findings shown that
56.1% of the respondents agreed that devolution was implemented in the right way in Meru County
while 43.9% of the respondents differed as shown in Figure 4.5 below. From the findings it can be
concluded that devolution was implemented in the right way in Meru county.

40
Figure 4. 5: Respondents Views whether devolution is implemented right way in Meru County

To answer research question 3 on what impact devolution had on health care workforce, the
researcher requested respondents to indicate whether health funds were allocated on time for
salaries and employment of more staff. The study found out that after devolution the major source
of health financing in counties is mostly from the National government. However, 91.1%
respondents pointed out that health funds were not received on time while only 8.9% differed. The
commitment of any government to the health sector is measured through timely and more financial
allocations to the health sector.90.2% of the respondents disagreed that financial allocations from
the National government were sufficient while only 9.8% of the respondents differed.

Majority of the respondents indicated that due to delayed financial allocations from the National
government to the County, this has led to go slow among the health workers due to delayed salaries
and also lack of medical supplies and drugs in hospitals as suppliers had not been paid. Reports
indicate that since devolution health financing had been a challenge which has made Counties
health facilities unable to offer primary health care services (Government of Kenya, 2015).Table
4.3 below depicts the findings.

41
Table 4. 2: Devolution of Health Finance

Health Financing Frequency Percent Total

Yes No Yes No Frequency Percent

Timely financial 30 305 8.9 91.1 335 100

allocation

Sufficient Financial 33 302 9.8 90.2 335 100

allocation

4.3 Hospital Leadership styles

The study established that 13.4% of the respondents rated the hospital leadership as excellent in
being participatory, effective and up to the task. Participatory leadership is defined as leadership
that allows people to fully utilize their full potential and act without any interference. According
to (Guay, 2013) positive style of leadership creates a sense of teamwork among the employees.
Also, a study by (Kottke & Pelletier, 2013) found out that leaders having strong moral standards
may facilitate effective employee performance and positive engagement.

Additionally, the findings also shown that 74.6% of respondents rated hospital leadership as being
average. This finding agrees with a study done by (O'Neil, 2008) who noted that in a hospital set
up, senior hospital management holds administrative roles and power. This include people in
charge of nursing, pharmacy, administration and its mostly headed by a medical superintendent.
The ones in control of clinical operations are mostly clinicians and nurses who execute their duties
without any specific administration roles.

Lastly, only 12.0% of the respondents indicated that hospital leadership was poorly participatory,
poorly effective and was not up to the task. Based on these findings we can conclude that the
leadership in most hospitals is one that is effective, participatory and one that is up to the task as
illustrated in Table 4.2 below.

42
Table 4. 3: Respondents Perception on Hospital Leadership

Hospital Leadership Rating Frequency Percent

Excellent 45 13.4%

Average 250 74.6%

Poor 40 12.0%

Total 335 100%

4.4 Conclusion

Empirical results generated from the study were analyzed and interpreted concisely in this chapter.
The study investigated impact of devolution of health systems (health infrastructure, health
workforce and health services) in Kenya with a special focus in Meru County. The research utilized
primary data that was collected through both closed and open-ended questionnaires and total of
335 questionnaires were answered and given back. They were then cleaned, coded and entered for
analysis.

The findings shown that most of respondents came from Tigania East Constituency at 40.3%.
Highest education level of the respondents was at 44.8%., Women were 52.2% while 47.8% were
men. Also 79.7% of the respondents agreed that devolution influences health care systems
(infrastructure, health workers, and health services) in Meru County while 20.3% differed.

Additionally, 56.1% of the respondents agreed that devolution process kicked off in the right note
Meru county including the implementation aspect while 43.9% differed.

Further, 13.4% of the respondents rated hospital leadership as excellent, 74.6% average while only
12.0% rated it as poor. However, 91.1% respondents indicated that health funding was not timely

43
received while only 8.9% differed. And lastly, 90.2% of the respondents disagreed that financial
allocations from the National government were sufficient while only 9.8% of the respondents
differed.

44
 Chapter 5

Discussion and Conclusion

This chapter summarizes findings, conclusions and offers recommendations for practice and
studies to be done in the future. An analysis of the impact of devolution on health systems with
Meru county as the case study was the main objective of the study.

5.1 Summarized Study Findings

Kenyan constitution was passed and promulgated August 27, 2010, it created a shift in the major
framework for governance in the country. The major change was a shift from a central authority
to a devolved system of authority. The study set out to analyze the impact of devolution on health
systems in Meru County. The study utilized primary data which was collected via closed ended
questionnaires. The objectives of study were to find out impact of devolution on healthcare
infrastructure, impact of devolution on access to health services and to analyze impact of
devolution on health care workforce in Meru county.

Salient findings of the study are:

In Meru County 79.7% residents agreed that devolution influences health care systems while only
20.3% of the respondents thought otherwise

The findings revealed that 53.9% of respondents concurred that health provision had battened since
the implementation of devolution while 11.8% respondents disagreed. Also, 48.0% respondents
agreed that devolution contributed to the increase of healthcare workforce in Meru County while
6.9% of the respondents differed.

The findings also shown that 17.6% strongly agreed, 42.2% agreed that devolution had led to an
increase in hospital infrastructure. 21.6% of the respondents were neutral, 13.7% disagreed while
4.9% strongly disagreed. Further, 24.5% strongly agreed ,50.1% agreed, 12.7% were neutral and
0% strongly disagreed that since devolution implementation health care has moved closer to the
common mwananchi.

45
Lastly, 42.2% respondents agreed, 23.5% were neutral while 11.8% strongly disagreed that
medical supplies and financial allocations to the health sector had improved since the onset of
devolution.

The findings shown that 56.1% of the respondents concurred that devolution was being
implemented in the correct way in Meru county while 43.9% differed.

The study found out that health funding was not timely by 91.1% while only 8.9% respondents
differed. In addition, 90.2% of the respondents disagreed that financial allocations from the
National government were sufficient while only 9.8% of the respondents differed.

5.2 Contribution to knowledge

The study found out that since implementation of devolution especially in health sector service
delivery has increased in terms of affordability, availability and accessibility to the common
mwananchi.

In addition, the study also revealed that devolution was being implemented in the correct way in
Meru county, but it is facing various challenges such as corruption, nepotism, delayed salaries etc.
These findings agree with (Wehner, 2000) , the study argued that factors such as inadequacy of
funds, poor management and corruption negatively impact devolution implementation.

This study also found out that medical supplies especially in county run pharmacies are not enough
and take time before the pharmacies receive them from the suppliers. Further, the study established
that health workers such as doctors and nurses are poorly motivated due to delayed promotions
and salaries.

Lastly, the study found out that health financing is the biggest challenge towards the realization of
the fruits of devolution in Meru County. The finances are not timely and also are insufficient to
meet the overall health sector needs in the County.

46
5.3 Recommendations

The recommendations are founded on the results of this study and are split into two parts. The first
section outlines the recommendation to policy makers while second section presents
recommendations providing suggestions for future research

The study found that funds allocated to the health sector were received late and also, they were not
sufficient. The study recommends that the National governments should come up with appropriate
mechanisms that will help counter the challenges associated with release of funds to the counties.

The study also found that leadership was averagely provided in the county. The study recommends
that both County government leaders and hospital management should be of people who are up to
the task, focused and performance oriented.

The study also found that implementation of devolution faced challenges such as nepotism,
corruption, delayed staff promotions etc. The study suggests that the county government should
come up with measures to counter corruption by reporting corrupt individuals to the relevant
authorities such as to the Ethics and Anti-Corruption Commission.

The study was limited to Meru county and thus its findings may not be generalized to represent
the situation in other counties. In this spirit further research needs to be done on impact of
devolution on health systems in other counties in Kenya. It also recommends future research on
the challenges faced by health sector since devolution was implemented in Kenya.

5.4 Limitations of the study

The major challenge encountered in data collection was health workers would decline to be
interviewed on fears of their job security as they thought it was a Meru County data collection
operation. The researcher assured the respondents that the data is purely academics and will not
be shared publicly to safeguard confidentiality.

Also, some respondents especially patients would demand to be paid in order to be interviewed.
The researcher would request them to cooperate since it was for academic and not any profit
generation. Those who would insist, researcher would politely stop the interview and proceed.

47
 References

Anit, M. (2016). "Fiscal devolution and health financing reform:Lessons for India from
Brazil,China and Mexico''. CGD Policy paper 97.

Ayub, k. M., & Keiyoro, P. (2017). INFLUENCE OF DEVOLUTION OF GOVERNMENT

SERVICE DELIVERY ON PROVISION OF HEALTHCARE: A CASE OF LEVEL FIVE
HOSPITAL IN MERU COUNTY, KENYA. International Academic Journal of
Information Sciences and Project Management | Volume 2, Issue 1, 300-315.

Barberia , L., & Biderman, C. (2005). Local Economic Development in Brazil: Theory, Evidence
and Implications for Policy. Associação Nacional de Pós-Graduação e Pesquisa em, 1-12.

Bardhan, P., & Mookherjee, D. (2006). Dencentralization and Local Governance in Developing
Countries: A Comparative Perspective. Cambridge,M.A: The MIT Press.

Barnes , J., O'Hanlon, B., Feeley, F., Kimberly, M., Nelson, G., & Caytie, D. (2010). Private
Health Sector Assessment in Kenya. Washington D.C: World Bank Publications.

Blaise, P., & Kegels, G. (2004). A realistic approach to the evaluation of the quality management
movement in health care systems: a comparison between European and African contexts
based on Mintzberg's organizational models. The International Journal Of Health
Planning And Management, 19(4), 337-364.

Cooper, D., & Schindler, P. (2006). Business research methods (8th ed). New Delhi: Tata
McGraw-Hill Publishing Company.

Creswell, J. (2008). Educational research: Planning, conducting, and evaluating quantitative

Research(3rd). Upper Saddle River, NJ: Prentice Hall.

Dewees, S., Lobao, L., & Swanson, L. (2003). Local economic development in an age of
devolution. Rural Sociology.68(2), 182-206.

Dubusho, T. (2009). Ethiopia:Improving health service delivery. Washington D.C: World Bank
and the international bank for reconstruction and development.

48
Fernando, A. (2009). Business Environment. New Delhi: Pearson Education.

Fisher, A., Laing, J., & Strocker, J. (1998). Operation Research Design in Sampling. Population
Council, 40-45.

Fram, S. (2014). When to use what research design. International Journal Of Social Research
Methodology, 17(3), 322-324.

Gardiner, B., Martin, R., Sunley, P., & Tyler, P. (2013). Spatially unbalanced growth in the British
Economy. Journal of Economic Geography, 889-928.

Government , O. (2008). Kenya National Health Sector Strategic Plan. Nairobi: Government
Printers.

Government of Kenya. (2015). Kenya Health Bill 2015. Nairobi: Government Printer.

Guay, R. (2013). The relationship between leader fit and transformational leadership. Journal of
Managerial Psychology, 28(1), 55-73.

Haughton, G., Counsell, D., & Vigar, G. (2008). Sustainable Development in Post-devolution in
UK and Ireland. Regional Studies,42(9), 1223-1236.

Hawkins, L. (2009). Devolution of health centers and hospital autonomy in Thailand:a rapid
assessment . Washington: World Bank.

International Rescue, C. (2015). Every voice counts program report. Nairobi.

Khaunya, M., Wawire, B., & Chepng'eno, V. (2015). Devolved Governance in Kenya; Is it a False
Start in Democratic Decentralization for Development. International Journal of
Economics,Finance and Management,4(1), 23-43.

Kibua, T., & Mwabu, G. (2008). Decentralization and devolution in Kenya. Nairobi: University
of Nairobi Press.

Kilonzo, S., Kamaara, E., & Magak, K. (2017). Improving Access to Maternal Health Care through
Devolution in Western Kenya. IDS Bulletin, 48(2).

49
Kottke, J. L., & Pelletier, K. L. (2013). Measuring and differentiating perceptions of supervisor
and top leader ethics. Journal of Business Ethnics, 113, 415-428.

KPMG. (2013). Devolution of health services in Kenya.Lessons from other countries.

Kumar , M. H. (2014). mprovement of Health Sector in Kenya. American Journal Of Public Health
Research,2(4), 159-169.

Linda, J. (2018). Devolution, shifting centre-periphery relationships and conflict in northern

Kenya. Political Geography, 63, 135-147.

Magokha, T. (2015). ''Blame game as Kenyas Health crisis hurts". standard.

Merrifield, A. (2010). The coming of The Coming Insurrection: notes on a politics of

neocommunism. Environment & Planning D: Society & Space,28(2), 202-216.

Ministry of Health. (2015). Kenya Demographic and Health Survey (KDHS), Key Health
Indicators.

Mitchell, M., & Jolley, J. (2013). Research design explained. Belmont, CA: Wadsworth, Cengage
Learning.

Mugenda, O., & Mugenda, A. (2003). Research methods: Quantitative and qualitative
Approaches. Nairobi: Acts Press.

Munge, K., & Briggs, A. (2013). The progressivity of health-care financing in Kenya. Health
Policy And Planning, 29(7), 912-920.

Mwangi, C. (2013). "Accessibility to the Kenyan healthcare system:Barriers to accessing proper

healthcare". Unpublished PhD thesis,Arcada University.

Ndetei, D., & Gitonga, P. (2011). Improving access to mental health care in Kenya. Ethnicity And
Inequalities In Health And Social Care, 4(3), 97-102.

Ndung'u, G. (2014). Analyzing the Impact of Devolution on Economic Development Potentialities

in Kenya. International Affairs and Global Strategy.26, 11-26.

50
O'Neil, M. (2008). Human resource leadership: the key to improved results in health. Hum Resour
Health,6(1), 10.

Rummery, K., & Greener, I. (2012). Introduction: UK Devolution. Social Policy &
Administration,46(2), 139-141.

Whitworth, B., & Whitworth, A. (2010). The social environment model: Small heroes and the
evolution of human society. First Monday,15(11).

Willet, J., & Giovannini, A. (2014). The Uneven Path of UK Devolution: Top-Down vs.Bottom-
Up Regionalism in England-Cornwall and the North-East Compared. Political
Studies,62(2), 343-360.

Zulu, J., Michelo, C., Msoni, C., Hurtig, A., Byskov, J., & Blystad, A. (2014). Increased fairness
in priority setting processes within the health sector.

51
 Appendices

APPENDIX 1: Individual Survey Questionnaire

THE IMPACT OF DEVOLUTION OF HEALTH CARE SYSTEMS IN KENYA- A CASE

STUDY OF MERU COUNTY HEALTH FACILITIES

Individual Survey Questionnaire

Please answer the questions with absolute honesty. All information provided during this interview
will be treated as anonymous and with confidentiality. Furthermore, the information will only be
used for academic purposes.

Respondent Agrees To Be Interviewed …………………………. (Proceed).

Respondent Does Not Agree To Be Interviewed………………. (End)

IDENTIFICATION PARTICULARS

Questionnaire ID No.

Administrative Area

Area Name Code

Constituency

District

Hospital

52
Please tick your response/choices as appropriate.

PART A: General Information

1. Gender
Male [ ]

Female [ ]

2. Age Bracket

25 years or below [ ] 26 to 35 years [ ]

36 to 45 years [ ] 46 to 55 years [ ]

56 to 65 years [ ]

3. (a) Patient [ ]

(b) Hospital staff, which capacity do you serve in the hospital?

Doctor [ ] Pharmacist [ ]

Clinical Officer [ ] Office Administrator [ ]

Technical Staff [ ] Hospital Management [ ]

Nurse [ ]

4. What is your highest verifiable level of education?

Never attended School [ ] Primary school [ ]

53
Secondary school [ ] College [ ]

University [ ]

5. Where do you come from?

Within Meru County [ ] Outside Meru County [ ]

PART B: The Relationship between Devolution and Health Care Systems-Health

Infrastructure and Health workforce

6. Do you think devolution influences health care systems?

Yes [ ] No [ ]

7. If yes, how?

………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………….

8. The table below relates to healthcare provision since the implementation of devolution.

Please tick the column that best describes your opinion

NB: 5-Stongly Agree (SA): 4-Agree (A): 3-Neutral (N): 2-Diagree (D): 1-Strongly Disagree (SD)

Statement 5-SD 4-A 3-N 2-D 1-SD

54
 Healthcare provision has improved since implementation of
devolution

Devolution has led to an increase in the number of

healthcare workforce in Meru County health facilities

Devolution has led to an additional and improvement of

hospital infrastructure

As a result of devolution, health care has been moved closer

to the common mwananchi in the grassroots

Medical supplies and financial allocations to health sector

have improved with devolution

PART C: Factors Affecting Implementation of Devolution of Health Systems

9. Do you think devolution of health services is being implemented in the right way in Meru
County?

Yes [ ] No [ ]

10. If No, why?

………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

55
11. To the best of your knowledge, is the hospital leadership one that is: participatory, effective
and up to the task? Please tick your rating on the leadership.

Excellent [ ]

Average [ ]

Poor [ ]

12. The financing of the health care by the County government is timely and sufficient in the
provision of qualified health services.

Yes (Agree) No (Disagree)

Timely financial allocation [ ] [ ]

Level of financing received sufficient [ ] [ ]

Thank you very much for your time and Participation

END OF INTERVIEW

56