First do no harm | Devolution in the health sector in Kenya

Twaweza has recently entered into a partnership with the International Budget Partnership (IBP) to produce a number of briefs focused on budget issues in Kenya. Through this partnership, Twaweza will support IBP’s work around the budget / public finance transparency, budget engagement and access to information agenda.

The first of these briefs was recently released in Kenya.  Kenya’s new constitution requires decentralisation in a number of key areas of spending and service delivery. Through an analysis of the health sector, IBP have highlighted some of the key challenges and issues around this process.

The brief was launched with an event that included 60 participants from government and civil society, including the media. Importantly the Transition Authority, which has oversight of devolution in Kenya and could potentially address some of the outstanding concerns, were represented.

Health was chosen because is the most important and expensive social sector to be devolved, and it is one where the consequences of failures in service delivery can have a big impact on people’s lives.

The brief covers three key areas.

1. Who is responsible for what?

An unclear division of responsibilities between national and county governments could paralyse vital services. The divisions require clear rationales, so that the logic of decision-making is transparent and coherent, and timeframes, since devolution is scheduled to take place over the next three years. The lack of this information raises concerns about continuation of, and accountability in, service delivery.

2. What costs what?

Although a number of arms of government have committed to a clear costing of individual activities within sectors , this is currently unavailable. The budget is obtuse when it comes to specific allocations in various sectors. Without clear and specific costs, allocation of funds between county and national governments becomes impossible and any shortfalls are unidentifiable. Ultimate authority for making these decisions rests with the Transition Authority, as per the Transition to Devolved Government Act. 

3. Where does the money go?

Devolution of spending should be based on the clear division of responsibilities. In the current budget, services have been devolved while money for them remains with the national government. Similarly some budgets have devolved while national government remains responsible for delivering those services. The danger is that the different levels of government will not have adequate resources to deliver the services they are responsible for, resulting in delays and stoppages that could be fatal.

The brief also outlines some clear recommendations to improve the current situation.

  1. Release any existing documents explaining their views on the correct division of responsibilities between the two levels of government
  2. Release all information related to the cost of delivering services.
  3. Provide a narrative explanation of why particular functions and finances have been assigned to particular levels of government, and explain how this is consistent with the Fourth Schedule and the principles proposed by the Taskforce on Devolved Government.
  4. Highlight the implications of this proposed division of functions for all major programs that provide services to the public so that citizens know who will be accountable for running these.
  5. Organize a series of open public consultations by sector (e.g., health, education, agriculture) on the sharing of responsibilities between levels of government at which the public is properly informed about the key issues and given an opportunity to provide feedback.
  6. Revise the overall distribution of functions and financial flows in accord with substantive feedback received from the public on the appropriate distribution.
  7. Provide a detailed timeline for the implementation of Steps 1-6.



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Authors: Jason Lakin



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