Devolution in Kenya, following the promulgation of the new constitution in 2010,

was motivated by the need for more efficiency in the delivery of public services
(International Institute for Legislative Affairs, 2015). The ratification of the County
Governments Act 2012 provided for the establishment of two distinct and
interdependent levels of government, namely the county and national governments,
the implementation of which is viewed as a better way of promoting accountability,
technical equity, and efficiency in the controlling of public resources in Kenya
(Murkomen, 2012). Not only does devolution provide communities with a right to
manage their social and development affairs, but it also allows for the protection of
the interests of marginalized groups (McCollum)

Devolution also facilitates the equitable sharing of resources and the decentralization
of state organs and their services (McCollum et al., 2018). Chapter 11 of the
Constitution of Kenya empowers county governments to provide social functions,
excluding education is of importance. This is because the provision of public services
through decentralized units can have an effect on governance owing to the availability
of resources and authority to make choices over the resources (McCollum et al.,
2018). As highlighted in Murkomen (2012), county governments have the
responsibility of providing an 'enormous' portion of public services, which is reflected
in their allocations in the national budget. 

In Kenya, the devolution of the health system was anticipated to serve several
purposes. It was expected to improve access to health services across the country,
eliminate discrimination in the quality of healthcare service between urban areas and
'low potential areas, and eliminate bureaucracy in the administration of health
services, especially in procurement (Murkomen, 2012). Moreover, devolved
healthcare was viewed as a way of promoting efficacy in healthcare service delivery
while promoting the quality of healthcare services.

The role of devolved governments in Kenya in the administration of healthcare

services cannot be understated. Not only are these governments’ custodians of the
funding of their healthcare services, but they also have deterministic powers over the
human resource providing these services. Article 235 bestows on county governments
the power for: ‘establishing and abolishing offices in its public service,' 'appointing
persons to hold and act in those offices’ and ‘exercising disciplinary control over and
removing persons holding or acting in those offices. The constitution further states
county governments are responsible for all healthcare delivery functions, including
procurement of medical supplies.

However, the ability of devolved governments to provide quality healthcare service is

mainly dependent on the nature of governance or administrative efficiency of the
semi-autonomous healthcare centres (McCollum et al., 2018). The role of governance
in the performance of the health sector and the achievement of futuristic goals such as
Universal Health Coverage (UHC) is widely recognized (Fryatt, 2017). County
governments are also responsible for handling any challenges relating to healthcare
services, including capacity building and overcoming industrial actions (Murkomen,
2012). 

Health administration is designed to promote efficiency and coordination in the

provision of healthcare services and related supplies. This may involve a team of
individuals working in liaison to manage different levels of a given healthcare system
(Wager). The role of health administration in hospitals at the county level is
undeniable. This organ of the health system serves to influence the accessibility and
availability of healthcare for all people (Chalkidou et al., 2016). It is also the role of
healthcare administrators to ensure that physicians and healthcare providers practice
their craft in a conducive environment. That the administration of healthcare in
county-level hospitals is an important consideration cannot be understated. Not only
do healthcare administrations make far-reaching decisions in a given hospital, but it
also influences the implementation of national health policies at the hospital level
(Chalkidou et al., 2016). 

Healthcare administrators influence community health services, which are critical to

the achievement of UHC in ways such as promoting public awareness and uptake of
healthcare services while countering health-related beliefs in their immediate societies
(McCollum et al., 2018). They form the backbone of the provision of healthcare
services and community involvement, especially in the aftermath of devolution. This
makes part of the reason why healthcare has been a popular theme in devolution-
centred debates. The state of governance in a region can therefore influence planning
and financial management in the health sector of the region (Tsofa et al., 2017). This
is why there is an imperative to bring devolution into the debate of hospital
administration in Kenya.

Healthcare has been a repeated theme in most governance-related debates, which

makes the administration of health services a key concern. Along with the United
Nations (UN), the government of Kenya aims at achieving the UHC, which is
concerned with access for all people to preventing, rehabilitative, curative, promotive,
and palliative health services (Magnusson, 2017). The government of Kenya has its
focuses on achieving sufficient quality healthcare that is affordable to all people. The
third pillar of the Big Four Agenda of the government of Kenya outlines the
government’s ambition to ‘address inequality of access to healthcare and improve
health outcomes (Parliamentary Service Commission, 2018). By the year 2022, the
government aims at achieving 100 percent UHC anchored by mass uptake of the
National Hospital Insurance Fund (NHIF) services.

Achieving this goal requires the national government to scale up the NHIF system to
rural areas as opposed to the adoption clustered in urban areas, as has been the
previous case (Parliamentary Service Commission (PSC), 2018). This is largely
dependent on the effectiveness and efficiency of the health administration system at
community health centres. Past research has shown that decentralization of authority
and resources can affect the provision of health services. In the Philippines, for
instance, health centres experienced enormous administrative challenges including a
lack of repairs for medical equipment, understaffing, and poor management of
resources, barely five years after devolution (Tsofa et al., 2017). Similarly, the
decentralization of health human resources saw rural districts face staffing challenges
that resulted in re-centralization.

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 is the lack of comprehensive and coordinated investment 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 centres.
But there are significant gaps in the availability of utility vehicles.

To supplement these efforts, it is imperative for the government to invest in the

maintenance of these investments (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 for about 35.9%, and the government and donors account 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). 

The Health Financing Strategy of 2010 was implemented by the government to ensure
the provision of quality health care to all. This strategy brought about 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 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 a need for the active participation of all stakeholders
in the provision of healthcare and their efforts should be aimed at providing an
efficient health system lastly, the system should include a sector-wide approach and
emphasise flexibility for rapid disbursement and constant monitoring of budgetary
resources. For effective & quality healthcare service to be realized, well trained and
well-supported healthcare workforce is mandatory. 

The healthcare workforce includes all the personnel involved in enhancing health
services. These professionals include technicians, management personnel, doctors,
nurses, and laboratory specialists among others who even though they do not engage
directly with the patients, their services are crucial for the smooth functioning of the
health sector. The healthcare personnel are responsible for the offering of healthcare
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:
Human Resource Development(HRD) and Human Resource Management (HRM).

The two form a lifetime pathway for all health workers from training, and
employment until they exit the health workforce. The coordination between 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 the demand and supply sides of the
health labour market and examine the difference(Kumar, 2014). The supply side is
made up of a trained and qualified healthcare workforce such as nurses, and
physicians among other caregivers 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 public and private
health facilities hire professional healthcare providers.
According to the 2012-2030 report, the Kenyan government made a commitment
towards improving the accessibility of quality medical services to the citizens by
providing affordable, equitable and quality services(Linda, 2018). The policy covers
major health guidelines for both the National and County government’s health sector.
Since Independence, the government has made significant investments in the health
sector, however, there is still a myriad of challenges facing the health workforce. The
situation has mainly contributed to 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 resources 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).