Recentralization within decentralization: County hospital autonomy under devolution in Kenya.

Publisher: Public Library of Science Country of Publication: United States NLM ID: 101285081 Publication Model: eCollection Cited Medium: Internet ISSN: 1932-6203 (Electronic) Linking ISSN: 19326203 NLM ISO Abbreviation: PLoS One Subsets: MEDLINE

Original Publication: San Francisco, CA : Public Library of Science

Politics* ; Practice Management, Medical*; Delivery of Health Care/*organization & administration ; Hospitals, County/*organization & administration; Child, Preschool ; Female ; Hospital Administration ; Humans ; Infant ; Kenya ; Local Government ; Male ; Qualitative Research

Background: In 2013, Kenya transitioned into a devolved system of government with a central government and 47 semi-autonomous county governments. In this paper, we report early experiences of devolution in the Kenyan health sector, with a focus on public county hospitals. Specifically, we examine changes in hospital autonomy as a result of devolution, and how these have affected hospital functioning.
Methods: We used a qualitative case study approach to examine the level of autonomy that hospitals had over key management functions and how this had affected hospital functioning in three county hospitals in coastal Kenya. We collected data by in-depth interviews of county health managers and hospital managers in the case study hospitals (n = 21). We adopted the framework proposed by Chawla et al (1995) to examine the autonomy that hospitals had over five management domains (strategic management, finance, procurement, human resource, and administration), and how these influenced hospital functioning.
Findings: Devolution had resulted in a substantial reduction in the autonomy of county hospitals over the five key functions examined. This resulted in weakened hospital management and leadership, reduced community participation in hospital affairs, compromised quality of services, reduced motivation among hospital staff, non-alignment of county and hospital priorities, staff insubordination, and compromised quality of care.
Conclusion: Increasing the autonomy of county hospitals in Kenya will improve their functioning. County governments should develop legislation that give hospitals greater control over resources and key management functions.

Soc Sci Med. 2017 Feb;174:104-112. (PMID: 28024239)
Soc Sci Med. 1998 Nov;47(10):1513-27. (PMID: 9823047)
Health Policy. 1995 Apr-Jun;32(1-3):245-55. (PMID: 10156641)
Health Policy. 2003 Apr;64(1):113-27. (PMID: 12644333)
PLoS Med. 2011 Aug;8(8):e1001079. (PMID: 21886488)
Health Policy Plan. 2002 Mar;17(1):14-31. (PMID: 11861583)
Health Policy Plan. 2017 Apr 1;32(3):329-337. (PMID: 27679522)
Health Policy Plan. 2003 Dec;18(4):357-69. (PMID: 14654512)
Rural Remote Health. 2003 Jul-Sep;3(2):220. (PMID: 15877513)
Int J Health Policy Manag. 2015 Nov 15;5(3):173-81. (PMID: 26927588)
BMC Health Serv Res. 2016 Sep 30;16(1):536. (PMID: 27716185)
Lancet. 2004 Oct 30-Nov 5;364(9445):1622-9. (PMID: 15519635)
Soc Sci Med. 2013 Nov;96:232-40. (PMID: 23958453)

United Kingdom WT_ Wellcome Trust; EP-C-15-003 United States EPA EPA

Date Created: 20170804 Date Completed: 20171006 Latest Revision: 20240603

20240603

PMC5542634

10.1371/journal.pone.0182440

28771558