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Kenya has been in transition since 2010, after a new constitution was Promulgated. The key pillar of the constitution was division of power and introduction of new levels of government.
A transitional authority was set up between 2011-2013 to prepare the ground for devolution.
The new constitution took effect after the 2013 General Elections. We are learning key lessons on how to manage health in a devolved system.
A. VARYING PRIORITIZATION OF HEALTH Different counties prioritize health differently at 2 levels: Political level: 1. Some political leaders at county level perceive health as an expense rather than an investment and hence cut back on county budget proposals in the Assemblies. There is more interest in infrastructural projects for political purposes
2: Some officials in the health departments do not view preventive / promotive health services at community level as primary. They are therefore largely left for NGOs to support
B: LOW BUDGETARY ALLOCATION FOR HEALTH Most counties do not invest sufficient funding for health – especially community health. Support is left to NGO partners
C: HUMAN RESOURCE CHALLENGES: Counties inherited a health workforce that existed before devolution and are expected to continue managing this resource. Most counties are in conflict with health workers since they froze recruitment, promotions and other staff benefits. This has created an environment that is not conducive for many health workers leading to industrial actions (strikes and go-slows), demotivated staff, high staff attrition
D: ATTITUDES OF OFFICIALS: A number of county officials tend to be territorial about work that happens in their jurisdictions and hence frustrate processes that involve officials from the national MoH.
The process of embedding QI can be structured using the Walt-Gilson Policy Process Model that helps us give an in-depth look at the Process, Actors, Content and Context
PROCESS Its important to ensure that all relevant stakeholders – both government and non-government – are involved in from the beginning of the process Every stakeholder has an interest and they will need to see how the embedding QI will support them in achieving them For sustainability, its key to formally institutionalize acceptable structures for QI that are aligned to the health system to ensure continuity
ACTORS The national and county level government actors have clearly defined roles. Remember to ensure their roles are not conflated whilst embedding QI. Power to implement health services is now at county level and that’s where to focus efforts to ensure success. National MoH roles are confined to Policy formulation, capacity building, guidelines and technical support / assistance
CONTENT Ensure that QI content is aligned to National and County priorities. Eg MoH national level are interested in development of a QI manual while counties are keen to have content that guides implementation of QI approaches All content needs to be simplified to facilitate understanding for actors with low levels of literacy CONTEXT While developing structures for QI, ensure that one understands the roles of any existing structures for leverage and avoiding redundancy of structures It is helpful to map any other actors in QI to synergize and complement QI efforts
Embedding Quality Improvement in devolved health settings
Learning to embed quality improvement
approaches at community level in Kenya’s devolved
Roles of National MoH
• Policy formulation
• Standards & guidelines
• Capacity building
• Technical support
Roles of Counties
• Implementation of policy
• Financing health care
• Human resource management
Challenges in Devolving Health
Low budgetary allocations
Varying Prioritization of Health
Human resource challenges
Attitudes of Officials
Delayed financial disbursements
Source: http://gadocartoons.com/the-only-county-devolution-has-not-happened-yet/ Source: Health Policy Project (2015)
Political Process of Embedding QI
in Devolved Setting
• Understand National vs County
• Understand power dynamics
• Align QI to National & County
• Consider interests at each level
• Understand pre-existing QI
• Map other key QI actors
• Ensure full consultation
• Consider ALL Interests &
• Institutionalize QI at all levels