Devolution — the transfer of authority and resources from central to local governments — has reshaped public service delivery in many nations. Among the most critical sectors affected is healthcare. By bringing decision-making closer to the people, devolution promised more responsive, equitable, and efficient health services. But nearly a decade into implementation in many countries, the county-by-county reality reveals a complex mix of achievements, challenges, and lessons.
The Promise of Devolution in Health
When devolved governance structures were established, health services were positioned as a core pillar of localized empowerment. The goals were clear:
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Closer decision-making: Allow counties to set priorities based on local health needs.
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Improved access: Expand health facilities to underserved areas.
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Responsive budgeting: Enable counties to allocate resources where they matter most.
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Enhanced accountability: Increase citizen oversight and participation in health planning.
Across countries with devolved systems — from Kenya to South Africa and select federated states elsewhere — counties/provinces took over primary health functions and, in many cases, parts of secondary care. The results have been uneven but instructive.
County-by-County Realities
1. Counties With Strong Institutional Capacity
Some counties managed to leverage devolution effectively:
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Significant investments in infrastructure: Many built health centers, maternity wings, and diagnostic units in remote sub-counties, reducing the distance citizens travel for care.
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Improved maternal and child health indicators: Where counties prioritized immunization, nutrition programs, and emergency obstetric care, maternal mortality and under-five mortality showed strong declines.
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Innovative service delivery: Counties adopted mobile clinics, telemedicine, and performance-based incentives for health workers.
These successes are often linked to effective leadership, institutional planning, and robust community involvement.
2. Counties Facing Persistent Gaps
Despite overall growth, others struggle:
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Chronic shortages of health workers: Recruitment delays, low morale, and uneven distribution leave rural facilities understaffed.
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Infrastructural deficits: In some counties, facilities remain poorly equipped with limited laboratories, unreliable power, and insufficient water supply.
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Weak referral systems: Patients often bypass primary facilities and seek care directly at overburdened referral hospitals.
In these settings, central challenges include poor planning, weak financial oversight, and limited technical expertise at the county level.
3. Fiscal Management: A Mixed Picture
Devolved finance systems aimed to match resources with needs, but results vary:
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Budget peaks at county headquarters: Some counties channel resources into main hospitals at the expense of peripheral facilities.
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Late disbursements: Transfers from national governments or own-source revenue shortages delay key procurements, affecting drug stocks and service continuity.
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Costly wage bills: Health worker salary demands and promotions sometimes consume significant portions of county health budgets, crowding out preventive care investments.
Positive outliers balance personnel costs with strategic procurement and preventive health financing.
4. Community Engagement: From Theory to Practice
Devolution elevated public participation mechanisms, with mixed outcomes:
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Active health committees: In some counties, community health committees and facility management boards help set priorities, monitor performance, and ensure transparency.
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Tokenistic engagement: Elsewhere, engagement is limited to periodic meetings without genuine influence on budgets and planning.
Counties with stronger civic engagement tend to show more responsive planning and better alignment with local health needs.
Key Lessons From the County Experiences
Leadership and Governance Matter
Counties with transparent systems, merit-based recruitment, and public accountability outperform others. Political will to shield health planning from shortsighted interests is pivotal.
Capacity Building Is Essential
Success depends on investing not just in facilities but also in managerial skills — from budgeting and procurement to data use for decision making.
Balanced Resource Allocation
Counties must guard against urban bias. Equitable distribution requires data-driven planning and adherence to minimum service standards across all sub-counties.
Strengthening Referral Networks
Devolution should not fragment health systems. Counties that link primary, secondary, and tertiary care through clear protocols and referral financing yield better patient outcomes.
Looking Forward
The county-by-county reality of health services after devolution is neither a uniform success story nor a failure. It is a mosaic shaped by local leadership, institutional capacity, and citizen engagement.
To deepen gains and close gaps:
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Counties must invest in human resources for health — not just numbers, but skills, motivation, and retention.
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Fiscal reforms should ensure timely, predictable funds for essential services.
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Performance monitoring and peer learning across counties can spread best practices.
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Stronger partnerships between national, county, and community actors will reinforce health systems.
Ultimately, devolution’s promise in health lies not in its structure alone, but in how county governments and citizens choose to translate autonomy into equitable, sustainable health outcomes.
