Letters

LETTERS: Strikes exposed loopholes in devolved units

ward

Patients in a ward during a strike by nurses last month. PHOTO | FRANCIS NDERITU | NMG

After a month-long standoff between Kenya National Union of Nurses and some devolved governments on implementation of the 2017 Collective Bargaining Agreement(CBA), the strike was recently called off. Yet, the issues that took them to the streets remain unresolved and presumably ripe for contestation in the future.

Healthcare provision was among functions entrusted to county governments under the 2010 Constitution with an intention of trickling health benefits downwards. Again, it was presumed that with devolution, access to healthcare would be enhanced, community involvement in decision-making processes, and rights and interest of minorities and marginalized groups promoted and protected.

To date, seeking healthcare services is a disappointment. Decentralisation of healthcare management began in the 1990s with the operationalisation of the Health Sector Strategic Plan, that established the District Health Management Boards and the District Health Management Teams, then mandated to oversee facility-level operations.

Under the devolved system, the district management structures were no longer tenable owing to competing interests. Although protests are not synonymous to devolution, with coming into being of devolved units’ health sector industrial actions have been too frequent and attributed to operational and managerial failures and corruption that have compromised on service delivery. By fronting the devolved governance model, its proponents were of the view that highly centralised governance systems were weak, unresponsive, inefficient, and lacked equity in health care delivery.

To them, taking healthcare closer to the people would cure these negativities besides promoting innovation, accountability, and transparency. Interestingly, under the decentralized system, healthcare was effectively and competently handled by a lean team of technocrats.

Command system

They included a four-tier management structure consisting of the medical superintendent of Health at the facility level, the medical officer of heath at the district level, the provincial director of health and the director of health services at the ministry headquarters. The lean command system was effective and responsive to the aspirations of Kenyans.

Under devolved units, operations initially handled in two-layer structures was reorganised into a string of executive and operational positions down from the cabinet executive committee of health, chief officers, directors of (public health, health and sanitation, and nutrition), facility-level chief executive officers, medical officer of health and facility in-charge.

With every layer down the pyramid, more personnel’s would get deployed.

These bloated bureaucracies makes decision-making and processes longer and unproductive.Certainly, the country risks not realizing its development objectives under food security, universal health care, affordable housing and clean water for all, considering the objectives lie within devolved mandates and on matters devolution, the country began on a wrong footing.

Coincidentally, the complexity of Kenya’s devolution framework attracts managerial inefficiencies, service disruptions, misappropriation, cronyism, a bloated inexperienced workforce, nepotism and disregard to rule of law.

Also resource diversions, programmes mismatch, skewed public participation practices, inter-county disparities, pay mismatch against qualifications and incompetence are common ills in the devolved system. Five years into devolution, we are yet to achieve a model practice and seemingly a challenge to the 6th Devolution conference in Kirinyaga County.