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

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Kenyan devolution reduced public hospital autonomy, weakening management and service quality. Granting county hospitals more control over resources and functions is crucial for improving healthcare delivery.

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Area of Science:

  • Health Services Research
  • Public Health Policy
  • Health Systems Management

Background:

  • Kenya's 2013 transition to a devolved government system.
  • Focus on early experiences of health sector devolution in public county hospitals.
  • Examination of changes in hospital autonomy and its impact on functioning.

Purpose of the Study:

  • To assess the impact of devolution on the autonomy of public county hospitals in Kenya.
  • To analyze how reduced autonomy affects hospital management and operational functioning.
  • To provide recommendations for improving county hospital performance through increased autonomy.

Main Methods:

  • Qualitative case study approach in three coastal Kenyan county hospitals.
  • In-depth interviews with 21 county and hospital managers.
  • Utilized Chawla et al. (1995) framework to assess autonomy across five management domains.

Main Results:

  • Devolution significantly reduced hospital autonomy in strategic management, finance, procurement, human resources, and administration.
  • Reduced autonomy led to weakened management, decreased community engagement, compromised service quality, and lower staff motivation.
  • Observed non-alignment of county and hospital priorities, staff insubordination, and a decline in the quality of care.

Conclusions:

  • Enhancing the autonomy of Kenyan county hospitals is essential for improving their operational functioning.
  • County governments should enact legislation to empower hospitals with greater control over resources and key management functions.
  • Increased hospital autonomy can lead to better healthcare service delivery and improved patient outcomes.