From Promise to Practice: A Systematic Review of Decentralization and Equity of Access to Healthcare in Kenya’s Arid and Semi-arid Counties.

From Promise to Practice: A Systematic Review of Decentralization and Equity of Access to Healthcare in Kenya’s Arid and Semi-arid Counties. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 21 August 2025 V1 Latest version Share on From Promise to Practice: A Systematic Review of Decentralization and Equity of Access to Healthcare in Kenya’s Arid and Semi-arid Counties. Authors : Abubakar Kheir [email protected] and Mary Moussa Authors Info & Affiliations https://doi.org/10.22541/au.175575798.82654736/v1 351 views 151 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Effective governance is fundamental to health system performance, with decentralization often promoted as a pathway to greater equity, responsiveness, and accountability. In Kenya, county-level devolution was introduced in 2013, aiming to strengthen healthcare delivery. This review evaluates whether devolution has improved equitable access to healthcare in the country’s Arid and Semi-Arid Lands (ASAL) counties, regions marked by harsh environments, socioeconomic marginalization, and persistently poor health outcomes. A systematic search of academic databases and grey literature identified 46 relevant records. Findings show that decentralization has yielded both opportunities and challenges. While counties gained autonomy to procure medicines beyond KEMSA, political interference and funding delays frequently undermined supply chains, particularly in ASAL counties. Central government delays in disbursing the equitable share and the pooling of revenues into County Revenue Funds often stalled timely access to essential medicines. Recruitment of health workers through county public service boards improved outreach in some cases but also introduced nepotism and widened staffing disparities. Most ASAL counties remain well below WHO-recommended health workforce densities. Geographical and financial barriers continue to impede access. In many ASAL areas, patients travel over three hours to reach the nearest health facility. Despite the official abolition of user fees, weak policy enforcement led to their reintroduction, disproportionately affecting ASAL populations. NHIF premiums also remained unaffordable for many households. Overall, the review concludes that without stronger institutional capacity and accountability frameworks, devolution may not achieve its intended equity goals in ASAL counties. Introduction: Effective governance is widely recognized as the backbone of well-functioning health systems, influencing how resources are allocated, how policies are implemented, and ultimately how populations access and utilize healthcare services. The World Health Organization (WHO) identifies governance as one of the six building blocks of health systems, underscoring its importance in ensuring accountability, equity, and responsiveness 1 . A critical governance strategy that has gained prominence globally is decentralization, defined as the transfer of administrative, financial, and political authority from the national government to local governments or other subnational entities 2,3 . The rationale for decentralization is anchored in the belief that local authorities are closer to the populations they serve, and therefore have superior contextual understanding of community needs, challenges, and preferences. This proximity theoretically enables them to design and deliver health services that are more responsive, culturally acceptable, and inclusive of historically marginalized groups 4,5 . From this perspective, decentralization is not only a technical governance tool but also a social justice mechanism, aimed at correcting historical inequities in service distribution and access 6,7 . By redistributing resources and decision-making power, decentralization is envisioned to enhance efficiency, equity, and accountability within health systems 8,9 . Proponents further argue that compared to centralized governance, decentralization represents an “exceptional gain” by aligning decision-making with local realities, reducing bureaucratic bottlenecks, and improving accountability 10 . This notion resonates with global health milestones such as the 1978 Alma-Ata Declaration on Primary Health Care, where WHO emphasized the limitations of centralized, top-down healthcare delivery and called for health systems that bring services “as close as possible to where people live and work.” The spirit of Alma-Ata has since inspired many LMICs, including Kenya, to pursue decentralization as a pathway to achieving equitable and universal healthcare coverage. Yet, the implementation of decentralization has often proven more complex than the theory suggests. Transferring functions such as human resources management, health financing, and service delivery to subnational governments can sometimes exacerbate inequities rather than resolve them, particularly if local authorities lack adequate technical capacity, financial resources, or institutional accountability mechanisms 11,12 . In some contexts, decentralization has led to duplication of efforts, fragmentation of services, and inter-county disparities. Instead of producing equity, these gaps have widened the divide between well-resourced and poorly resourced regions, raising questions about the real impact of decentralization on healthcare access. This dilemma is particularly pronounced in Kenya’s Arid and Semi-Arid Lands (ASALs), which comprise 23 counties (10 arid and 13 semi-arid). These counties make up nearly 89% of Kenya’s landmass, are home to about 36% of the population, and yet consistently record some of the country’s poorest health and development indicators [13]. The ASALs are characterized by harsh climatic conditions, high poverty levels, limited infrastructure, insecurity, and socio-cultural practices that complicate healthcare access. Before the onset of devolution in 2013, these regions already lagged behind in health indicators such as maternal and child health, immunization coverage, and healthcare workforce density. Fourteen years into the implementation of Kenya’s decentralization reforms, these disparities largely persist, raising concerns about whether decentralization has truly advanced the cause of equitable healthcare access in these historically marginalized regions. Existing literature in Kenya has made important contributions by examining decentralization’s effects on resource allocation, health financing, and system performance 13–15 . These studies highlight both opportunities—such as increased county-level autonomy in budgeting and health workforce deployment—and challenges, including weak financial management systems and variability in county governance capacity. However, to date, no systematic review has been undertaken to specifically examine how decentralization has influenced the equity of healthcare access in ASAL counties. Given the unique vulnerabilities of these regions—ranging from geographic remoteness to nomadic lifestyles and recurrent droughts—this knowledge gap is significant. By situating decentralization within the lived realities of Kenya’s ASALs, this review seeks to answer an essential but underexplored question: Has decentralization enhanced or impeded equitable access to healthcare in marginalized, resource-poor contexts? Addressing this question is critical for several reasons. First, Kenya’s ASALs represent the very populations decentralization was designed to benefit—marginalized communities historically excluded from mainstream development. Second, the findings will provide evidence for policy refinement, guiding national and county governments in strengthening health system reforms that genuinely promote equity. Finally, lessons from Kenya’s ASAL experience will contribute to the global discourse on decentralization in LMICs, offering insights for other countries grappling with similar governance reforms. Study Setting: ASAL Counties Kenya’s ASAL counties cover approximately 89% of the country’s land mass. These regions experience low annual rainfall (ranging between 150–850 mm) and are frequently affected by droughts and extreme temperatures 16 . Many inhabitants of these counties belong to minority ethnic groups that have faced long-standing socioeconomic and political marginalization, having historically been excluded from national development initiatives 17 . ASAL region is also home to most pastoral communities, with minimal agricultural activity and limited livelihood diversification. These ecological and structural vulnerabilities have contributed significantly to poor health and nutrition outcomes, accounting for 76% of all national acute malnutrition cases, affecting 2.8 million people with widespread water scarcity, and resulting in a high prevalence of waterborne diseases 18 . Furthermore, ASAL counties exhibit poor health indicators such as lower vaccination uptake, reduced skilled birth attendance, and limited postnatal care coverage when compared to the national maternal mortality 19 . Decentralization in Kenya Kenya’s most recent decentralization was introduced in 2013 under the 2010 Constitution 20,21 . This reform saw political, fiscal, and administrative authority being transferred to 47 newly established county governments aiming to promote equity and enhance service delivery 14 . Among the fourteen decentralized functions, health was a critical component. County governments assumed responsibility for primary (levels 1–3) and secondary (levels 4–5) levels of care; overseeing budgeting, human resource management, procurement of medical supplies, and health promotion while the national government retained control over the tertiary (level 6) level of care, policy formulation, and technical oversight 22,23 . Study Design: A systematic literature review was conducted in two main approaches. Search for Academic Articles: The first approach involved querying Scopus, Medline , and Web of Science . These databases were selected because of their reliability and frequent use in health policy research, particularly in studies related to decentralization 24 11 . These articles were then subjected to the inclusion and exclusion criteria. Search for Grey Literature (NGO and Government Reports): The second approach targeted policy documents and reports from both government and NGO sources. These were identified through structured searches on advanced Google scholar and official government websites (e.g., Ministry of Health {MoH}, Kenya Institute for Public Policy Research and Analysis [KIPPRA] and Kenya National Bureau of Statistics [KNBS]) aimed at identifying project reports, implementation reviews, and strategy documents relevant to decentralization and health equity. Additionally, snowballing method was employed to identify supplementary relevant articles by reviewing the reference lists of the selected articles. As noted by Greenhalgh and Peacock (2005), snowballing is a highly effective in literature reviews 25 , as it reduces the time required for searches and circumvents inconsistent keyword string challenges. Articles identified through snowballing were also subjected to the same inclusion and exclusion criteria as database-sourced literature. Given that decentralization can take various forms including deconcentration, delegation, devolution, and privatization this study limited its focus to “decentralization” in the form of devolution and therefore these terms are used interchangeably here, which is the actual form implemented in Kenya. Articles that used the term “decentralization” were closely examined using the inclusion and exclusion criteria to ensure that they referred specifically to devolution, and not to deconcentration, delegation, or privatization. To enhance the precision of the search, the following search string was employed: (“equity of access” OR “equitable access”) AND (“devolution” OR “decentrali ation”) AND (“health ”) . Inclusion Criteria To be considered relevant for this study, articles had to meet the following conditions: • Be published between 2010 and 2024. This timeframe was selected for three reasons. First, this period aligns with the adoption of Kenya’s 2010 Constitution, which formally introduced devolution, making it a relevant starting point for assessing post-devolution outcomes. Second, across all databases there is a notable increase in decentralization-related literature since 2010, providing a rich body of evidence for review. Third, limiting the scope to this timeframe allowed for practical management of the volume of available literature, ensuring a focused and systematic analysis. • Be peer-reviewed and original research articles, as these types of articles ensure methodological rigor through expert evaluation 26 . • Be published in the English language. • Focus on Kenya or countries classified as LMICs, according to World Bank classification. This focus was crucial for drawing comparisons within similar economic contexts and understanding the broader implications of devolution on health equity. This methodological choice aligns with Dwicaksono and Fox (2018) 27 , who also focused on LMICs when evaluating health systems’ performance. Importantly, articles from LMICs were only included if they referred explicitly to devolution. Exclusion Criteria The following were excluded from the review: • Articles focused on upper-middle-income or high-income countries (HICs). • Articles focusing on the decentralization of specific health services (e.g., Antiretroviral therapy, Maternal and child health and tuberculosis) as they did not address the broader health sector decentralization. • Articles referring to “deconcentration”, “delegation”, or “fiscal federalism”, as these forms differ conceptually from devolution 2 . • Articles treating “privatization” as a form of decentralization were also excluded. This is because privatization represents a shift of power from public to private entities, thereby involving inter-system rather than intra-system transfer of authority. This definition aligns with Collins and Green (1994) 28 , who referred to the classification of privatization as decentralization a case of “conceptual confusion.” Grey Literature Review Process As noted by Paez (2017) 29 , grey literature enhances the timeliness, relevance, and depth of a literature review. Therefore, to critically understand Kenya’s decentralization and equity of access to care information had to be sourced from relevant government sources such as the MoH, KIPPRA, and KNBS. These institutions have been widely recognized for their contributions to national health data and policy analysis. For example, decentralization studies conducted in Tanzania 30 and Indonesia 31 have relied heavily on data from national statistical bureaus, equivalent to Kenya’s KNBS. To address potential biases in government reporting, additional NGO-authored documents were included. These were identified via advanced Google Scholar using the search string: “Decentralization, health financing and access to care in Kenya”. Relevant reports from organizations such as ThinkWell and USAID were retrieved and then screened using the established inclusion and exclusion criteria. Limitations of Study Methodology This study’s literature search approach was subject to some limitations that may have influenced the scope and depth of the findings. First, compared to countries such as Indonesia, which has implemented devolution for over 24 years, Kenya’s experience with devolution is relatively ‘fresh’, having only been operational for approximately 14 years. Consequently, the volume of academic literature specifically examining the health implications of devolution in Kenya remains limited. Moreover, the few available articles tend to focus predominantly on non-ASAL counties. This trend is likely attributable to the historical marginalization of ASAL regions, which has resulted in minimal scholarly attention, thereby limiting the comprehensiveness of the literature review on these areas. Second, the absence of a standardized and universally accepted definition of various forms of decentralization such as fiscal federalism , fiscal decentralization , and administrative decentralization may have led to the exclusion of potentially relevant articles. These conceptual inconsistencies across literature posed challenges during the screening process, as articles referencing broader or overlapping decentralization frameworks had to be omitted if they did not meet the study’s specific focus on devolution. As a result, valuable insights may have been excluded. Lastly, the grey literature search was vulnerable to bias, especially from NGOs that are proponents of devolution. These institutions often presented devolution in a positive light, portraying it as a definitive solution for effective service delivery. This bias is understandable, considering that decentralization frameworks offer NGOs increased legitimacy and entry points to participate in subnational service delivery 32,33 . To counter this bias, academic literature was utilized to critically assess and cross-examine claims made in grey literature. Results A comprehensive literature search across three academic databases initially yielded 916 articles. After applying the inclusion and exclusion criteria and removing duplicates, 27 articles were identified as relevant. An additional 4 articles were identified through snowballing. The grey literature search identified 11 documents that met the selection criteria. In total, 42 records (31 academic articles and 11 grey literature documents) were reviewed. Below figures provide a summary of the study selection process. (Government-related sources) MOH, KIPPRA and KNBS 6 (Non-government related sources) USAID/HPP and PEPFAR 2 (Non-government related source) ThinkWell 3 Grey literature sources Academic Literature Sources Health Commodities Procurement Post‑Devolution The change in procurement system where counties could now allocate and procure resources on behalf of their facilities from the Kenya Medical Supplies Agency (KEMSA) and other suppliers produced mixed outcomes. In some ASAL counties, local leaders utilized this procurement autonomy to source adequate and effective health commodities from alternative suppliers, which mitigated challenges experienced with KEMSA. However, health‑facility managers in the ASAL county of Kilifi reported that county‑level political interference following decentralization and added bureaucratic steps often lengthened procurement timelines, mitigating much of the intended benefit 13 . Delays in Central Funding and Medical Supplies Across ASAL and non‑ASAL counties, delays in disbursement of equalization funds from national to county treasuries were repeatedly pointed as barriers to timely procurement 14,34 . During the COVID‑19 pandemic, three counties reported that late national disbursements directly slowed delivery of critical commodities, a dynamic likely amplified in revenue‑constrained ASAL counties 35 . In a cross-sectional survey of 60 facilities in the ASAL county of Tana River, patients often walked more than 20 km only to find no essential medicines on site 36 . Additionally, only 5 facilities indicated receiving adequate budget which gave them the leverage in availing medical commodities than those with delayed budgetary allocations 37 . Another qualitative research in Kilifi County mirrored Tana River’s findings, highlighting that budgetary delays severely constrained medicine availability 38 . Facility‑Level Financial Constraints Although decentralization granted greater fiscal autonomy but also led to some ASAL counties such as Kilifi and ten others mandate that all National Health Insurance Fund (NHIF) reimbursements from the national government and user‑fee revenues be pooled into the County Revenue Fund (CRF) before being re‑allocated to the facilities. This centralization of cash flow frequently delayed the disbursement of operational budgets 39 meaning that, in the event a health facility runs out of essential medicines, it will have to wait for the funds remitted to CRF to be budgeted and resent back to the health facility. This procedure has rendered health facilities without medicine while in some cases delayed availability 40 . Recruitment and Governance Post‑Devolution Prior to devolution, the Public Service Commission (PSC) centrally managed recruitment, promotions, training, and remuneration of healthcare workers through the MoH 13 . Post‑devolution, county public service boards (CPSBs) assumed hiring authority for all except the level‑6 cadres 41 . While there was evidence of increased local recruitment, findings from a qualitative research in the ASAL county of Kilifi revealed that by giving authority on recruitment to CPSB’s, it 42 led to inefficiencies such as increased insubordination of healthcare workers since they were now required to report to CPSB instead of the hospital management 43 . This impacted on the behavior of healthcare workers leading to misconduct such as absenteeism. Healthcare workers knew that they were employed under the influence of a county leader and therefore could not be summoned by health facility management in case of any misconduct. Therefore, there were several reports that the recruitment under CPSBs were politically influenced by county leadership 44,45 , risking the placement of under‑qualified staff and undermining quality of care 13,38 . Additionally, CPSBs in some ASAL counties have declined to appoint many qualified doctors solely because of their tribal background or not being from that particular county, exacerbating severe staffing shortages despite the need 13,46 . In one ASAL county, a health facility was closed as locals were demanding the removal of a healthcare worker, since she was from a different tribe. Staffing Levels and HRH Gaps Despite an overall increase in healthcare workers since devolution 41 , significant shortages remain: 79% of WHO’s six core cadres fell below minimum thresholds in at least ten ASAL counties. Only one ASAL county (Lamu) exceeded the WHO‑recommended 23 healthcare workers per 10,000 population, likely due to its relatively small population. In a descriptive analysis of five ASAL counties (Garissa, Kajiado, Kilifi, Narok, Wajir), staffing densities averaged fewer than six healthcare workers per 10,000, intensifying service pressures amid rapidly growing populations 47,48 . The situation was worse in Tana River County where a study established that 88% of those who dispensed drugs in the 60 out of the 62 health facilities were Community Health Volunteers (CHVs), bearing in mind they are not trained to offer such services 37 . In the ASAL county of Narok, low numbers of skilled birth attendants (SBAs) have driven women to rely on Traditional Birth Attendants (TBAs), correlating with the higher maternal mortality in the county 49,50 . Remuneration Barriers There have also been concerns on inequitable remuneration across counties 51,52 where the wealthy non-ASAL counties compete with the less wealthy ASAL counties in providing favorable remuneration for healthcare workers. This is reported to leave the poorer ASAL counties worse off in terms of skilled healthcare workers. Some of those employed resign due to being overworked while others engage in strikes for better pay. All these have been reported to discourage healthcare workers from moving to ASAL counties. Cultural Practices and Provider–Patient Discordance Movement of healthcare workers to ASAL counties due to inadequate staffing 53 has been seen to bring the challenge of cultural barriers between locals and the healthcare workers. Some healthcare workers who move from non-ASAL counties to ASAL counties are seen to exercise (either knowingly or unknowingly) medical and (or) non-medical practices which do not conform to the cultural and religious beliefs of the ASAL population. For instance, some women in the ASAL county of Garissa were reported to have preferred delivering at home due to what they termed as ‘unculturable birthing practices’ in health facilities like lying on the back instead of squatting 53 . This finding was also supported by Kisiangani et al., (2020) who found that, in most ASAL counties of northeastern, it is taboo for a female to be in seclusion with a male whom she isn’t related to, including a male doctor and therefore women preferred to be handled by the few female healthcare workers in these counties 53 or in most cases deliver at home. Although under decentralization local leaders were expected to notice such cultural preferences and provide alternative solutions, these counties have yet to adopt alternatives. Facility Distribution and Capacity According to a 2017 MoH report, the number of public health facilities increased from 8,616 in 2013 to 11,324. The report also noted an existing disparity in the number of health facilities in ASAL counties including the lack of level 6 hospitals. In the ASAL counties of Mandera and Wajir, there were few health facilities, i.e. 10 and 14 per 100,000 respectively, compared to Kirinyaga (53), a non-ASAL county 55 . Additionally, bed-to-population ratios in ASAL counties have either stagnated or declined since devolution. For instance, Baringo County experienced a drop in hospital beds from 11.7 to 10.6 per 10,000 population between 2014 and 2017 (MoH HMIS, 2017). Although in some ASAL counties there was a slight increase, the general beds provision in 2017 was lower than in pre-devolution. Distance and Travel Time to Health Facilities Devolution resulted in the creation of ten of Kenya’s largest counties, all in the ASAL region 56 . A Wilcoxon signed‐rank analysis showed that, post‐devolution, the mean distance patients travel to their nearest facility rose significantly in ASAL counties compared to non‐ASAL counties 57 . Furthermore, the average health facility travel time for 62% of counties in Kenya was reported to be less than one hour. In five non‐ASAL counties access was under 15 minutes. By contrast, in the ASAL counties of Marsabit, Garissa, and Turkana residents average over three hours to access a facility 58 . This finding corresponds with another study which found that the least distance to a health facility across all the 47 counties was 1.4km, and this was in a non-ASAL county (13.3 mins). The longest was Mandera (52.6km), Wajir (41km), Garissa (35.3km) and Narok (34.2km), all of which are in the ASAL region 53 . An MOH 2017 report also found that Turkana, Marsabit, Mandera and Wajir had less than 50% of their population living within 1 hour of the nearest facility. This is well-below the WHO recommendation of 5 km radius between users’ households and the nearest health facility. Abolition of User Fees The advent of devolution saw the abolition of user fees. Also, the national government committed to disbursing conditional grants to all primary healthcare (PHC) facilities throughout the counties to ensure that hospitals continue to function optimally even after abolition of user fees 40 . Additionally, the national government introduced an equalization fund across 14 ASAL counties to address existing disparities amongst counties 59 . Despite abolishment of user fees and allocation of the equalization fund to ASAL counties, there was a notable increase in out-of-pocket (OOP) expenditure across counties by 90% 60 . The incidences of catastrophic healthcare expenditure in ASAL counties were higher than non-ASALs 61 . From a study conducted across 15 counties including 4 ASAL counties, a health facility in charge at the ASAL county of Kitui pointed that, despite user fee being abolished at the PHC level, patients were still paying for some services such as laboratory services 62 . The study found that patients had to pay OOPs since reimbursements from the national governments were insufficient and could only cover few services. NHIF Coverage and Contribution Burden Despite average poverty rates of 64.4% in ten ASAL counties, NHIF’s flat KES 500 monthly premium for the informal sector (mostly in the ASAL region) did not account for ability to pay 61 . For many households, this fee competed directly with basic needs, forcing them to defer or abandon contributions until emergencies arise and rely instead on OOPs 63,64 . As a result, NHIF coverage remained below 3% in five of the poorest ASAL counties 65 . Discussion Availability of Human Resources for Health Devolution aimed to align health workforce deployment with local needs by transferring hiring powers to CPSBs. This was implemented to enhance equity by enabling underserved counties to prioritize local recruitment and fill staffing gaps quickly. In some cases, this has been achieved, with counties recruiting more local community health workers and support staff to expand the PHC reach. However, dependence on CPSBs for recruitment of healthcare workers has also exacerbated inequities in workforce distribution. These changes have increased political interference in the employment process of healthcare workers 42 and ethnic favoritism in hiring decisions leading to underqualified or untrained individuals being appointed to clinical roles, especially in ASAL counties 36 . These findings are consistent with Tanzania’s experience under devolution, where local government interference in the recruitment process similarly led to skewed healthcare workers deployment and weakened service delivery 66 . Such appointments increase the risk of misdiagnosis and poor treatment, deterring patients who experience substandard care from returning 67 . A similar finding was also reported in Ethiopia where women who were attended to unskilled providers developed obstetric complications which discouraged them from seeking care at the same facility in future 68 . Furthermore, devolution intensified inter-county competition for skilled healthcare workers. Wealthier, non-ASAL counties offered more competitive salaries and better incentives, attracting a disproportionate share of qualified personnel. Conversely, poorer ASAL counties, already constrained by limited fiscal capacity struggled to recruit and retain skilled healthcare workers 69 . The resultant staffing shortages in ASAL areas forced the remaining workforce into overtime, burnout, and attrition, leading to reduced operating hours and compromised service quality. These conditions discouraged both healthcare workers (via burnout and resignation) and patients (via mistrust and long waits), thus worsening inequities in access. Similar patterns have also been reported in rural Uganda and South Africa following decentralization 6,70 . In both countries, recruitment and retention of highly skilled healthcare workers was difficult in rural areas as they were in high demand in the urban centers and private facilities, likely due to better remuneration packages 70 . This was sometimes experienced even when health facilities had advanced equipment 6 . Lastly, some ASAL counties addressed absence of healthcare workers by deploying CHVs, this eroded confidence in public services and motivated patients to bypass local facilities for perceived higher‑quality care elsewhere, as users often do not trust services rendered by unprofessional staff in health facilities 71 . Cultural Acceptability By vesting CPSBs with recruitment authority, devolution aimed to align healthcare worker profiles with local cultural contexts. In theory, hiring locally based staff should enhance service acceptability, yet, inconsistent and politically driven recruitment has instead generated new cultural barriers. First, in some ASAL counties, CPSBs recruited non-local healthcare workers resulting to cultural disconnect with the local communities. These healthcare workers introduced some medical practices perceived as culturally inappropriate. This has led many women avoid facility-based deliveries, preferring home births despite associated risks 72 . These findings were consistent with broader literature suggesting that cultural misalignment between providers and patients can significantly hinder service acceptability and utilization, particularly in conservative communities 61 . Second, county-level tribalism in health workforce recruitment has worsened access. In several ASAL counties employment opportunities are skewed in favor of the dominant ethnic group, the health needs of minority populations are sidelined, and trust in the health system eroded. Geographical Accessibility Among devolution’s primary justification was to address historical disparities in health infrastructure distribution by empowering counties to plan and allocate resources according to localized needs. However, findings from this study indicate that while some progress has been made, geographical accessibility remains a major obstacle to equitable healthcare access in ASAL counties. Despite an increase in the number of health facilities nationally post-devolution, their distribution has remained highly uneven. Political interference in resource allocation has seen some health facilities constructed in areas with minimal need, largely driven by the interests of local political leaders rather than service delivery gaps. This has resulted in resource concentration in vote-rich or politically influential zones, leaving vast rural and remote areas under-served. These findings align with earlier reports from Kenya and Indonesia, where infrastructure development post-decentralization has disproportionately favored political elites’ constituencies, undermining equity goals 38 . Distance and travel time to health facilities in ASAL counties remain significantly higher than in non-ASAL counties. While some non-ASAL counties record travel times of under 15 minutes, some ASAL counties report averages exceeding three hours. For vulnerable populations who rely on trekking as their primary mode of transport, these distances present devastating barriers, ultimately discouraging care-seeking and deepening health inequities. Financial Affordability Affordability of healthcare is a fundamental determinant of healthcare utilization, particularly in resource‑constrained settings where both service fees and non‑medical costs (e.g., transport) pose significant barriers 73 . Kenya’s abolition of user fees at PHC facilities implemented alongside devolution sought to reduce financial barriers. Yet, in several ASAL counties, official fee abolition was undermined by the ad hoc reintroduction of the fees. Persistent delays and shortfalls in national allocations forced facilities to depend on user fees to sustain operations, thereby disproportionately burdening low‑income households already grappling with high transport costs. This was also seen in post‑devolution Cameroon, where delayed and insufficient transfers from national government forced local authorities revert to user fees, disproportionately harming the poorest populations 24 . On the other hand, non‑ASAL counties often benefit from diversified local revenue streams which buffer health facilities from national government delays and reduce reliance on user fees 74 . The resulting fiscal resilience has helped maintain free PHC services in many of these counties. Despite average poverty rates of 64.4% in ten ASAL counties, NHIF’s monthly premium for the informal sector fails to consider the population’s ability to pay. For many households in ASAL counties, this fee competes directly with essential needs such as food and shelter, forcing them to forgo or delay enrollment and instead rely on OOP when emergencies arise. As a result, NHIF coverage remains critically low—below 3% in five of the poorest ASAL counties—undermining the financial risk protection that decentralization aimed to expand. Lastly, the CRF model in some ASAL counties, where all facility‑generated revenues (NHIF reimbursements and user fees) are pooled centrally and later re‑allocated to facilities have compelled facilities to levy user fees, exposing patients to OOPs and deterring care‑seeking. While the 2012 Public Financial Management Act authorizes counties to legislate for facility‑level revenue retention, most counties are yet to enact those measures. Conclusion This study demonstrates that Kenya’s devolution has yielded unintended barriers to equitable healthcare access in ASAL counties. First, procurement autonomy has not uniformly improved medicine supply; instead, inefficiencies, inflated costs, and delayed fund flows have perpetuated stock‑outs and pushed the poor further from care. Second, shifting recruitment to CPSBs has intensified ethnic favoritism and pay disparities, resulting in uneven distribution of skilled staff, overwork, and compromised service quality. Third, while local hiring can enhance cultural alignment, non‑inclusive practices and inadequate cultural training have generated provider–patient disconnects that deter vulnerable women from facility‑based care. Fourth, political prioritization of facilities in vote‑rich areas, rather than need‑based siting, has left vast rural areas with prohibitive travel distances often exceeding three hours thereby reinforcing spatial inequities. Finally, financial autonomy has been stymied by central pooling of revenues into CRF, lengthy budget cycles, and the ad hoc re‑introduction of user fees, exposing patients to OOPs that deter utilization of healthcare. To advance equity under devolution, policy reforms must strengthen procurement and financial management systems, ensuring timely disbursements and retention of facility-level revenues. Transparent, needs-based approaches to recruitment and infrastructure planning, supported by equitable pay scales, are essential to reduce staffing disparities. Targeted capacity building for county health and finance teams, alongside standardized guidelines on culturally sensitive care, can mitigate cultural barriers to service uptake. Future research should assess the effectiveness of these reforms and draw lessons from alternative decentralization models in comparable LMICs, such as Tanzania, to inform policy adaptation. References: 1. Panda B, Thakur HP. Decentralization and health system performance – a focused review of dimensions, difficulties, and derivatives in India. BMC Health Serv Res . 2016;16(6):561. doi:10.1186/s12913-016-1784-9 2. Bossert TJ. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan . 2002;17(1):14-31. doi:10.1093/heapol/17.1.14 3. Sapkota S, Dhakal A, Rushton S, et al. 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Community financing of health care in Africa: An evaluation of the Bamako initiative. Soc Sci Med . 1993;36(11):1383-1395. doi:10.1016/0277-9536(93)90381-D 74. Barasa E, Nyawira L, Musiega A, Kairu A, Orangi S, Tsofa B. The autonomy of public health facilities in decentralised contexts: insights from applying a complexity lens in Kenya. BMJ Glob Health . 2022;7(11):e010260-e010260. doi:10.1136/bmjgh-2022-010260 Information & Authors Information Version history V1 Version 1 21 August 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords decentralization health systems kenya Authors Affiliations Abubakar Kheir [email protected] The University of Edinburgh View all articles by this author Mary Moussa Africa Health Business View all articles by this author Metrics & Citations Metrics Article Usage 351 views 151 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Abubakar Kheir, Mary Moussa. 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