Devolution and healthcare: Are counties bringing better care closer to Kenyans?

NAIROBI, Kenya, Sep 24 — More than a decade after Kenya transferred most frontline healthcare functions to county governments, patients are experiencing a health system that has expanded facilities, staffing and specialised services, but still faces challenges in access, medicines, equipment and the availability of health workers.

The 47 county governments manage the delivery of county health services, making them central to the question of whether devolution has translated into better, more accessible and affordable care for citizens.

For Violet Odongo, a health client at Railways Health Centre in Kisumu County, the change in staffing has been noticeable.

“Compared to the time when I was young, the nurses were few. But now, at least, the numbers have improved,” she recently told the World Health Organization.

Her experience provides one example of what changes in county-level healthcare can mean for patients.

At the same facility, nurse Esther Omagwa said the increase in staffing had changed how she handled patients.

“These days I can respond to patients efficiently. Even when one of us goes on leave, we still have capacity,” Omagwa said.

But the experience of devolution is not uniform across the country.

The question is whether patients can consistently find a health worker when they need one, obtain prescribed medicines, access functioning equipment and receive specialised treatment without travelling long distances.

What changed with devolution?

Kenya’s 2010 Constitution assigned county governments responsibility for county health services, including county health facilities, pharmacies, ambulance services and preventive and promotive healthcare.

The national government retained responsibility for health policy, standards, training of health professionals and national referral facilities.

The intention was to move decision-making closer to communities and allow counties to plan and manage services according to local needs.

More than a decade later, the county health system has expanded.

The Ministry of Health said in February 2026 that functional Level 4 and Level 5 hospitals had been established across all 47 counties, with specialised services increasingly being provided outside the traditional national referral centres.

Health Cabinet Secretary Aden Duale has emphasised that responsibility for healthcare delivery remains with counties.

“Health is a devolved function. I will not violate the Constitution,” Duale said in May 2025 while discussing the transfer of Universal Health Coverage workers’ payrolls and associated budgets to county governments.

The national government has continued to work with counties on healthcare financing, staffing and the delivery of Universal Health Coverage, reflecting the shared responsibilities created by the devolved system.

Medicines and equipment

For patients, the value of a health facility is determined less by its administrative structure than by what is available when treatment is needed.

A patient may reach a county facility, see a health worker and receive a prescription, but still have to find the medicine elsewhere if it is unavailable. The same applies to diagnostic and treatment equipment.

The Ministry of Health’s Service Availability and Readiness Assessment found that, on average, 33 per cent of twenty-three tracer essential medicines were stocked out in the seven days before the assessment among facilities offering pharmacy services.

All 47 counties reported stock-outs, with Nandi recording a 43 per cent stock-out rate. The report also found Kisumu had the highest rate at 59 per cent, followed by Bomet at 54 per cent.

The experience in Tinderet Sub-county in Nandi County provides a patient-level example.

In May 2026, residents told the Kenya News Agency that they were routinely being issued prescriptions and directed to private chemists to buy medicines expected to be available at public facilities.

They cited basic medicines including painkillers, antibiotics and antimalarial drugs. The report did not publish the amount individual patients spent on the medicines.

The Ministry of Health has been pursuing reforms to improve the availability and management of health products and technologies.

At the Kenya Health Summit in August 2026, the Ministry reported that the National Equipment Service Programme had deployed 862 specialised medical equipment units to 251 facilities in forty-four counties at a cost of Sh9.6 billion.

The Ministry said the investment is intended to expand specialised services at county hospitals and reduce unnecessary referrals, travel distances and costs for patients.

The availability of equipment, however, is only one part of the equation. A machine has to be operational, supported by trained personnel and supplied with the materials required to use it effectively.

Makueni County Referral Hospital provides an example of equipment being put into service.

In February 2026, the county said it had commissioned new surgical and diagnostic equipment at the hospital, including a laparoscopic tower and a digital X-ray system.

Hospital management reported that the X-ray unit was handling between seventy and eighty patients on busy days, while consultant general surgeon and endoscopist Dr Alex Ombati said the upgrades would reduce referrals and allow the hospital to manage more complex cases locally.

The same applies to medicines. Efforts to improve supply chains are important, but what ultimately matters to a patient is whether the medicine prescribed is available at the facility when it is needed.

Health workers: closer to patients, but not always enough

County governments employ a large share of the health workers providing services at local facilities. But staffing levels and the distribution of personnel remain important factors in determining the quality and availability of care.

The experience of Railways Health Centre illustrates what additional staffing can mean at facility level.

WHO reported that five years before its December 2024 feature, Omagwa was one of only two nurses at the facility and that the workload sometimes forced her to turn away clients. The nursing team had since expanded to four.

The health centre’s overall staff had also tripled to thirty, with specialists supporting services including maternal and child health, cardiology, orthopaedics and mental health.

Laboratory officer Violet Ouma said the broader range of services had reduced the need for some referrals.

“Since we have been able to incorporate more specialized services in each department, we haven’t had to refer as many patients to larger facilities,” Ouma said.

The experience demonstrates that staffing is not simply a question of the number of employees on a county payroll. It affects waiting times, continuity of care and whether a facility can provide services locally.

WHO also cited Professor Francis Wafula, chair of the Kenya Health Human Resource Advisory Council, who identified the distribution of health workers as a continuing challenge.

“We have a problem of poor distribution of health work force across the country,” Wafula said, noting that the challenge exists across the 47 counties and between urban and rural areas.

Maternal and child healthcare

Maternal healthcare provides another measure of what citizens are receiving from devolved services.

County facilities provide much of the antenatal, maternity and postnatal care accessed by women outside national referral institutions. But geographical access remains a challenge in some parts of the country.

In Samburu County, WHO documented the experience of Neshoo Leaungokiok, who went into labour in Lolmolong village where the nearest health facility was a six-hour walk away.

A reproductive health officer, Lucy Makena, from a nearby mobile outreach clinic reached Leaungokiok and supported the delivery.

WHO reported that Leaungokiok later developed heavy bleeding but received treatment to control the complication.

“The baby is feeding well now. I am grateful to have delivered safely and to have a healthy baby,” Leaungokiok said.

The case illustrates both sides of the access question. Bringing services to remote communities can help overcome geographical barriers, but distance and transport can still determine whether a woman reaches skilled care in time.

Child health is similarly dependent on the strength of primary and community healthcare. Immunisation, treatment of childhood illnesses and maternal and newborn services are among the areas where access to frontline healthcare remains important.

In Kisii County, the county government reported that its maternal mortality ratio fell by 30 per cent, from 159.17 to 110.66 deaths per 100,000 live births, following a partnership with Jacaranda Health and ThinkWell that began in August 2022.

The county also reported that 20,763 pregnant mothers had enrolled in the PROMPTS digital health platform against a target of 22,565.

The county attributed the wider improvement to interventions including healthcare workforce and facility improvements, the PROMPTS platform and the Kenya Quality Ecosystem initiative.

Are county referral hospitals delivering specialised care?

The development of county referral hospitals has provided some of the clearest examples of how devolution has changed healthcare delivery.

The Ministry of Health says Level 4 and Level 5 hospitals are now established across all 47 counties, with specialised services increasingly being offered outside traditional national referral centres.

The deployment of specialised equipment has supported this shift.

The Ministry says the 862 specialised equipment units deployed under the National Equipment Service Programme are intended to increase the ability of county facilities to provide services that previously required patients to be referred elsewhere.

The Council of Governors has also documented county-level examples.

In Makueni, neurosurgical services have been developed at Makueni County Referral Hospital, allowing some patients to receive brain surgery within the county rather than automatically travelling to Nairobi.

Such developments can reduce the distance patients travel and the associated transport and accommodation costs. They can also reduce pressure on national referral facilities.

But specialised care requires more than buildings and machines. It depends on specialist doctors, nurses, technicians, medicines, maintenance and reliable referral systems.

A 69-year-old man became the first patient to undergo brain tumour surgery at Makueni County Referral Hospital in May 2025.

The more than six-hour procedure was led by consultant neurosurgeon Dr Muthoka Mativo with support from Dr Angela Murunga after the patient presented with persistent migraines and seizures.

Makueni County later reported that the neuro clinic was receiving an average of ten to fifteen patients per day, alongside procedures including skull-fracture elevation, spina bifida repairs, spinal fusions and shunt revisions.

The county says distance and cost had previously been barriers to specialised treatment, although it has not published the individual patient’s travel distance or a specific amount saved as a result of the surgery being performed locally.

The referral question

A patient may begin treatment at a dispensary or health centre but eventually require a higher level of care.

The receiving hospital must have the necessary personnel, equipment, medicines and capacity to continue treatment. Delays at any point can affect the patient’s outcome.

The Ministry of Health has therefore been working on strengthening referral systems between different levels of care, with the aim of ensuring patients receive appropriate treatment at the right level.

For patients, a functioning referral system can mean the difference between receiving specialist attention close to home and having to travel to another county or to Nairobi.

Has healthcare become more affordable?

Affordability is more difficult to measure than physical access.

A county hospital located closer to a patient’s home can reduce transport costs, particularly where specialist treatment is available locally. MoH has specifically linked investment in specialised equipment to reducing unnecessary referrals, travel distances and costs for patients.

The wider healthcare financing system is also changing under the Social Health Authority.

At the Kenya Health Summit in August 2026, MoH said 32.3 million Kenyans had registered with SHA, while more than 10,000 health facilities had been accredited.

But affordability is not only about what a patient pays at a hospital.

For a patient, the real cost can include transport to another county, buying unavailable medicines from private pharmacies, paying for tests elsewhere or travelling repeatedly for specialist treatment.

At Vihiga County Referral Hospital, the facility’s records officer said in May 2026 that patients without active SHA coverage are often required to pay out of pocket.

He cited ICU admission as one example where patients are required to pay Sh20,000 upfront, with SHA covering the remaining costs. He also said dialysis and outpatient imaging were among services not fully covered under the arrangements described at the facility.

The experience under SHA therefore shows that registration does not by itself eliminate every direct healthcare cost.

At Vihiga, the facility said patients whose cover is inactive may have to make payments themselves, while some services still involve additional costs.

This means the affordability of devolved healthcare depends not only on the location of a facility but also on whether medicines, equipment, health workers and financing arrangements are functioning when patients seek care.

An uneven patient experience

There is evidence of tangible improvements.

At Railways Health Centre in Kisumu, increased staffing has enabled nurses to handle patients more efficiently and has supported the expansion of services.

In Samburu, mobile healthcare has provided skilled maternal services to a community where distance had made access difficult.

At county referral hospitals, investments in specialised equipment and specialist services are enabling some procedures and treatments to be provided closer to where patients live.

These developments point to areas where devolution has brought healthcare services closer to communities.

However, the benefits are not necessarily experienced equally.

The availability of a specialist service in one county does not mean the same service is available in another. Similarly, the number of health workers, availability of medicines and condition of equipment can vary between facilities.

The experience in Tinderet, Nandi County, provides a contrasting picture.

Residents reported in 2026 that public facilities were experiencing shortages of basic medicines, including painkillers, antibiotics and antimalarial drugs, with some patients being directed to private chemists after receiving prescriptions.

The Kenya News Agency report documented residents’ accounts of having to buy medicines outside public facilities, while health workers cited planning, deliveries and stock-management challenges.

For citizens, therefore, devolution is experienced at the point of care.

It is the nurse who attends to the patient, the doctor who makes the diagnosis, the pharmacy that either has or does not have the prescribed medicine, the laboratory that provides the test, and the referral hospital that determines whether specialised treatment can be provided locally.

More than a decade after healthcare was devolved, there is evidence that counties have expanded facilities, staffing and some specialised services. There are also documented cases where bringing services closer to communities has reduced the need for some patients to travel long distances.

At the same time, access to quality healthcare remains dependent on factors that devolution alone cannot automatically resolve, including the distribution of health workers, availability of medicines, functioning equipment, financing and referral capacity.

The healthcare test for devolution is therefore not simply whether counties have taken responsibility for frontline services. They have.

The more important question is whether that responsibility consistently translates into quality, affordable and accessible care for the person seeking treatment.

The evidence points to progress, but also to differences between counties and facilities.

Devolution has moved healthcare responsibility closer to citizens; whether it has moved consistently better healthcare closer to them remains a question answered differently depending on where a patient lives and the facility they rely on.