Devolved health system delivers gains but remains dogged by strikes
National
By
Mercy Kahenda
| Aug 29, 2026
Wards are deserted, theatres abandoned and maternity wings closed as health workers’ strikes persist, leaving Kenyans struggling to access essential care.
The crisis comes as the country marks 16 years of the 2010 Constitution, which devolved health services among other functions.
Yet, persistent strikes have become a recurring feature of the devolved health system, with at least 104 strikes reported since the docket was devolved.
This has raised questions about whether counties are pulling their weight in health, in recognition of everyone's right to access quality care as stipulated in the Constitution.
“Since devolution, we have had 104 strikes. Some counties report even two strikes in a year,” regrets Kenya Union Clinical Officers (KUCO) Secretary General George Gibore.
Though services are paralysed across the country, facilities are grounded in Kwale, Uasin Gishu, Elgeyo, Kericho, Mombasa and Nyamira.
Kirinyaga, according to KUCO, tops the list of worst-performing counties in terms of human resource and infrastructure. No single health worker has been promoted in the county since devolution.
Other worst-performing counties include Isiolo, Nyandarua, Marsabit, Mandera, West Pokot, Garissa, Lamu, Busia, Kakamega, Migori and Uasin Gishu.
In the counties, maternal services are poor, coupled with poor infrastructure and staffing.
“Counties like West Pokot have never advertised to employ healthcare workers; they hire people on contract,” adds Gibore.
Counties of Murang’a, Tharaka Nithi, Kajiado, Nairobi, Machakos and Makueni are doing better in terms of human resources and infrastructure.
“Counties may not be able to make changes. Even during the Health Summit, the President admitted to teething problems in human resources,” said Gibore. “On strike, no one is feeling the weight; 80 per cent of facilities are closed”.
With persistent strikes, there are calls by health workers from respective cadres for possible establishment of a Health Commission, just like teachers, the Judiciary and the police to manage human resources.
Establishment of the commission is likely to result in an amendment of the constitution, through referendum.
Kenya Medical Practitioners and Dentists Union (KMPDU) Deputy Secretary General Dr Dennis Miskellah notes that the commission will help address recruitment, deployment, promotions and remuneration, which have become recurring sources of conflict between health workers and county governments.
Asked whether reverting health services to the national government would require a referendum, Miskellah said KMPDU would not oppose one if it was necessary to resolve the crisis.
“We do not mind having a referendum. Kenyans will have to determine what they want,” said Miskellah.
“With our own auditors, the challenges are not likely to go away unless proper architecture to govern the health sector is adopted,” added Gibore.
But according to Kisumu Governor Anyang Nyong’o, reverting roles to the national government is not a solution.
Prof Nyong’o proposes allocation of additional resources to counties to help solve the human resource issue.
With adequate resources, he observed that counties will be able to hire, promote and meet the demands of striking staff.
Also, the governor acknowledges that not all functions earmarked for devolution have been fully transferred to counties.
Nyong’o, who served as Minister for Health Services before becoming Kisumu governor under the devolved system, said devolution should be viewed as an ongoing process rather than an exercise that must be completed in a hurry.
“No, not all have been devolved, it is (devolution) is a process. We must not hurry up,” said Nyong’o.
He called for continued dialogue between the national and county governments on functions that remain unresolved, arguing that additional responsibilities should only be transferred when the country is satisfied that counties are ready to take them on.
“Let us continue discussing what is not yet devolved. And when we are satisfied that we are ready to devolve it, we should do so,” he said.
Nyong’o said the national and county governments must continue negotiating the division of responsibilities, insisting that devolution was never intended to completely remove the national government from functions that have been transferred to counties.
“Devolution is a process. And I think that both the national government and the county government continue to discuss this issue,” he said.
On health, one of the key functions assigned to counties, Nyong’o says the Constitution already provides a framework for determining what each level of government should do.
He cautions against what he termed ‘territorialism’ between the two levels of government, saying the focus should instead be on ensuring Kenyans receive services.
“The national government, by the Constitution, and the county government, by the Constitution, are given the responsibility in health care. That is very clear in terms of division of labour,” he said.
Nyong’o argued that disputes over responsibilities and resources should not leave citizens without services, saying national and county governments should work together where their functions intersect.
“We should not really fight about it, because that is in law,” he said, adding that areas where the system is not working should simply be improved.
Further, Nyong’o says the national and county governments should therefore sit down and agree on responsibilities such as the training and financing of health workers.
Additionally, he cites the takeover of the Jaramogi Oginga Odinga Teaching and Referral Hospital by the national government as an example of how responsibilities can evolve under devolution.
According to him, the move relieved Kisumu County of a major wage burden while allowing it to redirect resources to other county hospitals.
He says unresolved issues should be addressed through dialogue.
Previously, there has been a push and pull in managing the health system between the national and county governments.
Despite health being devolved, the two entities seem to clash in the implementation of key roles aimed at ensuring Kenyans access quality healthcare.
A clash was witnessed during the establishment of Social Health Insurance laws, with the Council of Governors claiming to have been sidelined.
Controversy was also witnessed during the adoption of the NESP programme, after termination of the Managed Equipment Services (MES) project, with some governors claiming to have been forced to append their signature for the programme.
Wrangling between two arms of government was also witnessed in the employment of 107,800 Community Health Promoters (CHPs).
The promoters are paid Sh5,000 stipends, shared equally by national and county governments.
Two years later, some counties have been accused of non-remittance of stipends.
However, devolving the docket has brought services closer to people, as compared to the centralised system.
Governor Nyong’o notes that under centralised units, a district would have a single facility, which resulted in congestion and delay in service delivery.
Theatre services are also distributed across the country, including in ASAL counties.
His sentiments are also echoed by Gibore, who adds, “Key success is improvement in terms of infrastructure, increased facilities and to an extent the counties have increased number of healthcare workers”.
Though the country has witnessed increased infrastructure, Gibore cites the need to equip hospitals to guarantee quality care.
“If counties are not able to equip facilities, patients are forced to buy medicines. In some scenarios, patients are forced to buy gloves,” adds Gibore.
Despite the majority of counties struggling to man healthcare, Makueni and Murang’a are listed among counties embracing technology for efficiency.
Murang’a, for example, uses digital technology to bring medical care closer to locals in a rural setup.
Among key innovations in the county is the adoption of telemedicine that has seen at least 170 public health facilities connected to high-speed satellite internet to power remote video and app-based specialist consultations.
With the technology, patients visit local dispensaries coordinated by hubs like Muriranjas Sub-County Hospital to consult doctors for a standard fee of Sh100.
The county also has a mobile dialysis unit, developed with partners like Benacare and JKUAT, Kenya's first fully mobile dialysis truck that brings hospital-grade kidney treatment and early screening directly to underserved rural communities.
With digitalisation, the county embraces a paperless system that has automated patient records, under the Digital Health Integrated System.
Additionally, Kang’ataCare Health Program, a digitalised social health scheme, provides free inpatient, outpatient, chronic disease management, and specialised care coverage for tens of thousands of vulnerable households.
As facilities across the country struggle to manage FIF, Murang’a has successfully operationalised the fund, linking facilities through a shared hospital management information system integrated into Taifa Care, and strengthened unified ambulance referral services.
In the county, public, faith-based and private facilities are connected, allowing hospitals to transfer patients, commodities such as blood, and even ambulance requests more efficiently.
Automated ambulance systems can identify the nearest available ambulance to ferry a patient.
Makueni has also embraced telemedicine, where specialists give guidance and monitor procedures through cameras mounted in theatres.
Other consultants are also invited into the procedure virtually through secure logins, allowing them to observe the surgery in real time from their respective locations.
Governor Mutula Kilonzo Junior applauds the technology, saying it continues to improve the quality of healthcare in Makueni and across the country.
The governor, also a maternal health ambassador, observes that the rapid pace of innovation in medicine requires continuous upskilling of doctors and nurses, adding that technology is helping bridge critical gaps in expertise.
“We cannot train enough nurses and doctors to meet all the needs we have. Our specialists must continuously improve their skills because every day there is something new in the market,” he says.
Makueni was the first county to embrace and strengthen primary healthcare by establishing Makueni-care, and increased the number of hospitals offering primary healthcare.
Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN) explains that devolution was well conceived under the Constitution.
“The purpose of devolving the sector helps in policy formation while working with communities was to bring healthcare closer to the people, improve accountability and enable counties to respond to their specific health needs,” explains KELIN.
In many respects, KELIN notes that the principle remains sound.
However, according to the entity, implementation has also resulted in significant fragmentation in how healthcare is governed and delivered across the 47 counties.
This is particularly evident in the management of human resources for health, including recruitment, remuneration, deployment, career progression and working conditions.
“Salary delays, job insecurity, inconsistent terms of employment, poor working conditions and an increasingly demotivated health workforce affect the quality and continuity of healthcare and ultimately threaten Kenya's progress towards UHC,” added KELIN.
But even with talks to revert that docket back to the national government, KELIN maintains such will not bring on board solutions.
“Complete recentralisation may not be the answer. It could return Kenya to a system in which critical decisions affecting healthcare across the country are concentrated at the national level, potentially increasing bureaucracy and disconnecting decision-making from local realities,” KELIN told The Standard.
One option worth exploring, according to KELIN, is a stronger two-tier health governance model.
With the model, counties could retain responsibility for service delivery, health budgets and infrastructure development, while a strong national body or commission provides greater oversight and standardisation of human resources for health, including recruitment, deployment, career progression and professional management.
As Kenya commemorates 16 years of promulgation of the constitution, President William Ruto has reaffirmed the government’s support for the health sector under devolved units.
He maintains that counties have managed the health docket exemplary since devolution.