The paper examines health sector reforms in Kenya at the district level based on the Government of Kenya's Health Policy Framework of 1994. The authors present the context of and historical perspective to health sector reforms in Kenya and discuss the major reform policies including decentralization to the district level. The authors then review intended policy outcomes, investigating assumptions on which the implementation and effectiveness of the reform agenda at the local level are based. The authors argue that emphasis on outcomes rather than process has not supported sustainable reforms or achieved the government's goal of improving health and ensuring equity for the citizens of the country.
Motivation
Across the Global South, unclear institutional frameworks undermine progress in improving services. Often, ongoing decentralization reforms reduce clarity further. Policy professionals working on institutional reform lack comparative models.
Purpose
To identify key challenges for the institutional arrangements for urban sanitation in decentralizing contexts, in Kenya and elsewhere, and to propose possible responses.
Approach and methods
We use key informant interviews and literature review in a problem‐driven analysis, drawing from three comparative case studies: South Africa, Indonesia and Tamil Nadu State. The analysis builds upon research on institutional effectiveness—co‐operation, collaboration and co‐ordination—rooted in game theory and elaborated in the 2017 World Development Report.
Findings
Three key problems in Kenya are identified: overlaps and competition around sector leadership at national and devolved levels; weak incentives for county governments to commit policy attention and finance, despite devolution; and limited regulatory oversight.
Policy implications
We identify a range of options for urban sanitation policy‐makers: (a) to engage non‐sectoral authorities in co‐ordinating multi‐sectoral issues across all levels of government; (b) to encourage political commitment to pro‐poor sanitation services at decentralized levels; and (c) to use incentive‐based and risk‐based approaches to regulate decentralized entities and strengthen local capacity for monitoring and enforcement.
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