Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia

Abstract

IntroductionDevolution reforms in Indonesia and Kenya have brought extensive changes to governance structures and mechanisms for financing and delivering healthcare. Community health approaches can contribute towards attaining many of devolution’s objectives, including community participation, responsiveness, accountability and improved equity. We set out to examine governance in two countries at different stages in the devolution journey: Indonesia at 15 years postdevolution and Kenya at 3 years.MethodsWe collected qualitative data across multiple levels of the health system in one district in Indonesia and ten counties in Kenya, through 80 interviews and six focus group discussions (FGD) in Indonesia and 269 interviews and 14 FGDs in Kenya. Qualitative data were digitally recorded, transcribed and coded before thematic framework analysis. Common themes between contexts were identified inductively and deductively, and similarities and differences critically analysed during an inter-country analysis workshop.ResultsFollowing devolution both Indonesia and Kenya experienced similar challenges ensuring good governance for health. Devolution reforms transformed power relationships, increasing responsibilities at subnational levels and introducing opportunities for citizen participation. In both contexts, the impact of these mechanisms has been undermined by insufficiently clear guidance; failure to address pre-existing negative contextual norms and practices varied decision-maker values, limited priority-setting capacity and limited genuine community accountability. As a consequence, priorities in both contexts are too often placed on curative rather than preventive health services.ConclusionWe recommend consideration of increased intersectoral actions that address social determinants of health, challenge negative norms and practices and place emphasis on community-based primary health services.

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

“…Such observations in the Philippines are not unique. Other studies have likewise reported on how, for example, tribal affiliations rather than qualifications influenced the hiring of staff by local governments in Kenya [41], or how decisions for local health services in Indonesia and Kenya were made based on their appeal to the electorate [42,43], or how political interference in health planning in Tanzania led to a complex relationship between the local politician and the local government technocrat [44].…”

Tracking health sector priority setting processes and outcomes for human resources for health, five-years after political devolution: a county-level case study in Kenya

“…One of the overall devolution goals in Kenya was to improve local accountability over the management of public resources [ 7 , 8 ]. Early post-devolution studies however reported that the structures established following devolution had limited avenues for public participation, with compromised community participation & accountability as well as the public losing local accountability to the county executives [ 7 , 16 , 31 , 32 ]. For instance, an earlier study reported that the vetting and public participation in the recruitment of senior government officials as required by law was conducted merely as a public relations exercise as there was limited capacity for the relevant structures to undertake this excercise [ 10 ].…”

Using research networks to generate trustworthy qualitative public health research findings from multiple contexts

“…Intercountry analysis was aimed at identifying areas of thematic convergence while highlighting areas of difference. For example, in two countries where governance of the healthcare system had been devolved (Kenya and Indonesia) on different time scales, comparing data from the two sites allowed us to look at the influence of context under similar health system governance, whereas comparing data from those two sites to the others gave an idea of the influence of devolution on the intervention [33]. Throughout the analysis process, we looked for commonalities to see where similar contexts yielded similar results and where they differed, viewing both types of findings as valuable.…”

“…Throughout the analysis process, we looked for commonalities to see where similar contexts yielded similar results and where they differed, viewing both types of findings as valuable. Not all inter-country findings were generalized across all settings; some publications were limited to a sub-set [33][34][35][36][37]. A detailed example of empirical and conceptual transferability is captured in Table 4.…”