Who is responsible? Local government and accountability for service delivery in Kenya’s devolved health sector

One of the arguments in favour of local governments is their ability to deliver public services better because of their proximity to demand. This is typically achieved through decentralisation – the transfer of some level of formal responsibility, authority and/or resources to smaller, lower tiers of government. This paper examines service delivery in the health sector in Kenya within the context of the country’s newly introduced devolved system of government, which created 47 county governments under the 2010 Constitution. It examines three key responsibilities: i) resource mobilisation, distribution and administration, ii) decision-making, and iii) political accountability, and their bearing on outcomes for delivery of health services. The paper argues that devolution of the health function in Kenya has been only partial, leading to challenges of coordination between the national and county governments and ambiguity over responsibility for service delivery; both factors which risk undermining the opportunities that devolution creates or promises.