Does Decentralization Deliver Health Services to Vulnerable Groups in Kenya? A Case Study of Busia and Kakamega Counties, Kenya

Abstract

William N Okedi

Background: Decentralization has become an increasingly important concept in development theory and practice in the world since the 1970s. Decentralization is generally understood to be referring to policies and processes that shift the locus of decision-making and management to the local level, Hellington [1]. According to Elamon, decentralization is particularly attractive because some forms of it promise direct accountability of public institutions; improved management of resources; more reliable information for planning and a more effective interagency collaboration and coordination [2]. Furthermore, it is argued that local officials and community leaders have better knowledge and information about the local context and are therefore more aware of what can work best within the resource constraints while contributing to the achievement of the broader social, economic and development goals of central government. In the health sector, the impetus for decentralization has its roots in the Alma-Ata declaration of Primary Health Care, WHO [3]. This was enhanced by the World Health Organization’s advocacy for strengthening the health system at district level as the most appropriate level for planning and providing health services. Bankausaikaite argues that decentralization therefore appeals to the health sector largely because it is seen as a means to achieving the Primary Health Care (PHC) goals and for its potential to achieve multiple objectives [4]. Furthermore, decentralization continues to be a subject of intense discussions in the health sector reform processes and is seen as a key strategy for achieving poverty reduction objectives and for attaining the global Millennium Development Goals (MDGs). Klouda argues that in the context of Sub-Saharan Africa, a region that has the majority of poor countries in the world, poor health indices and high burden of preventable diseases including a devastating impact of HIV/AIDS, decentralization is perceived as offering a key development strategy in addressing these complex problems [5]. In the specific case of HIV/AIDS, decentralization is perceived as suited to stimulate far-reaching changes that can respond to the complex factors that lead to its transmission and the multiple services necessary to adequately support affected communities through multisectoral actions. Furthermore, Ribot has said that development is often argued as a motive for decentralization [6]. It is argued that decentralization facilitates integrated local development, a necessary factor in the control of HIV/AIDS. The United Nations Development Program, UNDP has actively promoted decentralization in local government and points out that one of the earliest efforts in using decentralization to address the HIV/AIDS pandemic in sub-Saharan Africa has been through the Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa [7]. These efforts have been supported by donor agencies such as USAID, UNDP, World Bank and Private Foundations. According to Schneider the Ford Foundation in Southern Africa (South Africa, Zimbabwe, Namibia, and Mozambique) for example, focused its grant making on strengthening local government and civic responses to HIV/AIDS at district and community levels [8]. In Kenya, the government adopted a deconcentrated form of decentralization at independence in 1963However, since the presidential and local elections of 2002, the government has tended to shift towards a more devolutionary form of decentralization by enacting policies and Acts of parliament that enable it to transfer funds to decentralized levels. According to NCCK these funds include the Constituency HIV/AIDS Fund of 2003, established by legal notice 170 of the Corporations Act 1999 [9]. According to Orege this fund is primarily expected to support prevention, care and mitigation of the impact of HIV/AIDS within the communities [10]. Managed by the National AIDS Control Council (NACC), it provides grants to civil society organization at constituency and district levels. According to NACC the Constituency AIDS Control Committees (CACCs) are responsible for the implementation, coordination and management of funded projects at the local level [11]. The overall aim of the study is to assess how the decentralized AIDS Funds are used to respond to the social problems among children affected by HIV/AIDS in Amagoro constituency in Busia County and Mumias and Matungu constituencies in Kakamega County.

Methods

Study Design: A case study design was chosen for this study because of the complexity of the issues to be investigated and depth and accuracy was required.

Study Setting: The study was conducted in Amagoro Constituency in Busia County; Mumias and Matungu constituencies In Kakamega County. The choice of the sites was informed by a number of factors; the highest prevalence of HIV/AIDS (14.9%) compared to the national average of (7.1); convenience and accessibility of key actors in government and beneficiary communities.

Study Population: A purposive sample of key actors directly involved in implementing and managing the decentralised HIV/AIDS programme at the national, regional county and constituency levels were included in the study. At the Community level, interviewees included key informants drawn from CBOs, management committees; members of associations of people living with AIDS. A total of ninety eight (98) individuals were interviewed across the three sites.

Data collection: Document analysis, key informant interviews and semi-structured interviews were the main methods used in this study. A full listing of documents collected at the national and local levels are provided in the Appendix.

Data Analysis: Thematic analysis was primarily used to analyse the data according to the pre-determined topics identified in the conceptual framework, namely authority, accountability, management, technical capacity and information flows. At an analytic level, a comparative analysis of findings across the study sites was done to identify county and constituency level factors that affected the implementation of the Constituency AIDS control programme. At the conceptual level, findings and lessons emerging from descriptive and analytical levels prompted reflection on the theories and assumptions underlying the promotion of decentralization as a development approach.

Results: The study found that the AIDS committees delivered services to about 11% of children estimated to be affected by the pandemic. Factors affecting the delivery of services to vulnerable children identified in the study include weakness in accountability due to patronage, corruption and non-enforcement of sanctions. Others include conflict of interest among members of the committees; diversion of funds to pay sitting, lunch and facilitation allowances to the officials, complacency and inaction by national officials and outright abuse of office through technical manipulation of civil society proposals by consultants.

Conclusion: This study has analysed data collected from interviews with both policy and implementing level key informants at district and community levels across the three constituencies. The information collected has been triangulated with information from secondary sources and with information collected through informal conversations with a range of stakeholders in the three constituencies. The study identifies a range of factors embedded within the project cycle that have affected the implementation and outcomes of the CACC program. Manipulation of CBOs projects at various stages of development and at various levels of the decentralized NACC structures was the greatest problem encountered by implementing agencies. The study concludes that problems affecting decentralisation are deep-seated as these are influenced by broader socio-political contextual factors.

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