Healthcare Workers and Devolution: Kenya’s Pursuit of Universal Health Coverage

In Garissa County, a single doctor is expected to serve over 41,000 people, while the nurse-to-population ratio stands at a staggering 1:2,543.^[1] Across Kenya, the medical professionals tasked with keeping the population alive are trapped in a fragmented system that threatens to derail the country’s goal of achieving Universal Health Coverage (UHC) by 2030.^[2]

While the 2010 Constitution intended to bring services closer to the grassroots, the devolved governance of the health workforce has instead produced two structurally embedded crises.^[3] The first is a “Three-Employer Dilemma” that renders labor relations legally incoherent, leaving essential workers caught in a tug-of-war between the Ministry of Health, the Council of Governors, and individual County Public Service Boards.^[4] The second is a cruel "Postcode Lottery," which entrenches geographic inequality by tying a healthcare worker's pay and career mobility directly to the fiscal health of the county where they serve.^[5] 

The term "governance" deserves a much closer look. Pushed heavily in the 1980s alongside structural adjustment programs, the neoliberal idea of governance strips the state of its fundamental duty to guarantee public welfare, treating it instead like just another player alongside private capital and the free market. When applied to healthcare, this language is dangerous: it depoliticizes failing systems and reduces the basic human right to health into a cold exercise in "managerial efficiency." If we uncritically adopt this framing, we hide the real issue. The chaos in health workforce management isn't merely an administrative glitch; it is the direct result of an economic system that values budget cuts over essential public labor, treating health workers as legally "essential" but politically disposable.^[6]

While public debates frequently center on health financing and infrastructure, the wellbeing of the human beings actually delivering that care is dangerously overlooked.^[7] The absence of harmonized employment standards and functional intergovernmental coordination has eroded the efficiency of the healthcare workforce.^[8] This misalignment between devolved management and national health goals is actively compromising the equitable, quality provision of care that lies at the very heart of UHC^[9]

Devolution and Health: The Legal and Policy Framework

The fourth schedule of the 2010 Constitution provides the division of responsibilities between the county and national governments. County governments are responsible for service delivery, including recruitment, payment, and deployment of health personnel.^[10] The national government is responsible for policy formation, national referral services, health financing, and capacity building.^[11] Article 43 of the 2010 Constitution provides that everyone has the right to the highest attainable standard of health.^[12] The Health Act 2017 reinforces this by mandating free maternity care and vaccination for children under five.^[13]

On collaboration between the national and county governments, section 106 of the Health Act provides that the Cabinet Secretary responsible for health shall bear primary responsibility for the Act, and that the respective levels of government shall collaborate, consult, and enter into agreements to better its implementation.^[14] The Kenya Health Human Resource Advisory Council (KHHRAC), established under section 30 of the Health Act,^[15] reviews policy and establishes uniform norms on posting of interns, inter-county transfers, transfer between levels of government, welfare and rotation of specialists, and the maintenance of a master register of practitioners.^[16] Section 59 of the County Governments Act confers upon the county public service board the authority to establish offices, appoint persons, confirm appointments, exercise disciplinary control, and facilitate the development of coherent county development plans.^[17]

Devolution of Human Resource Management

The health workforce is defined as the stock of all people engaged in actions whose primary intent is to enhance health. The Human Resources for Health investment area encompasses availability of appropriately and equitably distributed health workers, attraction and retention of health workers, improving institutional and health worker performance, and training, capacity building, and development.^[18] A staffing norm has been defined for each level to outline the minimum health workers, by cadre, needed to assure provision of the Kenya Essential Package for Health (KEPH) — the government’s defined basket of primary and preventive care services.^[19] Under the devolved system, the Public Service Commission (PSC) is mandated to provide employment for national government employees and oversight of the entire public service at both national and county level.^[20] At the county level, the constitution provided for the establishment of County Public Service Boards (CPSBs) that would serve as the overall employer of all public servants in each county.^[21]

Beyond overall responsibility for the management of county government employees, it was unclear what specific operational human resource management responsibilities the CPSB would have for the respective technical county departments, leading to a lack of clarity over HRH management responsibility between the CPSB and the County Department of Health (CDoH).^[22]

Structural Contradictions in HRH Governance

The “Three-Employer Dilemma”: Fragmentation of Employment Authority

While the Kenyan Constitution (2010) distributed service delivery to counties, it inadvertently created a legal no-man’s-land for the labour tasked with carrying it out. This structural incoherence has split the health sector into distinct failure points that continue to threaten worker stability and, by extension, the UHC project itself.

The fundamental source of this instability is the “Three-Employer Dilemma,” a circumstance where the identity of the employer is obscured by overlapping authority the simultaneous and unresolved claims of the Ministry of Health, the Council of Governors, and the individual County Public Service Board over any given health worker. The Employment Act of 2007 requires a clear employer-employee connection.^[23] However, in the post-devolution era, this link is fractured: the Ministry of Health retains the policy mandate under the Fourth Schedule and is the institution to which the public turns during crises;^[24] individual counties, as demonstrated in County Government of Kisii v KMPDU [2024], can successfully argue that they are distinct corporate entities not bound by financial promises made by the national government or the Council of Governors;^[25] and the union finds itself negotiating with an interlocutor that lacks the authority to bind its members. When strikes disrupt services, the Cabinet Secretary typically executes return-to-work agreements that prove unenforceable at the local level. The Kisii County ruling illustrated this precisely: the County characterized the strike as a separate local dispute and claimed that the union had rejected a locally proposed Memorandum of Understanding.^[26]

This dilemma reflects a deeper political economic logic. County autonomy, as structured by the 2010 Constitution, creates perverse incentives for governors to compete rather than coordinate on health worker welfare. Each county executive has strong political reasons to resist national CBAs that would constrain its fiscal discretion, particularly where health worker payrolls represent a large share of recurrent budgets. The “essential services” doctrine compounds this dynamic: counties increasingly invoke section 81 of the Labour Relations Act to secure court orders compelling healthcare workers to return to duty, not as a genuine crisis-management tool, but as a mechanism of labour control that forecloses collective bargaining. In Kisii, the court ordered health workers to return to work unconditionally even as their grievances on promotions remained unresolved,^[27] effectively weaponizing the essentialness of health care against the workers. The result is a system in which workers are legally “essential” but politically dispensable: indispensable enough to be compelled to work yet insufficiently protected to command timely pay or career progression.

The Geography of Inequality: Remuneration and Mobility in a Devolved System

The absence of a unified financial mechanism has produced what can only be described as a “postcode lottery” of remuneration. In the absence of a central Health Service Commission, terms of service are dictated by the fiscal health of each county. The Commission on Revenue Allocation (CRA) data reveals a considerable divergence: counties with strong own-source revenue, like Nairobi, can supplement national allocations to ensure salaries are paid on time,^[28] while counties relying almost entirely on equitable share transfers from the National Treasury, frequently cannot pay their employees when those transfers are delayed. The consequence is that two doctors with identical qualifications and responsibilities may radically experience different economic realities depending solely on their county of deployment.^[29]

This fiscal disparity is not accidental. It reflects how deeply rooted historical inequalities are built into the devolution architecture. The counties that struggle most to pay health workers on time—arid and semi-arid regions with weak tax bases—are precisely those. that Kenya’s colonial and post-colonial development patterns left furthest behind. Devolution, intended as a corrective to that history, has in many respects reproduced it: counties with entrenched economic disadvantages lack the revenue base to compete for and retain skilled health workers, creating self-reinforcing cycles of understaffing and poor service quality. The Garissa County case study is instructive: a doctor-to-population ratio of 1:41,538 and a nurse-to-population ratio of 1:2,543 are not mere statistics but evidence of a governance structure that systematically under-delivers in the periphery.^[30]

The devolved structure has also erected an “Iron Curtain” that paralyses career mobility. The current legal framework renders inter-county transfer structurally near impossible: a specialist seeking to relocate must normally resign and reapply, because each CPSB functions as a separate employer. As demonstrated in Okiya Omtatah Okoiti v Cabinet Secretary for Health,^[31] even regulatory appointments have been subject to executive manipulation, undermining the independence of the professional bodies that might otherwise enforce national standards. Crucially, immobility serves as a political function as well. County-level patronage systems depend on health worker appointment processes remaining locally controlled; central mobility frameworks would threaten the dispensing of public sector jobs as political rewards. This makes reform politically costly even where it is technically straightforward and explains why successive proposals for a national Health Service Commission have stalled in intergovernmental negotiations.

Implications for Universal Health Coverage

The three pillars of UHC- access, quality, and financial protection  are actively undermined by the fragmentation of human resource management. The World Health Organization asserts that without a workforce, health cannot exist; the devolved control of Kenya’s health workforce has unintentionally produced conditions that may render the UHC-by-2030 goal unreachable.

Disruption in Services and Industrial Unrest

Industrial action has caused persistent disruption in service delivery. Since devolution in 2013, strikes have become more frequent and more prolonged, eliminating “access” from the UHC equation for months at a time. The Kisii verdict confirms that the disruption of essential services puts public health and lives in jeopardy,^[32] and the court observed that the strike constituted a genuine risk to the public.^[33]

Critical Staff Shortages and “Medical Deserts”

The system’s long-term viability is threatened by recruitment failures, and the brain drain they accelerate. Evidence from Garissa County illustrates the severity: a doctor-to-population ratio of 1:41,538 and a nurse-to-population ratio of 1:2,543.^[34] High employee turnover, caused by poor working conditions and a lack of professional growth opportunities, is the root driver of this shortage. Specialists leave behind “medical deserts” in the very areas that UHC seeks to prioritize as they migrate from underserved rural settings to urban centers or the private sector.^[35]

Procurement Failures and Quality Erosion

The HRH fragmentation also threatens the quality pillar of UHC. The Arale and Kiruthu study found that poor recruitment and inadequate training were closely linked to reduced healthcare performance across dimensions of access, equity, efficiency, and quality.^[36] Moreover, the human resource crisis is linked to material resource failures: inefficient county-level procurement processes caused delays in the supply of medications and medical supplies, leaving health workers unable to provide quality care despite their professional commitment.^[37]

Comparative Lessons: Ghana, South Africa, and Kenya’s iHRIS Success

Kenya is not alone in confronting the HRH governance challenges that accompany health decentralization. Comparative experience offers both cautionary lessons and actionable models. Ghana’s decentralization of health services in the 1990s produced patterns remarkably like Kenya’s postcode lottery: wide inter-district disparities in health worker distribution, with urban and wealthier districts attracting a disproportionate share of trained personnel. Ghana addressed this through a centralized Health Service Commission that retained authority over posting, promotion, and disciplinary processes even as service delivery was devolved to districts.^[38] The Commission’s ability to impose national posting standards, including mandatory rural postings as a condition for promotion, reduced distributional inequality without eliminating district-level management flexibility. Kenya’s failure to establish an equivalent body, despite repeated proposals, represents a significant governance deficit.

South Africa’s post-apartheid provincial health system offers a further comparison. Like Kenya’s counties, South African provinces inherited stark fiscal and infrastructure disparities, and the transition to democratic governance risked entrenching rather than correcting them. South Africa’s response was a conditional grant architecture: the national government ring-fenced health workforce expenditure through equitable share mechanisms that prevented provinces from raiding health payrolls to cover other fiscal pressures.^[39] This did not eliminate inter-provincial disparities, but it protected the wage floor for health workers in poorer provinces and reduced the frequency of strike action driven by salary arrears. Kenya’s current fiscal arrangements contain no equivalent ring-fencing mechanism, which is why the postcode lottery persists.

The considerations for the Ghanaian or South African models must occur within some caveats. Though these models offer hopeful alternatives, the realities on the ground in operating Ghana’s and South Africa’s example is much messier. Ghana’s government deploys doctors to rural areas from a central desk in Accra. The result has been rather a quiet but massive boycott. In 2025, the Health Minister admitted that a staggering 70% of doctors sent to rural posts simply didn't report for duty. The refusal revealed one reality that you cannot just order medical professionals into areas completely stripped of basic infrastructure and expect a promised 20% salary bump to make up for the neglect.^[40] South Africa isn't faring much better. They try to protect health budgets by locking the funds away, but the system is so poorly managed that the money is constantly swallowed up by bureaucratic chaos and a tidal wave of medical negligence lawsuits.^[41] The lesson for Kenya is clear: we can't just copy-paste these models to fix our own unequal system. Without real safeguards against local mismanagement, and careful modification of the above models we are just importing new ways to fail.

Kenya’s own IHRIS (Integrated Human Resource Information System) project demonstrates that the country possesses the technical capacity for centralised HRH data governance. The iHRIS platform, implemented across all 47 counties, provides real-time visibility regarding staffing levels, deployment gaps, and training records.^[42] Its existence proves that the informational infrastructure for a national Health Service Commission is already in place; what is lacking is the political will to convert that infrastructure into a binding governance authority. This gap between technical capacity and institutional action is itself a product of the political economy dynamics. County governors have resisted proposals that would transfer posting authority to a central body, because such transfers would reduce their patronage leverage over health worker appointments.

Conclusion

The devolution of healthcare in Kenya has ironically separated health workers from stable and coherent management, despite the Constitution’s intention to bring services closer to the people. This article has shown how the existing HRH architecture constitutes a legal no-man’s-land where county sovereignty is purchased at the cost of labour relations certainty. The Kisii County ruling finding that national Collective Bargaining Agreements are rendered unenforceable at the local level and trapping workers in cycles of industrial unrest that the courts are asked to terminate under the “essential services” doctrine,^[43]  is a symptom of structural incoherence. Empirical evidence from Garissa County confirms that fragmentation has produced severe disparities in recruitment, training, and remuneration, creating a postcode lottery that disadvantages the very regions UHC seeks to prioritize.^[44]

A fragmented workforce cannot coexist with the goal of Universal Health Coverage. A system that builds hospitals but cannot retain specialists, or that procures equipment but fails to compensate the workers meant to use it, is structurally flawed. The governance of the health workforce must transition from fragmented autonomy to what might be called intergovernmental interdependence — a model in which devolution is preserved as a principle of service delivery, but employment authority, fiscal guarantees, and training standards are co-governed through institutions with genuine national reach.

Recommendations

Harmonising workplace relations requires resolving the tension between county-specific MOUs and national CBAs, a tension that, as the Kisii case demonstrates, currently renders national agreements legally unenforceable at the county level. The Ministry of Health and the Council of Governors should jointly develop a legally binding Intergovernmental Framework for HRH Collective Bargaining, under which any CBA negotiated at the national level is automatically domesticated by County Assemblies within a fixed legislative window. Such a framework must close the “Three-Employer” evasion strategies that counties currently exploit in litigation. Achieving this will require political will from the Council of Governors: individual governors benefit from the current ambiguity, which allows them to disclaim national commitments while retaining operational control of health workers. Progress will therefore depend on conditional federal-level incentives including linking compliance with intergovernmental bargaining frameworks to access to national health sector grants that alter the political calculus for governors who currently have little reason to relinquish labour authority voluntarily.

Addressing the “postcode lottery” of payments demands restructuring fiscal management systems to ensure that health worker remuneration is insulated from county-level fiscal volatility. The National Treasury should establish a Conditional Grant mechanism ring-fenced specifically for health worker compensation, drawing on the South African precedent. This mechanism would guarantee that funds designated for health worker wages cannot be repurposed by county treasuries, and would link disbursement to timely payment records and transparent payroll management. Counties should additionally be required to ring-fence recruitment budgets and subject appointment processes to merit-based criteria audited by a central body, countering the patronage dynamics that currently allow political loyalty to override technical competence in hiring decisions. The intergovernmental bargaining required to implement such a system will be difficult: county finance executives will resist any mechanism that reduces their discretion over equitable share allocations. Conditional grants represent the most viable tool because they offer fiscal resources which counties need in exchange for governance concessions that counties are otherwise reluctant to make.

The erosion of training standards necessitates centralized oversight that can guarantee equitable professional development opportunities regardless of county fiscal capacity. A National Training and Rotation Policy, enforced by a designated regulatory authority, should require County Governments to fund Continuing Professional Development (CPD) as a contractual obligation for all health workers. This policy must also address the “Iron Curtain” of inter-county immobility by establishing a mandatory rotation mechanism through which specialists are deployed to underserved counties for defined periods as a condition of career progression analogous to the Ghana model discussed above. The deployments to the underserved areas should be engaged simultaneously with improving infrastructure in ways that can minimize the refusals recorded among Ghanaian doctors. The political economy of this reform is challenging: CPD mandates impose fiscal costs on county governments, and rotation mechanisms directly threaten the localized patronage networks that health worker appointments currently sustain. Framing these measures as UHC compliance requirements and tying them to conditional health financing from the national government is likely to be more effective than purely normative arguments about equity.

Finally, reinstating the integrity of professional regulation requires that the Cabinet Secretary for Health scrupulously follow statutory nomination procedures when forming boards for bodies such as the Public Health Officers and Technicians Council (PHOTC), a requirement that the Okiya Omtatah verdict confirmed has not always been honoured.^[45] These councils must embrace transparency by subjecting all professional fees and regulations to public participation and parliamentary review, and must be structurally insulated from executive manipulation. More broadly, the governance of professional regulation should be understood as a site of intergovernmental contestation: both the national executive and county governments have incentives to influence regulatory bodies, and neither has consistently acted in health workers’ interests. Independent, adequately resourced regulatory councils — whose boards are appointed through transparent, competitive processes — represent the institutional safeguard most likely to maintain professional standards and worker protections across the devolution architecture.

Nehemiah Mutharimi is a law student at Kabarak University and a trainee at the Kabarak Law Review. His research focuses on Kenyan devolution, healthcare governance, and the legal frameworks governing human resources for health in the pursuit of social justice and equity.

Twitter/X: @mutharimi31800   LinkedIn: Nehemiah Mutharimi   Instagram: @nemcrates

Endnotes