The 2010 Constitution of Kenya transformed the governance of healthcare by devolving most health functions to the county level. In doing so, it created what the Council of Governors (CoG) aptly summarises as “48 governments, one nation.” This dual arrangement—47 county governments plus the national government—has brought services closer to the people. But it has also introduced new challenges that continue to shape Kenya’s health outcomes.
Under this framework, county governments manage all health facilities from primary care up to level 5 hospitals, and they control the bulk of human resources for health (HRH), infrastructure, and day-to-day operations. The national government, on the other hand, sets health policy and oversees the highly specialised level 6 referral hospitals. While this structure was designed to strengthen responsiveness and accountability, it has produced uneven results across the country.
Three persistent issues illustrate the gaps that still need to be addressed.
1. Persistent Inequity in Access and Quality of Care
Despite progress, the distribution of health workers and quality of services remain markedly uneven across counties. A review of Ministry of Health workforce statistics reveals sharp disparities in staffing levels—disparities that translate directly to differences in access and quality. Against a national target of 23 core healthcare workers per 10,000 people, Nairobi County has 37, while a county like Narok has only 6. These figures illustrate a fundamental contradiction: although devolution aimed to enhance equity, Kenyans’ access to skilled health workers is still largely determined by their postal code.
These imbalances ripple across the health system. Facilities in well-resourced counties tend to provide more comprehensive services, attract more specialists, and benefit from more predictable funding. Meanwhile, counties with fewer healthcare workers struggle to meet population needs, leading to delayed care, referrals for routine services, and ultimately worse outcomes.
2. Instability in Human Resource Management and Industrial Relations
A second challenge relates to industrial harmony. HRH management has become one of the most volatile components of devolved healthcare, with periodic strikes disrupting services every election cycle or administrative transition. Recent history captures this vividly: prolonged strikes in Laikipia, Kirinyaga, and, more recently, Kiambu County left patients stranded while healthcare workers and county governments disagreed on contracts, promotions, and working conditions.
Although these disruptions were isolated to specific counties, the consequences extended beyond their borders. Public health cannot thrive in pockets; population health is interdependent. When one county’s workforce is paralysed, national progress toward Universal Health Coverage (UHC) is undermined. UHC aspires to ensure that all Kenyans receive essential health services without financial hardship—but fragmented HRH governance means that one county’s crisis becomes a national setback.
3. Mismatch Between Improved County Capacity and Public Perception
The third challenge is more subtle but equally consequential. Counties have invested heavily in new infrastructure, expanded staffing, and upgraded diagnostics. Many level 4 and 5 hospitals across the country are now equipped to provide services that previously required referral to national facilities. Yet, public perception lags behind reality. Many Kenyans still believe that quality care can only be found in far-off level 6 hospitals, leading to unnecessary overcrowding in referral centres and underutilisation of competent county facilities.
This perception gap is not a failure of devolution—it is a failure of information.
Introducing a National Hospital League System
To address these sector-wide gaps, the Ministry of Health (MoH) can play a catalytic role by introducing a national hospital league—an objective, scientific system that scores hospitals based on staffing levels, infrastructure and equipment, clinical outcomes, and patient feedback. The results should be published annually by the MoH’s Quality Assurance directorate and displayed prominently in every facility, just like hotel star ratings.
A transparent rating system would achieve three important outcomes.
First, it would empower patients and families to make informed choices about where to seek care. A family looking for the shortest specialist waiting time or the highest surgical safety score could easily identify the best-performing public facility.
Second, it would create a healthy peer-review dynamic among counties. Performance visibility encourages accountability, fuels competition, and motivates county governments to invest in improvements.
Third, it aligns seamlessly with proposed legislation such as the Patient Safety and Quality Healthcare Bill, which aims to cement quality and safety as national healthcare priorities.
Ultimately, a hospital league system would complement devolution—not undermine it. It would ensure that the benefits of local autonomy are matched by national standards of excellence, helping Kenya realise a more equitable, efficient, and trusted health system.
