Table 4 Effects of devolution on health care policies

Policy adaptation to local needs

The county works within committees such as health and policy committees. We use the health committee when we want to talk to the assembly. There is a committee that brings all the committees of the county assembly together, where members of the health committee are also members there. They deliberate and approve it first, and then we take it to the governor’s office where the last approval happens then we launch the document. (R12, county level)

Intra-governmental communication

…regular updates on the KEPI schedule because we’ve been introducing several vaccines in the last three years but there’s been no trainings going on the schedule, the complete schedule. So we are training on specific antigen. … before, it was very clear if they were 9 they were 9 and everyone knew they were 9 now people don’t know if they are 10 or 20 but they know there is something, yeah they brought something ‘ya’ (for) diarrhoea, there is something ‘ya’ (for) pneumonia but nobody is talking about the package… ok we have introduced fine, but what is the package? …information is scanty. (R04, county level)

Delineation of responsibilities

“With the vaccine policy of I think 2013, the national government is supposed to procure the vaccines and the county government is supposed to implement and make sure people get the vaccines or the vaccines get to the end users. There have been many challenges with the devolved system because there was a year we did not have budget allocation for procuring vaccines, all the money went to the counties, and when it reached there, it could not go back [to national procurement]. I think there is a gentleman’s agreement where the money to procure the vaccine remains at the national level, but I am not sure the counties even have the budget to administer the vaccines and take them to the community.” (R07, county level)

…initially the funding for everything would come from Nairobi, but now we are finding that the funding has to come from the county. Now at the county level, to access now the funding, now it has become a problem. (R17, county level)

Resource provision within government

Proper planning and resource mobilization is also critical, we have had some challenges in the past. Yes, it’s important especially for resources… like when we were doing the switch for the OPV (oral polio vaccine) vaccines we didn’t have enough resources, when we were introducing rotavirus the resources came way later so it posed a challenge for us. (R03, county level)

Lack of IEC (information, education and communication) materials, I don’t know the last time we had IEC materials on vaccines so it is very difficult to educate communities without that. (R06, county level)

…of course we’ll always say resource limitation, as much as now we have a budget on EPI it is still very limited, it is less than 1% of the total county budget on health. (R11, county level)

When it comes to vaccine distribution, we are talking about transport, in terms of net cost, we are talking about storage facilities for the cold chain of the vaccines, which this year I’m aware, Nairobi County has budgeted for procurement of cold chain equipment like fridges and other equipment, bearing in mind that vaccine program was run at the national level, and the county at the county level, it has not been fully taken over as a county function in terms of allocation of resources. (R07, county level)