Devolution and Family Planning: The View from Kenya
By Dr. Josephine Kibaru-Mbae
Director General of the National Council for Population and Development, Kenya
Kenya is in the midst of an ambitious devolution process that, once complete, promises to bring government closer to the people and improve the delivery of public services. The 2010 Constitution of Kenya created a decentralized system of government with 47 counties, each of which is responsible for providing health care and other services to its citizens. The actual process of devolution got underway in March 2013, when the new county governments were elected and began taking on their devolved powers and responsibilities.
For Kenya’s family planning program, these first two years of devolution have been a period of learning and adjustments. We are transitioning from a highly centralized system—with policy and implementation handled for the whole country by the National Council for Population and Development (NCPD) and the Ministry of Health—to one in which each individual county is responsible for planning, budgeting, and implementing family planning services. Naturally, there have been some challenges.
One big challenge is the sheer loss of continuity and institutional memory, which is probably unavoidable in a transition of this nature. The new county governments are starting from scratch, learning what needs to be done, why it needs to be done, and how. NCPD’s role is to act as technical advisor and facilitator, helping to build the capacity of the county governments to keep family planning services on track.
The second challenge, and very much related to the first, is the funding gap that has emerged for contraceptive commodities. The national budget line for commodity procurement was eliminated upon devolution of health services, with the expectation that counties would take over this budget function. But the counties were unprepared for this, and initially there were no county allocations for family planning at all. For the first two years of devolution, Kenya was totally dependent on outside donors for contraceptive commodities.
The third challenge involves the in-country distribution of commodities. The Kenya Medical Supplies Authority (KEMSA) is a national agency that distributes drugs, contraceptives, and other supplies throughout the country. Before devolution, contraceptive commodities were automatically sent to the doorsteps of the facilities from the central stores; with the new devolved system, there is no distribution budget for commodities. They are only distributed if counties place orders for medicines and the commodities can be piggybacked onto those orders. If counties don’t place orders for medicines, then no commodities are shipped out. Local stock-outs are an inevitable result.
These are thorny issues, but we’re making very good progress on resolving them. One thing we’ve all learned is that there simply must be a national program for commodity purchasing to ensure sustainability and equity. It’s not yet clear how to organize that within the context of our devolved system, but discussions are ongoing. In the meantime, the National Treasury has restored the national budget line for commodities, allocating 50 million Kenyan shillings for the 2015/16 financial year.
We have also noted great progress at the county level, as the county governments grow into their roles as community leaders. NCPD is working closely with members of the county assemblies and county executives to help them understand the importance of family planning and how it fits into their development agendas. More and more counties are now allocating funds for family planning, developing their own county-specific health plans, and even forming their own family planning technical working groups. Kenya’s FP2020 strategy is a key factor here, as counties incorporate the objectives into their own plans and take ownership of the process.
Overall, the long-term outlook for family planning in Kenya is excellent. Devolution is a complicated process that will take years to unfold and institutionalize. But the result we’re working towards will be worth it: sustainable, community-driven family planning programs that are rooted in local concerns and responsive to local needs.
Dr. Kibaru-Mbae has been a public health leader for more than 20 years, and formerly served as the director general of the East, Central and Southern Africa Health Community (ECSA-HC).