FUNCTIONAL DEVOLUTION AND ACCESS TO MATERNAL HEALTHCARE SERVICES: EVIDENCE FROM MARSABIT COUNTY, KENYA
Abstract
Statement of the Problem: Kenya’s devolution of healthcare was intended to improve responsiveness and bring essential services closer to communities. In Marsabit County, however, the benefits of transferred service-delivery functions are constrained by a vast geographical area, dispersed pastoralist settlements, transport limitations, healthcare-worker shortages, and uneven facility capacity. These conditions make it important to establish whether functional devolution has translated into improved access to maternal healthcare rather than merely transferring responsibility from the national to the county level.
Purpose of the Study: The study examined the effect of functional devolution on access to maternal healthcare services in Marsabit County, Kenya.
Research Methodology: The study used a cross-sectional mixed-methods design. The target population comprised 9,600 women of reproductive age seeking maternal healthcare services in four county-managed Level Four hospitals. A sample of 384 respondents was selected proportionately through stratified random sampling. Quantitative data were collected using structured questionnaires and complemented by key informant interviews with healthcare stakeholders. Descriptive statistics were used to summarize respondents’ perceptions, while correlation and multiple regression analysis were used to test the relationship between functional devolution and maternal healthcare access. The functional-devolution coefficient was interpreted from the thesis multiple-regression model controlling for fiscal, governance, and administrative devolution.
Findings: The detailed Chapter Four results showed mixed but generally positive evidence. Regarding the overall contribution of functional devolution, 43.49% of respondents agreed or strongly agreed that it had improved access to maternal healthcare, 27.08% were neutral, and 29.42% disagreed or strongly disagreed. Positive perceptions were also recorded for better maternal healthcare services (41.92%), improved quality of care (38.29%), and increased antenatal and postnatal attendance (39.84%). The bivariate association between functional devolution and maternal healthcare access was positive but weak (r = 0.089). In the multivariate model, functional devolution recorded a positive and statistically significant coefficient (β = 0.077, p = 0.015), the largest reported coefficient among the four devolution dimensions.
Conclusion: Functional devolution has made a positive contribution to maternal healthcare access in Marsabit County, particularly through improvements in service delivery, perceived quality, and utilisation of antenatal and postnatal services. Nonetheless, the gains remain uneven because geographical and health-system constraints continue to restrict access for women in remote and pastoralist communities.
Recommendation: Marsabit County should strengthen primary healthcare facilities, mobile clinics, community outreach, ambulance and referral systems, and service-delivery capacity in hard-to-reach areas so that devolved maternal healthcare functions translate into more equitable access.
Keywords: Functional Devolution, Maternal Healthcare, Access, Devolved Health System, Marsabit County, Kenya
References
Abimbola, S., Baatiema, L., & Bigdeli, M. (2019). The impacts of decentralization on health system equity, efficiency and resilience: A realist synthesis of the evidence. Health Policy and Planning, 34(8), 605–617. https://doi.org/10.1093/heapol/czz055
Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10. https://doi.org/10.2307/2137284
Bossert, T. (1998). Analyzing the decentralization of health systems in developing countries: Decision space, innovation, and performance. Social Science & Medicine, 47(10), 1513–1527.
Constitution of Kenya. (2010). The Constitution of Kenya. Government Printer.
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE Publications.
KDHS. (2022). Kenya Demographic and Health Survey 2022. Kenya National Bureau of Statistics.
Kilonzo, S., Kamaara, E., & Magak, K. (2017). Improving access to maternal health care through devolution in Western Kenya. IDS Bulletin, 48(2), 91–108. https://doi.org/10.19088/1968-2017.118
Kimathi, L. (2017). Challenges of the devolved health sector in Kenya: Teething problems or systemic contradictions? Africa Development, 42(1).
McCollum, R., Theobald, S., Otiso, L., Martineau, T., Karuga, R., Barasa, E., Molyneux, S., & Taegtmeyer, M. (2018). Priority setting for health in the context of devolution in Kenya: Implications for health equity and community-based primary care. Health Policy and Planning, 33(6), 729–742. https://doi.org/10.1093/heapol/czy043
Mugenda, O. M., & Mugenda, A. G. (2003). Research methods: Quantitative and qualitative approaches. Acts Press.
Penchansky, R., & Thomas, J. W. (1981). The concept of access: Definition and relationship to consumer satisfaction. Medical Care, 19(2), 127–140.
Rondinelli, D. A. (1981). Government decentralization in comparative perspective. International Review of Administrative Sciences, 47(2), 133–145.
Tsofa, B., Goodman, C., Gilson, L., & Molyneux, S. (2017). Devolution and its effects on health workforce and commodities management: Early implementation experiences in Kilifi County, Kenya. International Journal for Equity in Health, 16, 169. https://doi.org/10.1186/s12939-017-0663-2
Wahome, C. W. (2019). Impact of devolved health on maternal healthcare in Kenya: The case of Nyandarua County [Master’s thesis, University of Nairobi]. University of Nairobi Repository.
