Effective governance is fundamental to health system performance, with decentralization often promoted as a pathway to greater equity, responsiveness, and accountability. In Kenya, county-level devolution was introduced in 2013, aiming to strengthen healthcare delivery. This review evaluates whether devolution has improved equitable access to healthcare in the country's Arid and Semi-Arid Lands (ASAL) counties, regions marked by harsh environments, socioeconomic marginalization, and persistently poor health outcomes. A systematic search of academic databases and grey literature identified 46 relevant records. Findings show that decentralization has yielded both opportunities and challenges. While counties gained autonomy to procure medicines beyond KEMSA, political interference and funding delays frequently undermined supply chains, particularly in ASAL counties. Central government delays in disbursing the equitable share and the pooling of revenues into County Revenue Funds often stalled timely access to essential medicines. Recruitment of health workers through county public service boards improved outreach in some cases but also introduced nepotism and widened staffing disparities. Most ASAL counties remain well below WHO-recommended health workforce densities. Geographical and financial barriers continue to impede access. In many ASAL areas, patients travel over three hours to reach the nearest health facility. Despite the official abolition of user fees, weak policy enforcement led to their reintroduction, disproportionately affecting ASAL populations. NHIF premiums also remained unaffordable for many households. Overall, the review concludes that without stronger institutional capacity and accountability frameworks, devolution may not achieve its intended equity goals in ASAL counties.
Kheir et al. (Thu,) studied this question.