Policy Harmonization as a Political Instrument: How Programs for Human Resources for Health in Kenya Reinforce National Dominance over Devolved Units

Abstract

The article highlights a major paradox in Kenyan health governance where recurrent efforts to harmonize policies in mitigating chronic human resources for health (HRH) crises like national strikes and workforce imbalances have been prevalent in the devolved system. This is an evidence-based proposition on the idea that harmonization processes are often manipulated in the political interest of state recentralization contributing, inadvertently, to the perpetuation of the instability. This study disentangles the harmonization process using a very rigorous conceptual analysis of secondary data, including legislative statutes, policy documents and empirical case studies. Our results show a critical discontinuity. On the one hand, top-down structures such as national legislation and collective bargaining agreements tend to restrict county autonomy and generate financial inefficiency. On the other, successful resolution can be achieved through bottom-up and horizontal vehicles such as the county-level work councils, council of governors and inter-governmental mediation. This fact complicates the very basic premise that increased national coordination is an undisputed good, and finds that such a system posits the coordination process itself as a venue of intergovernmental politics. We find that long-term stability of HRH needs a paradigm shift in the form of enabling rather than coercive harmonization paradigm, which is a formal incorporation of the local problem-solving formations. The most important contribution of the study to program and policy harmonization is the necessity to examine not only the technical compliance, but the balance of power and restructuring results of harmonization policies. It recommends measures that reflect equity in intergovernmental decisions, and true devolution of the HRH management.