OPINION: When public systems are mistaken for status: Politics of misreading devolved health sector

Ahmednadhir Omar, Garissa County Executive for Health./HANDOUT 

Kenya’s health sector is among the most professionally diverse and intellectually endowed domains of public service. It brings together clinicians of the highest specialisation, nurses whose discipline anchors patient care, public health experts who safeguard populations, as well as administrators and other professionals who must hold the entire system together. It is, by design, a complex system. And like all serious systems, it is governed not by sentiment or status, but by rules.

Yet from time to time, public discourse reduces this complexity into something far more simplistic. It is recast as a contest of professions. Authority is questioned not on the basis of law or institutional mandate, but on perceived clinical hierarchy. In that reduction lies a consequential misunderstanding of how modern health systems function.

A health system is not a theatre of individual brilliance. It is a structure of coordinated responsibility. Leadership within it is not conferred by specialisation alone, but by lawful appointment, defined roles, and the discipline to steward resources, personnel, and policy in a manner that serves the public interest. To confuse this with a hierarchy of professions is to mistake public governance for prestige.

The more serious question, even as we consider who supervises whom, is whether the system within which all professionals operate is coherent, lawful, and accountable. Under Kenya’s devolved framework, anchored in the Constitution of Kenya and operationalised through instruments such as the County Governments Act, the intent was never to diminish professional excellence. It was to locate that excellence within responsive, accountable, and context-sensitive systems.

Devolution has brought healthcare closer to communities, expanded primary care networks, and strengthened referral pathways in many regions. It has also enabled counties to respond with greater agility to local health burdens long obscured by centralisation.

In professional development, for instance, hundreds of health professionals across historically underserved regions have, under devolution, accessed training, specialisation, and advancement opportunities that were previously beyond reach.

The gains are not theoretical. Across counties, there has been a measurable expansion of health infrastructure, increased recruitment of frontline health workers, more deliberate investment in maternal and child health, and improvements in health indicators. In previously underserved areas, facilities that did not exist a decade ago now form part of a growing facilities that did not exist a decade ago now form part of a growing continuum of care.

Imperfect, certainly. Uneven, at times. But undeniably progressive. Yet these gains are often obscured by narratives that favour immediacy over accuracy, and visibility over substance. It is precisely because these gains are real that the current tenor of some proposed interventions warrants careful scrutiny.

Recent commentary has, in parts, been framed as concern for professional dignity, career progression, or institutional fairness. These are legitimate themes. No serious system can afford to ignore them. Yet there is an emerging pattern in which such concerns are selectively amplified and detached from their procedural context, where isolated administrative matters are recast as systemic failure, less to strengthen governance than to leverage visibility.

There is, regrettably, a tendency in some quarters of political life to resort to public pressure, or to construct selective narratives under the guise of advocacy, particularly when other avenues of influence over county governments, unrelated to the quality of healthcare or service delivery, have not yielded the desired outcome.

The politicisation of health services, covert or overt, is among the most serious threats to the integrity of devolved governance. It erodes confidence within the workforce. It invites the public to view administrative processes not as safeguards, but as obstacles to be circumvented. Most critically, it risks transforming a system designed for service delivery into one susceptible to pressure and perception.

More concerning still is the invocation of legal and constitutional platforms, established to strengthen governance, in ways that undermine the very structures they were meant to support. When institutions are compelled to set aside policy and law in favour of the theatre of public contestation, the centre of gravity imperceptibly shifts from governance to spectacle.

This is not to suggest that the system is beyond critique. Far from it. Devolution remains a work in progress. There are legitimate questions about areas requiring further strengthening.

These, however, deserve careful, structured, and evidence-based engagement within the appropriate forums, informed by policy, data, and the lived realities of service delivery. What this does not warrant, however, is reduction into binaries that pit one cadre against another, or narratives that imply that leadership in public health is a function of professional background rather than institutional responsibility.

It would be both inaccurate and unjust to suggest that any one profession is inherently unsuited to leadership. Equally, it would be misguided to suggest that expertise alone confers exemption from the rules that govern public service. The strength of a health system lies precisely in its ability to integrate diverse forms of expertise within a coherent and disciplined framework.

The real danger, then, is not that professionals differ in training or perspective. It is that the system within which they operate is subjected to pressures that erode respect for process, elevate anecdote over analysis, and privilege immediacy over institutional integrity. 

Kenya stands at an important juncture in the evolution of its devolved health system.

The question is not whether challenges exist. They do. The question is how they are confronted. 

If the response is to fragment the system through the misuse of legal platforms, then the progress achieved thus far will prove difficult to sustain. If, however, the response is to reinforce governance, uphold due process, and engage in serious, good-faith dialogue, then devolution will continue to mature into what it was always intended to be: a system that is closer, fairer, and more accountable to the people it serves.

A health system cannot be governed by applause. It is governed by rules. The sector will not be strengthened by the language of contest, but by the discipline of systems.

And in the end, it is systems, not sentiment or political expediency, that endure.

The writer is the Garissa County Executive for Health

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