By Victorine Ndinda Kenya’s health system is not failing because the country lacks hospitals or policies; it is failing because of power struggles. National and county governments, politicians, donors, and professional groups are locked in battles over control, leaving ordinary Kenyans to pay the price. The result is medicine shortages, endless strikes, understaffed rural clinics, and preventable deaths. The problem goes beyond service delivery failures. It is fundamentally about who holds power, who makes decisions, and whose voices are excluded. More than a decade after devolution, it is increasingly clear that unless Kenya confronts these entrenched power dynamics head-on, the promise of quality healthcare for all as envisioned in its Constitution will remain a distant dream. This struggle is not unique to Kenya; many countries in the Global South, from Nigeria to the Philippines, face similar battles as they decentralize health systems and navigate political, donor, and community interests. Unless these dynamics are addressed, Kenya and its peers will continue to build hospitals but fail to save lives. Promises Broken: Power Still in the Wrong Hands In 2010, Kenya adopted a new Constitution that sought to decentralize power and bring decision-making closer to citizens by creating 47 local governments (counties). Under the Fourth Schedule, county governments were assigned responsibility for delivering most health services, while the national government retained policy, regulatory, and national referral functions. However, more than a decade later, power remains concentrated at the top. Although Counties manage an estimated 70% of health functions, the national government controls major funding streams and often makes unilateral decisions. The rollout of the Social Health Insurance Fund (SHIF) in 2024 intended to replace the National Health Insurance Fund, illustrated this imbalance. The national government implemented the new financing mechanism without adequate county involvement, despite counties being responsible for service delivery. These power struggles are not merely political theatre; they are hurting Kenyans. Persistent tensions between Parliament, county governments, and the Ministry of Health have delayed reforms, disrupted service delivery, and left counties uncertain about how to plan and budget. As leaders debate authority and control, patients face medicine stock-outs, stalled programs, widening gaps in care, and death. Politics Over People Kenya’s competitive politics oftentimes distorts health priorities. Politicians favor highly visible projects; new buildings, ambulances and equipment over less glamorous but essential investments like preventive care, staffing, and supply chains. This “politics of visibility” produces impressive ribbon-cutting ceremonies while communities are left with empty hospitals, idle machines and false hope. Recurring doctors’ and health workers’ strikes compounded by finger-pointing and delayed action from both levels of government, have turned manageable labor disputes into prolonged crises needlessly costing countless Kenyan lives. In 2024 alone, health worker strikes shut down services across most counties disproportionately affecting rural populations that rely heavily on public primary healthcare. Staffing shortages further expose these systemic weaknesses. Data from the Kenya National Bureau of Statistics shows the country has a doctor to patient ratio of 19 practitioners per 100,000 people, translating to 1 doctor per 5,000+ people. This is substantially below widely referenced benchmarks such as 1 doctor per 1,000 people by the WHO, highlighting a critical shortage of medical practitioners. Poor hiring and deployment practices compound the problem, concentrating staff in urban areas while rural facilities remain understaffed and under-equipped. Unlike Brazil and Thailand that deliberately redistributed their health workers so as to improve health outcomes in rural areas, Kenya still largely relies on ad hoc recruitment shaped by personal preferences and political patronage. When Donors Hold the Purse Strings Like many countries in the Global South, Kenya’s health financing landscape is heavily influenced by external donors. For instance, between 2001 and 2016, donor funding exceeded government health expenditure by at least 50%. Donors finance majority of the critical programs including HIV/AIDS, malaria, and immunization programs, often through top-down initiatives that reflect global priorities more than local needs. Similar patterns are countries like in Malawi and Mozambique, where over 60% of health budgets depend on donors, leaving governments vulnerable to abrupt policy and funding shifts. This reliance carries significant risks. When USAID reduced funding in 2025, Kenya faced imminent antiretroviral drug shortages, with stocks predicted to last only a few months. Prevention programs were scaled back, and HIV infections rose, especially among young people. At the same time, non-communicable diseases like cancer and diabetes which cause 41%% of deaths, are severely underfunded. When financing follows donor priorities rather than population needs, essential services fall through the cracks. Unequal by Design: How Resources Follow Power, Not Need Power dynamics are evident in how health resources are distributed across Kenya’s health system. Higher-level facilities tend to attract specialized staff, larger drug allocations, and greater funding, while lower-level facilities that serve most rural and marginalized communities remain under-resourced. This imbalance weakens primary health care and entrenches geographic inequities, with urban and wealthier counties consistently better resourced than historically marginalized areas. As such, disparities in infrastructure, staffing, and supply chains translate into sharply unequal health outcomes across the country. Civil Society and Citizens: Power by the People, for the People? Civil society organizations (CSOs) have demonstrated that power can be shifted from the bottom up. In contexts where CSOs engage meaningfully in health planning and budgeting, communities are better informed and services improve as they push for transparency, mobilize citizens to demand accountability, and give voice to marginalized groups. However, CSOs in Kenya face persistent barriers including political intimidation, underfunding, and exclusion from formal decision-making. Women, rural communities, and people with disabilities remain under-represented in forums that shape health priorities. Without meaningful participation, health decisions will continue to reflect elite interests rather than community needs Conclusion: Power Must Shift to Save Lives Kenya is not short on policies or strategies, it is short on power where it matters most; at the point of care, in communities, and in county governments that deliver services. Unless Kenya confronts and rebalances the power dynamics between national and county governments; political elites and technical experts; donors and local priorities; elites and marginalized citizens, health reforms will remain superficial. Countries across the Global South offer both cautionary tales and inspiration. Brazil shows that when power is shared fairly, staffing is strategic, and communities are engaged, health outcomes improve. Nigeria, by contrast, illustrates what happens when power and funding aren’t aligned. The World Health Organization estimates that more efficient use of resources could save up to 40% of health spending, resources that Kenya could be redirected towards saving lives. Efficiency alone, however, will not fix the system. Kenya must deliberately shift power by granting counties real decision-making authority, aligning donor funding with national priorities, deploying health workers based on need rather than politics or geography, increasing domestic resource mobilization as envisioned in the Abuja Declaration, and institutionalizing meaningful community participation. These reforms are not simply about governance; they are about survival. Kenya cannot afford to keep playing power games with people’s health because they are not abstract political contests; they are matters of life and death. Victorine Ndinda is a health systems strengthening practitioner with over a decade of experience designing and managing integrated health programmes across Kenya, funded by USAID and the European Union. Her work focuses on health financing, governance, and policy advocacy, with a strong track record of supporting national and county governments, civil society, and development partners to advance equitable, accountable, and locally led health systems.