County Governments and Long-Term Care in Kenya: Can Devolution Support More Responsive Local Systems?

An older person’s need for sustained support is experienced locally. A fall happens in a home, a family begins struggling with care in a particular community, a hospital discharge returns somebody to a specific neighbourhood, and access to rehabilitation depends on services that can actually be reached. National policy matters, but long-term care ultimately succeeds or fails through these local realities.

That makes Kenya’s devolved system highly relevant to the future of ageing and care. The country’s 47 county governments already hold important responsibilities for county health services and for areas such as local planning, county transport, housing-related implementation, public amenities and community development that can influence independence in later life. At the same time, national government retains major responsibilities for national policy, standards, social protection and wider system direction. Within the Kenya Ageing, Long-Term Care & Community Support Knowledge Hub, this national-county relationship is central to understanding how a more developed care system could operate.

The opportunity is not simply to transfer a new category called long-term care to counties. Kenya does not currently operate a comprehensive national long-term-care entitlement comparable with systems found in some older societies. The stronger approach is to recognise the functions that national and county institutions already perform, identify where older people encounter gaps between them, and develop local care infrastructure without fragmenting rights, standards or accountability.

Devolution can make support more responsive to local conditions. It can also produce variation. The strategic task is to gain the advantages of local adaptation without allowing a person’s access to essential protection and support to depend excessively on the fiscal capacity, priorities or administrative maturity of the county in which they happen to live.

Devolution changes where care-system decisions can be made

Kenya’s 2010 Constitution created two distinct but interdependent levels of government: national government and 47 county governments. The Fourth Schedule distributes functions between them rather than treating counties simply as administrative branches of central government.

Health demonstrates the importance of that distinction. National government has responsibilities that include health policy, while county governments are responsible for county health services. The Health Act further places substantial service-delivery responsibilities at county level, including implementation of national health policy and standards within devolved functions.

Long-term care, however, does not fit neatly inside a single constitutional service category. An older person requiring continuing assistance may interact with primary healthcare, rehabilitation, social protection, family support, community organisations, housing, transport and privately purchased care. Some of these relationships are primarily national, some county-based and others sit outside government altogether.

This creates an operational requirement for coordination rather than institutional simplification.

The State Department for Social Protection and Senior Citizen Affairs retains national responsibilities relating to policy and programmes for older persons and ageing, while national social assistance includes the Older Persons Cash Transfer under Inua Jamii. Its social development structures also operate through county and sub-county offices. County governments, meanwhile, influence many of the services closest to people’s homes.

A mature long-term-care model would therefore not ask which single level of government “owns” an older person. It would establish how responsibilities connect around the person.

County variation is a reason for local design, not an argument against national standards

Kenya’s counties differ enormously. Nairobi’s population density, provider market and hospital infrastructure bear little resemblance to sparsely populated pastoral areas. Coastal counties have different settlement patterns from densely populated counties around major urban centres. Poverty, transport, workforce availability, disease patterns and family migration also vary.

A uniform delivery model would struggle to reflect those differences.

Home-based support that can be organised through relatively short travel routes in a dense urban county may require a completely different workforce and scheduling model in a geographically large rural county. A day centre can be practical where enough older people live within an accessible catchment; the same investment may have limited reach where communities are dispersed.

Devolution creates room for such adaptation. County-specific planning can connect care to existing primary healthcare, community structures and local organisations rather than building parallel systems.

Yet local flexibility should not mean that basic expectations around dignity, safeguarding, quality or access become entirely discretionary. The broader principles of organisational structure and accountability become particularly important where responsibility is distributed between institutions.

National direction can define outcomes, minimum expectations and common evidence requirements while counties determine how those outcomes are achieved within local circumstances. The distinction is important: standardising the purpose of care is different from standardising every delivery mechanism.

Kenya already has building blocks for a more local care system

Developing county-level long-term care would not necessarily require creating an entirely new bureaucracy. Kenya already has infrastructure that could support earlier identification, coordination and prevention.

Community Health Promoters provide an important connection between households and the primary healthcare system. Primary Care Networks are intended to strengthen relationships between community-level services and facilities. County hospitals and health centres already encounter older people whose medical conditions affect their ability to function independently.

Alongside this health infrastructure, national social development structures operate across counties and sub-counties, while civil society, faith organisations, community groups and private providers deliver varying forms of support.

The opportunity is to make those components more visible to one another.

An older person should not need to understand constitutional functions before receiving coherent support. If a Community Health Promoter identifies that somebody is repeatedly falling, the pathway should not end with recording a health concern. If a hospital knows that an older person cannot manage personal care after discharge, the absence of a conventional social-care department should not make that information operationally irrelevant.

Building a local care system therefore begins with pathways, not buildings.

Counties could progressively map:

• where older people with significant functional needs are being identified;
• which health, rehabilitation and community services are available;
• what families and community organisations are already providing;
• where people repeatedly experience avoidable deterioration or hospital use;
• which formal and informal providers operate locally; and
• where geographic or financial barriers make nominal services inaccessible.

This type of mapping creates a foundation for investment because it connects population need with actual local capacity.

Community-based care could become one of devolution’s strongest contributions

Kenya’s developing legal and policy debate around older people has increasingly recognised the importance of community-based support. Proposals concerning older persons have envisaged county-level community programmes that could include home-based support, prevention, promotion of independent living and county-specific interventions.

The distinction between enacted obligations and proposed reforms remains important. Not every proposal has become an implemented national entitlement. However, the direction reflects a practical reality: counties are well placed to understand how support needs differ between communities.

Community-based care does not need to begin as a comprehensive package of daily personal care. Early county models could connect prevention, rehabilitation, family information, social participation and targeted home support around people at greatest risk of losing independence.

The wider principle of community benefit and local partnership is particularly relevant. Counties do not need to deliver every intervention directly. Community organisations, faith groups, local providers and older people’s groups may contribute distinctive capabilities, provided that public responsibility is not simply displaced onto unpaid community networks.

A county identifies a gap after repeated hospital discharges

Imagine a county hospital noticing that some older patients return within weeks of discharge after falls, medication difficulties or inability to manage safely at home. Each admission is treated appropriately, but the recurring pattern has never been examined as a local care-system issue.

A county-level review brings together hospital staff, primary healthcare representatives, Community Health Promoters, rehabilitation professionals and social development contacts. The review shows that many of the people concerned do not require institutional care. They need short periods of rehabilitation, family guidance, home follow-up or help reconnecting with routine healthcare.

Instead of establishing a large new service immediately, the county pilots a defined post-discharge pathway in selected sub-counties. Community teams receive clear referral information, families are contacted before discharge where appropriate, functional recovery is reviewed and recurring problems are escalated.

The pilot is measured against practical outcomes: repeat admissions, falls, restoration of daily activities, family experience and the proportion of people remaining safely at home.

If the evidence is positive, expansion becomes a budget and planning decision supported by local data rather than an assumption. If outcomes vary between sub-counties, the county can investigate why.

This is where devolution can add value: national policy may establish the importance of community care, but local governance can connect that principle to patterns of need visible within one county.

County planning must connect healthcare with functional need

Older people often experience the consequences of fragmented planning because healthcare systems classify need through disease while long-term support is driven heavily by function.

A person with controlled diabetes may still need substantial assistance because of visual impairment or reduced mobility. Another person with several diagnoses may remain highly independent. Someone recovering from stroke may move rapidly from intensive medical treatment to a household expected to provide nearly all continuing support.

County health planning can become more responsive to ageing by incorporating functional outcomes alongside clinical activity.

This does not mean turning every county health worker into a care assessor. It means recognising whether people can move around, prepare food, manage medication, communicate, maintain hygiene and participate in community life when those factors materially affect health and safety.

The principles within outcomes-focused support are useful here because they shift attention from what service was delivered to what changed in the person’s life.

For county leadership, that creates a stronger evidence question. The issue is not only how many older people attended facilities, but whether local services helped prevent avoidable deterioration and maintain independence.

Organisations examining how responsibilities, escalation and oversight connect across a complex service system can use the Governance Maturity Assessment to structure that analysis. It is not a Kenyan governmental framework, but its underlying questions about accountability and assurance can help test whether responsibilities are clear enough to function in practice.

Financing determines whether local responsibility becomes real capacity

Devolution can place decision-making closer to communities, but responsibility without adequate resources does not create a service.

County governments operate within Kenya’s wider intergovernmental fiscal architecture, receiving nationally determined transfers while also raising permitted own-source revenue. They must allocate resources across competing priorities including health, infrastructure and other devolved functions.

Long-term care therefore enters an already contested budget environment.

This makes the design of new responsibilities important. If counties are expected progressively to develop community support for older people, policymakers need to understand what is being funded, whether resources follow expectations and how differences in county fiscal capacity will be managed.

Not every useful intervention requires a large new funding programme. Better referral, earlier rehabilitation and coordination may improve outcomes using existing infrastructure more effectively. But sustained personal care, respite, transport, equipment and specialist community services have real costs. They cannot be built indefinitely through coordination alone.

Kenya’s Older Persons Cash Transfer also illustrates why funding streams need to be distinguished. Inua Jamii provides income support to eligible older citizens aged 70 and above. That income can strengthen household security, but it is not a county long-term-care budget and should not be treated as a substitute for services where significant dependency exists.

A stronger financing approach would make different purposes visible: income security, healthcare, prevention, rehabilitation and sustained assistance are related, but they solve different problems.

For counties developing new models, the practical question becomes what level of need justifies public intervention and what form that intervention should take. Targeted programmes may initially be more realistic than universal service entitlements, but targeting requires transparent criteria and safeguards against arbitrary exclusion.

Local purchasing can build capacity, but only if outcomes are clear

County governments do not necessarily need to employ every worker or own every facility involved in future long-term care. Depending on the service and applicable procurement arrangements, support could involve direct county provision, partnerships, contracted organisations, community groups or referral to services funded through other routes.

This creates an emerging market-shaping role.

If public purchasing focuses only on the lowest immediate cost, providers may struggle to train workers, supervise practice or maintain continuity. Conversely, poorly specified contracts can fund activity without demonstrating whether older people actually become safer or more independent.

Service purchasing therefore needs to connect price, quality and purpose.

A county funding a home-support pilot might need evidence about response times, continuity, workforce competence, safeguarding concerns and outcomes for people using the service. A community organisation receiving public resources for an older people’s programme should be able to demonstrate participation and impact without facing reporting requirements so burdensome that small local organisations are effectively excluded.

This balance between accountability and proportionality is essential.

System partners developing evidence requirements can use the Commissioner Evidence Builder as a generic framework for thinking through service evidence, monitoring and assurance. Its UK terminology does not make it a Kenyan procurement instrument; its value here lies in the transferable discipline of deciding in advance what evidence would demonstrate that publicly supported services are achieving their intended purpose.

A rural county considers purchasing home support

A geographically large county identifies a group of older people who repeatedly require family members to travel long distances to provide basic assistance. Some live close to small trading centres, while others are dispersed across remote communities.

A conventional urban home-care model based on short scheduled visits would be expensive because workers could spend much of their day travelling. Simply copying a Nairobi provider model would therefore produce either high costs or unreliable coverage.

The county instead considers a mixed approach. In denser settlements, trained workers could support several people within manageable routes. More remote communities might use locally recruited workers linked to primary healthcare and clear escalation arrangements. Rehabilitation and clinical tasks remain connected to appropriately qualified professionals rather than being transferred indiscriminately to care workers.

Before expanding the model, the county tracks travel time, unmet visits, workforce retention, family experience, safeguarding concerns and changes in independence. It also compares the cost of different geographical models rather than assuming one county-wide unit price.

The lesson is not that every rural county should adopt this structure. It is that devolution allows service design to respond to geography. National standards can establish expectations around quality and protection while local operating models reflect the distances, settlements and workforce actually present.

Workforce development requires both national coherence and local intelligence

A future Kenyan long-term-care workforce would operate across national and county boundaries of responsibility. Counties understand local labour markets and service pressures, while national institutions are better placed to establish coherent occupational expectations, training frameworks and wider workforce policy.

Fragmenting workforce development into 47 unrelated approaches would create problems. Workers may move between counties, private providers may operate in several locations, and families need reasonable confidence that descriptions such as caregiver or home-support worker carry meaningful expectations.

At the same time, national workforce planning can miss local realities.

A county may have adequate numbers of nurses overall but limited rehabilitation capacity outside its main town. Another may have potential community workers but struggle to retain specialist professionals. Urban counties may face high turnover as workers move between providers, while remote counties may experience recruitment difficulties because travel and housing affect employment choices.

The wider discipline of workforce planning therefore needs both levels of intelligence.

Counties could contribute evidence about vacancy patterns, travel requirements, emerging roles and local training needs. National policy could use that evidence to support occupational development and avoid unnecessary variation in basic competence expectations.

Care work also needs to be treated as work. Reliance on women, relatives or poorly paid household workers can conceal the labour required to sustain older people at home. As formal services expand, employment conditions, supervision, worker safety and progression will influence both recruitment and quality.

Quality cannot depend entirely on where somebody lives

Local adaptation is one of devolution’s strengths, but quality variation is one of its risks.

Counties will inevitably develop at different speeds. Some may have stronger health infrastructure, more active community organisations, larger provider markets or greater administrative capacity. Innovation can emerge from that diversity, but persistent differences in basic protection require attention.

National standards are therefore particularly important where services involve personal care, residential support or significant dependency. Kenya already has national standards and guidelines relating to institutions for older persons. As community and home-based services develop, equivalent clarity may progressively be required about safeguarding, workforce competence, complaints, records and minimum service expectations.

The objective should not be to regulate a neighbour occasionally helping an older person in the same way as an organised provider delivering intensive daily care. Oversight should reflect the nature and level of risk.

Quality information also needs to travel upwards. Counties should be able to identify recurring problems within providers or pathways, while national institutions need enough visibility to recognise patterns across counties.

The principles of quality monitoring systems are useful because measurement should lead to action rather than simply produce reports.

A small common national dataset could support comparison while leaving counties free to collect additional information relevant locally. Measures might include access, continuity, serious safeguarding concerns, functional outcomes and user experience rather than relying only on the number of services delivered.

Safeguarding needs clear routes across institutional boundaries

Long-term care brings older people into relationships of dependency. Most family and professional care is supportive, but dependency can also increase vulnerability to neglect, financial exploitation, coercion or abuse.

Devolution makes clarity about safeguarding especially important because concerns may surface through different routes. A Community Health Promoter may notice neglect. A hospital may identify unexplained injuries. A social development officer may receive a family concern. A private provider may discover financial exploitation. Police involvement may be required where criminal conduct is suspected.

The older person should not bear the burden of working out which institution has jurisdiction.

County-level protocols can clarify how concerns move between relevant actors while respecting national law and responsibilities. The wider principle of multi-agency working is especially relevant where no single service holds all the information needed to understand risk.

Good safeguarding also protects autonomy. Families or professionals should not use safety as an automatic justification for removing an older person’s control over money, residence or daily decisions.

This requires practical routes for hearing the older person’s own account, involving trusted supporters where appropriate and distinguishing an informed choice from coercion or inability to understand a particular decision.

A safeguarding concern crosses national and county services

An older man receiving the Older Persons Cash Transfer lives with relatives in a county town. A Community Health Promoter notices that he appears increasingly undernourished despite the household receiving his transfer. The man says a relative controls his mobile transactions and becomes visibly anxious when money is discussed.

The concern cannot be resolved simply by confirming that the national cash transfer was paid correctly. Payment administration is only one part of the situation.

A functioning local pathway would allow the concern to reach an appropriate social or safeguarding response without assuming financial abuse before the facts are understood. The older man would be spoken with privately where possible, immediate health needs addressed and information shared proportionately between relevant actors.

If misuse of the benefit is identified, national programme mechanisms may become relevant. If neglect or abuse is present, additional protective action may be required. If the underlying problem is extreme household poverty rather than deliberate exploitation, the response may need to address wider family circumstances.

The governance lesson is that national programmes generate local consequences. Accountability cannot end when a payment leaves a central system; equally, county services cannot alter national programme rules independently. Effective protection depends on an escalation pathway joining the two.

Data can make local need visible without creating 47 information silos

Devolution creates valuable opportunities for local intelligence. Counties can observe patterns that national averages conceal, including remote communities with poor access, facilities experiencing repeated discharge problems or neighbourhoods where older people are increasingly living alone.

However, 47 unrelated information systems would make national learning difficult.

Kenya’s existing social protection and health information infrastructure provides a foundation for greater coordination. The national Single Registry is designed to connect information across social protection programmes, while digital health and community health systems are developing through separate but potentially complementary pathways.

The aim should not be to construct one enormous database containing every detail about an older person. Interoperability is more useful when it enables appropriate information to support a defined purpose.

For example, county planners may need aggregated information about functional need and service access without seeing an individual’s financial records. A professional supporting a hospital discharge may need current contact and care information without accessing unrelated government data.

The principles of interoperability and system integration are therefore as much about governance as technology.

Counties also need the capability to interpret data. Dashboards that show activity without revealing inequalities or outcomes can create an illusion of control. The Quality Dashboard Builder offers a generic way to structure meaningful performance and outcome measures. Used in an international context, its value lies in helping leaders distinguish information that supports decisions from data collected simply because it is available.

County innovation needs a route into national learning

One of devolution’s greatest potential advantages is the ability to test approaches under different local conditions. One county may develop a strong rehabilitation pathway, another a community-based older people’s programme, and another an effective partnership with faith-based or private providers.

The benefit is lost if successful approaches remain isolated.

Kenya therefore needs mechanisms through which county experience can inform wider policy without assuming that every successful local programme should be replicated identically elsewhere.

Evidence should explain why an intervention worked. Was success caused by population density, an unusually strong provider network, existing community infrastructure, dedicated leadership or a particular funding arrangement? What would another county need before adapting it?

Learning should also include unsuccessful initiatives. A service that attracts little demand, loses its workforce or proves too expensive can generate useful evidence if the reasons are examined rather than hidden.

This is where learning and continuous improvement become system functions rather than provider-level activities.

National institutions can support shared definitions, evaluation and dissemination. Counties contribute operational evidence. Universities and other research partners can help test outcomes. Older people and families should contribute experience that quantitative measures may miss.

The result is a learning system in which variation becomes a source of intelligence rather than simply inconsistency.

Older people need a stronger voice in county decisions

Devolution is intended partly to bring government closer to citizens. Long-term-care development provides a practical test of that principle.

Older people should influence how services are designed rather than appearing only as recipients once programmes have been established. Public participation processes can provide formal opportunities, but meaningful involvement requires more than inviting people to a meeting.

Mobility, transport costs, hearing or visual impairment, literacy and digital access can all affect participation. People with the greatest care needs may be among those least able to attend conventional consultation events.

Counties therefore need multiple ways of hearing experience: community engagement, older people’s organisations, family networks, home-based conversations and accessible complaints or feedback routes.

This is not simply participatory good practice. It improves operational intelligence.

An older person may explain that a health centre is geographically close but impossible to reach by affordable transport. A family may identify that discharge instructions assume equipment they cannot obtain. A caregiver may reveal that a service operates at hours incompatible with employment. These are implementation problems that administrative data alone may not expose.

The broader principles of co-production and lived experience therefore have direct relevance to county planning, even though the precise participatory mechanisms must reflect Kenyan institutions and communities.

Local participation changes a county programme

A county plans a daytime programme for older people in its main urban centre. The initial design assumes that participants will travel independently to a central facility where health promotion, social activities and basic rehabilitation support can be offered.

During engagement, older residents from outlying areas explain that transport would make regular attendance unaffordable. Some people with the greatest need would require relatives to leave work to accompany them. A centralised programme could therefore attract relatively independent residents while excluding those it was partly intended to support.

The county revises the model. Some activities remain at the central facility, but outreach sessions rotate through existing community locations. Referral links with primary healthcare are strengthened, and attendance information is reviewed by location and functional need rather than simply total numbers.

The change does not eliminate every access problem, but it alters the programme before significant resources are committed to an unsuitable design.

The scenario demonstrates why participation is part of governance. Consultation becomes valuable when it can change an operational decision and when decision-makers can explain how local evidence affected the final model.

National policy and county delivery need a deliberate interface

Kenya’s National Care Policy, endorsed by Cabinet in December 2025, strengthens the strategic context for thinking about care as an issue extending beyond private household responsibility. Its emphasis on care, unpaid work, coordination and accountability creates implications for both national and local institutions.

Endorsement of a national policy does not mean that a comprehensive county long-term-care system appeared immediately. Implementation requires responsibilities to be translated into plans, financing, workforce arrangements, service models and measurable outcomes.

This is precisely where the national-county interface matters.

National government can provide strategic direction, policy coherence and common expectations. Counties can interpret need locally and connect care with devolved health services and community infrastructure. Intergovernmental mechanisms are needed where responsibilities overlap or where national policy creates implementation expectations for devolved functions.

Without this interface, two opposite problems can emerge. Excessive central prescription can produce models poorly suited to local conditions. Excessive localisation can create fragmented systems with inconsistent standards and limited portability.

A stronger model combines national coherence with local discretion.

The underlying governance questions are straightforward even when the institutional answers are complex: who is responsible, what resources support that responsibility, what minimum outcomes are expected, what can vary locally, what information is shared, and what happens when implementation persistently falls short?

Equity must be assessed between counties as well as within them

Devolution makes local inequalities more visible, but it can also create new ones.

Within a county, older people may experience very different access depending on rurality, income, disability, gender and family support. Between counties, fiscal capacity, infrastructure and workforce availability can produce additional variation.

National oversight therefore needs to distinguish legitimate local adaptation from inequitable access.

A sparsely populated county may reasonably deliver community support differently from Nairobi. That is variation by design. An older person being unable to access basic protection solely because their county lacks administrative capacity is a different matter.

Equity monitoring should consequently examine outcomes and access rather than demanding identical organisational structures.

This may require national and county decision-makers to consider:

• whether older people with comparable levels of need can reach some form of appropriate support;
• whether remote communities are systematically excluded from services concentrated in county headquarters;
• whether public resources disproportionately benefit people able to navigate complex systems;
• whether people below the age threshold for older-person cash support become invisible despite substantial care needs; and
• whether county innovations are reaching people with disabilities, dementia and high dependency rather than only healthier older residents.

Equity does not require every county to spend the same amount or provide the same service. It requires sufficient visibility to understand what different local arrangements mean for people.

Devolution can support prevention before dependency becomes entrenched

County governments have an important opportunity to influence long-term-care demand before intensive support is required.

Prevention in later life is not limited to health promotion. It includes reducing falls, maintaining mobility, managing chronic disease, supporting nutrition, improving accessible environments and helping people remain socially connected.

Many of these factors sit close to devolved functions.

A county that improves primary healthcare but leaves older residents unable to reach it because local transport is inaccessible has addressed only part of the pathway. Similarly, rehabilitation that restores mobility has less effect if the person returns to an environment that prevents them leaving home.

Prevention therefore rewards joined-up local planning.

Investment decisions can also be assessed through a wider social and economic lens. Supporting an older person to remain independent may reduce pressure on relatives who would otherwise leave employment or reduce working hours. Community programmes can create local jobs while strengthening participation. Accessible infrastructure benefits people with disabilities and families as well as older residents.

The Adult Social Care Social Value Report Builder provides a generic framework for considering wider community outcomes and evidence. It is not a Kenyan public-finance methodology, but the principle of measuring broader social impact can help prevent care investment from being judged only by its immediate service cost.

A realistic county model would develop progressively

Kenya does not need to move directly from predominantly family-based support to a comprehensive publicly funded long-term-care system in every county. Such a transformation would create major fiscal, workforce and administrative demands.

A more credible pathway is progressive development.

Counties could begin by understanding need, strengthening referral routes and connecting existing health and community resources. Selected services could then be developed around clearly identified gaps, such as rehabilitation after hospital discharge, caregiver information, dementia support or targeted home assistance.

Evidence from these services would inform subsequent investment.

As provider markets develop, counties would need stronger approaches to quality, purchasing and workforce assurance. National institutions could progressively strengthen standards and common outcome frameworks. Digital infrastructure could support coordination where it solves defined operational problems.

Different counties would move at different speeds, but national policy could maintain direction and protect against the most serious inequities.

This incremental model also allows Kenya to learn what forms of long-term support fit its own institutional and cultural context rather than importing structures developed elsewhere.

International learning: decentralisation works when responsibility and capability travel together

Many countries distribute responsibility for long-term care across national, regional and municipal institutions. Their arrangements vary substantially. Some local governments administer extensive statutory care entitlements; others organise community services within nationally financed systems.

Those models cannot be transferred directly to Kenya because fiscal capacity, workforce supply, legal entitlements and institutional history differ.

The transferable lesson is narrower but important: decentralisation is most effective when local responsibility is matched by capability, financing, information and clear national expectations.

Local decision-making can improve responsiveness because services are designed closer to communities. It can stimulate innovation and allow different approaches to geography and culture. But decentralisation can also amplify inequality where richer or administratively stronger areas can provide substantially more than others.

Kenya’s advantage is that devolution is already embedded within its constitutional structure. The question is therefore not whether long-term care should invent a separate local-government architecture. It is how an emerging care system can use the architecture that already exists while respecting the division of functions between levels of government.

That requires national policy to be specific enough to create coherence but flexible enough to permit county adaptation.

The future is likely to be nationally guided and locally assembled

A mature Kenyan long-term-care system is unlikely to consist of one national service delivered identically everywhere. The country’s geography, devolution arrangements, family structures and mixed provider environment make a more plural model likely.

National government can set policy direction, maintain social protection, develop standards and support system-wide learning. Counties can connect care to local health infrastructure, community organisations, transport, housing and population need. Families will remain important partners, while private, faith-based and civil-society providers may deliver increasing amounts of formal support.

The effectiveness of this arrangement will depend on the interfaces.

People should not disappear between national and county responsibilities. Providers should understand who holds oversight. Counties need usable evidence about need and outcomes. National institutions need visibility of persistent geographic inequality. Families need pathways that do not require expert knowledge of government structures.

Devolution therefore offers more than administrative decentralisation. Used well, it can become the mechanism through which broad national ambitions about care acquire a locally meaningful form.

Conclusion

Kenya’s 47 county governments occupy an increasingly important position in the country’s long-term-care future because many of the factors that determine independence in later life are already experienced through devolved systems. County health services, community infrastructure, rehabilitation, local planning and partnerships can all influence whether an older person remains supported at home or reaches help before a manageable difficulty becomes a crisis.

The strongest direction is neither complete centralisation nor 47 separate care systems. National government has an essential role in policy, social protection, standards, equity and system-wide learning. Counties bring the ability to adapt delivery to geography, population need, local organisations and existing health infrastructure. The challenge is to make those roles complementary.

Implementation will require more than assigning responsibilities. Financing, workforce capability, safeguarding routes, outcome information and mechanisms for sharing learning all need to develop alongside services. Variation can be productive when it reflects local circumstances; it becomes problematic when it leaves people with comparable needs facing fundamentally different levels of protection.

Kenya’s devolved structure nevertheless creates a significant opportunity. Long-term care can grow from local realities rather than being designed only at national level. If national ambition is combined with county capability, common expectations and meaningful accountability, devolution can help turn care policy into support that is recognisable in the places where older people actually live.