From devolution to post–COVID-19 UHC scoping review of human resource for health reforms in Kenya: a signalling and sensemaking analysis

Background Kenya's pursuit of Universal Health Coverage (UHC) has been profoundly shaped by health sector devolution 2010 and the COVID-19 pandemic both of which have exposed persistent challenges in human resources for health (HRH), including workforce shortages, geographic maldistribution, governance fragmentation, and declining motivation. While numerous studies have examined these challenges, less attention has been paid to how HRH reforms are interpreted by health workers and how policy signals shape workforce behaviour over time. Objectives This scoping review synthesises evidence on HRH reforms in Kenya from 2000 to date (2025), examining the evolving HRH landscape, key barriers to recruitment, retention, and motivation, and documented interventions to strengthen workforce capacity. The review applies signalling and sensemaking theories to understand how HRH policies and reforms influence health worker perceptions, motivation, and retention. Methods Following the Arksey and O'Malley framework and reported using PRISMA-ScR guidelines, we conducted a scoping review of peer-reviewed literature, policy documents, and grey literature published in English between 2000 and 2025. Searches were conducted across major bibliographic databases and institutional repositories. Sixty three sources met the inclusion criteria and were analysed using descriptive and thematic synthesis, guided by HRH and organisational theory frameworks. Findings The evidence reveals a phased evolution of HRH reforms in Kenya, spanning pre-devolution, early devolution, maturing devolution, pandemic response, and post-COVID reform consolidation. Across these phases, inconsistent policy signalling—such as facility expansion without commensurate staffing, delayed remuneration, and fragmented governance—shaped health workers' sensemaking, often undermining motivation and retention, particularly in public and rural facilities. Conversely, credible signals, including digital health investments, task-sharing policies, strengthened community health systems, and leadership development initiatives, were associated with improved workforce engagement and performance. Conclusion Kenya's HRH experience demonstrates that workforce reforms function not only as technical interventions but also as signals that health workers interpret through sensemaking processes. Aligning HRH policy design with clear, credible, and consistently implemented signals is critical to strengthening workforce motivation, retention, and performance in devolved health systems. These insights offer transferable lessons for other low- and middle-income countries pursuing UHC through decentralised governance.