From national strategy to local implementation: a policy analysis of eye health integration and financing in Kenya’s devolved health system

Background In 2010, Kenya’s Constitution created a devolved governance structure, with county governments assuming responsibility for health service delivery after 2013. Eye health carries a burden, with blindness prevalence at 0.37% and vision impairment affecting 11.0–37.5% across regions. Policy and financing mechanisms shaping service availability remain poorly understood. Kenya has advanced through seven strategic plans, the latest being the National Eye Health Strategic Plan (NEHSP, 2020–2025). While plans provide direction, they have operated without a policy framework, limiting financing, accountability, and sustainability. The Ministry of Health is developing Kenya’s first eye health policy, offering an opportunity to address gaps. We conducted documentary analysis of national and county documents to assess eye health integration and financing in Kenya’s devolved health system. Methods Sources included national strategic plans and disease-specific policies, county policies and draft policies, and documents: County Integrated Development Plans (CIDPs), Annual Development Plans (ADPs), and Budget Review and Outlook Papers (BROPs) aligned with the 2023–2027 cycle. Two researchers coded policy documents using indicators from the Walt and Gilson policy triangle framework, reaching consensus on items. Findings apply to seven selected counties. Results Nationally, the NEHSP provides direction but does not mandate budget allocations. At county level, one county had a validated policy and strategic plan; two had strategic plans; and four had draft policies. All seven County CIDPs mention eye health, with four establishing budget lines. Six counties included budget estimates in CIDPs or ADPs. However, actual expenditure could not be traced as resources may be embedded within broader allocations. Budget estimates exist, but disbursement or expenditure cannot be confirmed. Moreover, most policies are dated 2025-2026, while fiscal documents were prepared earlier in the 2023–2027 cycle. This temporal mismatch limits linkage between policy adoption and documented allocations. Conclusion County-level policy adoption and fiscal visibility remain limited in the seven purposively selected counties. Most evidence is confined to budget estimates rather than documented allocations or expenditure. Kenya’s first national eye health policy is an opportunity to embed financing and accountability provisions. Findings underscore the need for vertical coherence in decentralized systems and suggest an inductive adaptation of the Walt and Gilson policy triangle to capture multilevel governance dynamics.