Operationalizing Health Systems Strengthening in Decentralized Settings: A Leadership- and Management-Centred Approach from Kenya

Abstract Background Health systems strengthening (HSS) is widely recognized as essential for achieving Universal Health Coverage. Yet translating HSS into practice remains challenging because the WHO Health System Framework identifies key system components but provides limited guidance on who should operationalize HSS and how. This challenge is compounded by the context-specific nature of health systems, making universal best practices difficult to apply across settings. Responding to the need for empirical research on operationalizing HSS, this study developed and examined an operational approach grounded in the view that health managers develop two core competencies—servant leadership and systems thinking—through health systems management (HSM) training and apply them within an enabling external environment. Methods: The approach was developed from the WHO Leadership and Management Strengthening Framework, comprising four components: an adequate number of managers, appropriate competencies, an enabling working environment, and functioning support systems. A mixed-methods case study was conducted in Kenya. Quantitative data were collected through an online survey and analysed using multiple linear regression to identify factors associated with the development and sustained application of the two core competencies. Independent-samples t -tests and the Jonckheere–Terpstra test were used to determine which training types most effectively developed these competencies. Qualitative data were collected through in-depth interviews and analysed thematically. Findings from both analyses were integrated to generate a comprehensive interpretation. Results: Servant leadership and systems thinking emerged as essential and trainable competencies for effective HSM. These competencies were most effectively developed through comprehensive, leadership-inclusive HSM training. Two enabling conditions were critical for their sustained application: (i) organizational commitment to team-oriented work environments through clearly defined roles, effective digital communication for coordination, and comprehensive HSM training across managerial cadres, rather than primarily increasing manager numbers to meet staffing norms; and (ii) national policy frameworks institutionalizing community health as an integral component of the health system. Conclusions: The findings support the proposed approach to operationalizing HSS, suggesting a practical and context-sensitive pathway for strengthening decentralized health systems in low- and middle-income settings.