Health worker strikes in Kenya: A symptom of governance inadequacies in a devolved health system

Recurrent health worker strikes in Kenya since the 2013 devolution reforms reflect more than episodic labour unrest; they signal broader governance challenges that may be particularly pronounced in decentralised and resource-constrained health systems. Despite constitutional protections for labour rights and decentralised service delivery, Kenya's health sector has experienced persistent industrial disputes, exposing gaps in legal frameworks, institutional coordination, and dispute resolution systems. We conducted a qualitative policy analysis of health worker strikes in Kenya between 2010 and 2025. Data were drawn from legal statutes, policy documents, government reports, peer-reviewed literature, and grey sources. Guided by Walt and Gilson's policy triangle, complemented by complex adaptive systems and health governance frameworks, we analysed how institutional arrangements, stakeholder dynamics, and policy processes shape labour relations in a devolved health system. Several interrelated drivers of recurrent strikes were identified, including tensions between the constitutional rights to strike and to health, fragmented governance and weak intergovernmental coordination under devolution, persistent workforce challenges and failures to implement Collective Bargaining Agreements (CBAs) and Return-to-Work Formulae (RTWFs), ineffective dispute-resolution mechanisms, and the absence of enforceable minimum service arrangements during industrial action. Through their interaction, these factors generate recurring cycles of non-compliance, labour unrest, and institutional mistrust. Recurrent disputes over CBA and RTWF implementation suggest that the central issue lies not in the absence of legal protections or negotiated settlements, but in translating commitments into sustained action. Addressing recurrent strikes requires systemic reform beyond short-term dispute settlement to address underlying governance, accountability, and implementation challenges. Priorities include strengthening independent dispute resolution mechanisms, clarifying responsibilities across levels of government, improving accountability for negotiated commitments, harmonising human resource management systems, and institutionalising minimum service protections. Kenya's experience offers important lessons for decentralised health systems on aligning authority, accountability, and implementation capacity to strengthen resilience and advance universal health coverage.