The Impact of SDG 3 on Health Priorities in Kenya

Abstract

In September 2015, the United Nations General Assembly adopted the 2030 Agenda for Sustainable Development, which includes 17 Sustainable Development Goals (SDGs). Like the previous Millennium Development Goals (MDGs), the SDGs are global goals, which potentially risk shifting attention and resources away from national development priorities. This article is based on a qualitative study that examined whether the UN’s global health goal—SDG 3—is overriding local health priorities in Kenya. The study found that (a) SDG 3 aligns in many ways with Kenya’s development and health policies, and (b) Kenya is implementing SDG 3 targets selectively. This article, therefore, contends that SDG 3 is not overriding Kenya’s local health priorities.

Keywords

Sustainable Development Goals Millennium Development Goals national health priorities participation Kenya

Introduction

In September 2015, Kenya joined the other 192 members of the United Nations to unanimously adopt the 2030 Agenda for Sustainable Development, including 17 Sustainable Development Goals (SDGs) and 169 targets (United Nations General Assembly [UNGA], 2015). These goals and targets provide a nested framework to guide international development for 15 years (2016–2030). The UN General Assembly has called on state and non-state development actors to align their policies, strategies, and programs with the SDGs and many UN member states are engaged in the process of integrating and localizing the SDGs into their national- and local-level policy and planning processes. This SDG framework was preceded by and reflects lessons learnt from the implementation of the UN Millennium Development Goals (MDGs), which steered international development for 15 years between 2001 and 2015.

Global goals, such as the MDGs and SDGs, aim to rally support for important development objectives. The MDGs provided a platform for a global consensus and coordinated action and successfully mobilized global expertise and funding to reduce multidimensional poverty throughout the world (Sumner & Tiwari, 2009; Waage et al., 2010). While there is general recognition that global development benefited from the specific, quantifiable, and time-bound MDG targets and indicators, some studies show that the quantification of targets and indicators also resulted in unintended consequences and distorted national policy and development narratives (Fukuda-Parr, 2014; Fukuda-Parr, Yamin, & Greenstein, 2014; Langford & Winkler, 2014; Unterhalter, 2014). The MDGs limited previous poverty eradication efforts by adopting “approaches that were conceptually narrow [and] vertically structured … neglecting the need for social change and the strengthening of national institutions” (Fukuda-Parr et al., 2014, p. 110). As such, the MDG framework created an impetus for the implementation of unsustainable short-term development solutions (Langford & Winkler, 2014).

While the MDGs were intended to focus international development efforts on a limited number of priorities and mobilize resources to achieve them, development actors misapplied the quantified targets and indicators by using them instead as tools for national planning (Fukuda-Parr, 2014; Fukuda-Parr et al., 2014). This repurposing undermined complex national planning processes and neglected more comprehensive approaches to development and previously agreed-upon international development frameworks that addressed the root causes of poverty (Fukuda-Parr et al., 2014; Unterhalter, 2014; Yamin & Boulanger, 2014). Moreover, the benchmarks were unfair to the poorest countries, which had the greatest distance to go in meeting the global benchmarks, while some middle-income countries had already achieved them (Fukuda-Parr, 2014). Further, the adoption of global goals as national goals without adaptation to context contradicted the principle of national ownership, which calls for national and local authorities to create and take ownership of their own development agendas (Fukuda-Parr, 2014). The unintended influences of the MDGs on national development planning were especially severe in low-income countries that were more reliant on donor funding (Lucci, Khan, & Hoy, 2015; Sarwar, 2015; Seyedsayamdost, 2014).

In contrast, the SDGs have been praised because, unlike the MDGs, they were formulated through a broad global consultative process; they are more interlinked, comprehensive, and universal than the MDGs; and they focus on inclusion, requiring countries to not only achieve set targets, but to also ensure that no one is left behind (Bamberger, Segone, & Tateossian, 2016; Fukuda-Parr, 2016; MacNaughton, 2017; Winkler & Williams, 2017). Like the MDG framework, however, the SDG framework establishes global development benchmarks, which risk shifting attention and resources away from addressing locally identified development priorities and limiting development to meeting just the global minimum standards. While global targets and indicators are useful to compare outcomes across countries, they risk establishing low thresholds for some countries and unrealistically high benchmarks for others, and they tell little about the complexity of processes and outcomes in particular countries (UNICEF, 2012).

Unlike the MDGs, however, the “SDGS are a relatively loose set of goals and targets, enabling governments to adapt them to domestic development agendas in ways that were previously impossible with the more precise, quantifiable and limited MDGs” (Horn & Grugel, 2018, p. 82). One early study suggests that policymakers in middle-income countries are engaging selectively with the SDGs. In a study on SDG implementation in Ecuador, Horn and Grugel (2018, p. 75) theorized that middle-income countries, like Ecuador, are selective in the SDGs they address “in accordance with domestic visions of what development should mean within specific middle-income countries.” The broad nature of the SDGs and the lack of specific instructions on implementation leave room for them to be interpreted in various ways such that policymakers can borrow and adapt them as they deem appropriate in their own contexts. Since interpretations in different contexts differ, outcomes would be expected to differ from one context to another (Horn & Grugel, 2018). The authors point out that the SDGs offer a “set of ideas” that development actors can use to “shape or legitimize domestic institutional arrangements” (Horn & Grugel, 2018, p. 75).

In their study, Horn and Grugel (2018, p. 73) found that implementation of the SDGs in Ecuador is dependent on policymakers’ political preferences, their positioning in the governance structure (in the case of decentralized governance), and “the context-specific challenges they face.” In the case of Ecuador, this selective implementation resulted in a focus on SDG target 10.2—“empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status”—and SDG 11—“make cities and human settlements inclusive, safe, resilient and sustainable” (UNGA, 2015, p. 21). Both objectives “were identified as priority areas in earlier national planning rounds” (Horn & Grugel, 2018, p. 74). As such, the SDGs are selectively leveraged to bolster national priorities, rather than adopted wholesale into national development planning. The researchers attribute this change in influence of the SDGs in comparison to the MDGs in part due to the broader and less quantifiable nature of the SDGs and also Ecuador’s emergence into a middle-income country that is less dependent on donors and therefore more autonomous in governance.

To consider whether the SDGs, like the MDGs, will override local priorities, this study examines the process through which SDG 3— “ensure healthy lives and promote well-being for all at all ages”—is translated into national and county planning processes in two districts in Kenya. Importantly, during the MDG era, Kenya’s context changed with the adoption of a new constitution in 2010 that devolved administrative, fiscal, and political power to county governments (Government of Kenya, 2010, Chapter 11). As a result, most of the responsibilities for ensuring healthy lives have devolved to county governments. In light of the 2010 Constitution, this study considered specifically the implications for the national and county priorities of the requirement to report on the SDG 3 global health goal, targets, and indicators.

Following this introduction, this article looks briefly at the historical development of Kenya’s healthcare law and policy from independence in 1963 to the present, as well as the associated health outcomes. With this background, this article then explains the research methods for the study, details the findings, and discusses the implications of SDG 3 and its targets and indicators on local development priorities in the area of health in Kenya.

Brief History of Health and Healthcare Law in Kenya

Healthcare Law and Policy

Kenya’s effort to ensure healthy lives to its people started immediately following independence. In the first independent government’s development blueprint, the government identified poverty, disease, and illiteracy as the three enemies of the state. It planned to fight these enemies to achieve “social justice, human dignity and economic welfare for all” (Government of Kenya, 1965, p. 1). Despite early efforts to achieve universal health care, in 1989, Kenya, like many developing countries, succumbed to the International Monetary Fund and World Bank structural adjustment programs (SAPs) and introduced user fees in the health sector, which resulted in drastic decline of health services’ utilization (Anangwe, 2008; Pineo, 2019). While children, vulnerable populations, and the poor were exempted from paying user fees, mechanisms to implement the exemptions were inadequate (Chuma & Okungu, 2011). Introduction of user fees, therefore, worsened the situation of vulnerable groups (Anangwe, 2008).

More recently, in 2008, Kenya adopted Vision 2030, which aims to provide “equitable and affordable health care at the highest affordable standard” (Government of Kenya, 2007, p. 133). Further, in 2010, Kenya adopted a new constitution that guarantees everyone “the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care” (Government of Kenya, 2010, Article 43). This language brings into domestic law the international obligation for the right to the highest attainable standard of health set forth in the International Covenant on Economic, Social and Cultural Rights, to which Kenya became a State party in 1972. Under the new constitution, the government also devolved the health function to the 47 county governments, giving people an opportunity to participate in decision-making pertaining to the provision of health services in their localities (Government of Kenya, 2010, Chapter 11). To operationalize the right to health, the government developed Kenya Health Policy 2014–2030, which established structures for provision of healthcare under the devolved system (Government of Kenya, 2014). Subsequently, in 2017, the Parliament enacted the Health Act 2017 to “establish a unified health system, [and] to coordinate the inter-relationship between the national government and county government health systems” to facilitate the equitable realization of the right to health (Government of Kenya, 2017b, p. 420).

Health Outcomes

Kenya is classified as a lower middle-income country by The World Bank (n.d.) with a GNI per capita (PPP) of US$3,120. Life expectancy at birth is now 67 years (The World Bank, n.d.). Kenya is, however, ranked 146/188 on the Human Development Index, just squeezing into the Medium Human Development category (United Nations Development Programme [UNDP], 2016). Although Kenya has long sought to improve healthcare and health outcomes, the results of these efforts have been mixed. It is noteworthy that health outcomes improved during the years following independence, but worsened again in the 1990s. For example, the infant mortality rate and the under-five mortality rate both declined steadily until 1989 and then increased in the 1990s (Kenya National Bureau of Statistics [KNBS], 2014). Also, life expectancy increased steadily until 1989, but then started to decline in the 1990s (KNBS, 2014). The poor health outcomes in the 1990s have been attributed to various factors including: (a) the introduction of SAPs, which resulted in a reduction in the per capita expenditure in health, negatively impacting the quality of health services, (b) the HIV/AIDS pandemic, which further strained an already struggling health system, and (c) drought, which worsened the quality of life especially for people living in poverty (Anangwe, 2008). Since the turn of the millennium, however, there have been significant improvements in infant and child health outcomes as shown in Figure 1.

Since 2009, the maternal mortality ratio has also fallen. Figure 2 shows trends in maternal mortality from 1993 to 2014.

Figure 1.

Source: KNBS (2014).

Figure 2.

Source: KNBS (2014), KNBS (1998).

Makueni and West Pokot Counties Health Outcomes

At the local level, this study examined two counties in Kenya—Makueni and West Pokot. Makueni is categorized as an arid and semi-arid land. According to the Kenya National Bureau of Statistics (KNBS), 60.6 percent of the county’s population live below the poverty line of a dollar a day, which is far above the national average of 42.8 percent (KNBS, 2010). The KNBS economic survey 2017 ranked Makueni County 38 out of 47, making it one of the 10 poorest counties in the country (KNBS, 2017). Further, Makueni’s health indicators are about 10 points below the national average. For example, life expectancy is 57.1 years, 10 points lower than the national average of 67 years. Similarly, the county’s under-five mortality rate is 84 per 1,000, much higher than the national rate of 52 deaths per 1,000; while the infant mortality rate is 45 per 1,000, which is much higher than the national average of 39 per 1,000 (County Government of Makueni, 2016; KNBS, 2014).

West Pokot county is also categorized as an arid and semi-arid land, with 68.7 percent of its population living below the poverty line. The county is also among the 10 poorest counties in Kenya—ranked 40 out of 47 counties (KNBS, 2017). Unlike Makueni, health outcome data are not available for West Pokot County.

Research Design and Methods

This qualitative study examined the implementation of SDG 3 in Kenya to consider the impact of global goals and targets on local development priorities. The main research question was whether the global health goal—SDG 3—is overriding local health priorities in Kenya? To address this question, researchers considered: (a) What is the process of localizing SDG 3 into the national and county planning process? (b) Are there avenues for local participation? (c) Is Kenya continuing to work to achieve its national and local priorities or is it shifting to focus on the achievement of SDG 3 and its targets?

Kenya makes for a remarkable case study for several reasons. First, Kenya was at the center of SDG consultations as a member of the High-Level Panel of Eminent Persons, which advised the UN Secretary-General on the global development framework beyond 2015 (HLP, 2013, p. 67). In addition, Kenya’s Permanent Representative to the UN co-chaired the UN General Assembly Open Working Group on SDGs (Government of Kenya, 2017a). Moreover, the country has already developed an SDG Road Map to guide the implementation of the SDGs (Government of Kenya, 2017a), and Kenya is one of the 43 countries that presented a voluntary national review on its progress toward achieving the SDGs at the High Level Political Forum in 2017, a UN platform for follow up and review of SDG implementation (United Nations Division for Sustainable Development, 2017). Due to Kenya’s active participation in the development of the SDG framework and its commitment to begin immediately on implementation of the SDGs, there is substantial evidence to examine for this early case study.

Further, Kenya is a useful case study as it recently devolved the health function to the county governments, which provides an opportunity to analyze how (if at all) global goals shape the development narrative and influence policy at the local level. Researchers examined policy and planning both at the national level and in two counties, Makueni and West Pokot. These were purposively selected because they have both been recognized as models for positive governance practices, such as enhancing public participation, and therefore, there is evidence of local involvement in health policymaking to examine.

This study was based upon document analysis and interviews with key informants. First, the researchers collected and analyzed the key law, policy and planning documents currently guiding the healthcare sector, including: (a) the Constitution of Kenya 2010, (b) Kenya Health Policy 2014–2030, (c) Vision 2030 Second Medium Term Plan 2013–2017, (d) Makueni County and West Pokot County Integrated Development Plans 2013–2017 and 2018–2022, (e) Roadmap to Sustainable Development Goals (SDGs): Kenya’s Transition Strategy 2016–2018 (Government of Kenya, 2016b), (f) Implementation of the Agenda 2030 for Sustainable Development in Kenya (June 2017), and (g) Health Act 2017. The first four documents were adopted before the SDGs, while the last three documents were developed after the SDGs.

Second, in January 2018, the researchers conducted semi-structured interviews with 17 key informants at the national level and in the two counties, including three National Ministry of Health officials, five county government department of health officials, five national-level civil society organization (CSO) health leaders, and four county-level CSO health leaders. The selection of key informants was based on their central roles in the implementation of the Kenya’s Health Policy 2014–2030 and SDG 3. The interviews were recorded, transcribed, and analyzed using QSR Nvivo 11 software, with coding based on both predetermined and emerging themes. Ethical approval was granted by the University of Massachusetts Boston (#2017208) and a research permit (#NACOSTI/P/17/21821/20670) was granted by the Kenya National Commission for Science, Technology and Innovation.

Findings

Localizing SDG 3 into National and County Planning

The government has made efforts to localize the SDGs in its development agenda both at the national and county levels. This was evidenced by the Kenya’s policy documents—Roadmap to Sustainable Development Goals (Government of Kenya, 2016b), a planning document, and the Implementation of the Agenda 2030 for Sustainable Development in Kenya report (Government of Kenya, 2017a), a voluntary national review report. The Roadmap to Sustainable Development Goals underscores the importance of localizing the SDGs at the national and county levels, noting that “they should not be seen as a one size fits all for responding to the development needs of all countries given the differences in political, economic, and social-demographic dynamics” (Government of Kenya, 2016b, p. 8). This understanding of the uses of the SDGs is demonstrated in Figure 3 from the Roadmap on the process of localizing the SDGs in Kenya (Government of Kenya, 2016b, p. 9).

Figure 3.

Source: Government of Kenya (2016b, p. 9).

Further, both the Roadmap to Sustainable Development Goals (Government of Kenya, 2016b) and the Implementation of the Agenda 2030 for Sustainable Development in Kenya (Government of Kenya, 2017a) voluntary report underscore the alignment between the SDGs and Kenya’s Vision 2030 (Government of Kenya, 2007). For example, the voluntary national review report states: “the Kenya Vision 2030 is well aligned to the global development framework and its implementation is directly linked towards achieving the SDGs” (Government of Kenya, 2017a, p. 1). Indeed, “[t]he timeframe of the Vision coincides with the timeframe for the SDGs” (Government of Kenya, 2017a, p. 1).

Similarly, informants reported that the process of integrating the SDGs into domestic plans was seamless as the SDGs and Kenya’s pre-SDG development blueprint, Kenya Vision 2030, are “in tandem” and their “efforts were synergistic.” One national civil society informant commented,

[I]f you read our Vision 2030 and then you read SDGs, there is a lot of sync. They really speak to each other … So even when SDGs came, Kenya did not struggle to reform a lot of its thinking, because we were in line. (National CSO Actor 5)

Likewise, government health officials consider the SDGs to be in line with the government’s efforts at both the national and county levels. A county government official (12) stated, “[L]argely, there is no conflict between where the SDGs want to go, where the nation wants to go, and where the county wants to go. These are efforts that are synergistic.”

The synergy between the Kenyan health policy and plans and SDG 3 was attributed to inclusive global consultations in developing the SDG framework as well as the loose and broad final SDG framework, which allows countries room to tailor implementation of the SDGs to their own domestic situation. Additionally, according to one CSO actor, during the UN consultations on the SDGs, Kenya influenced the formulation of SDG Target 3.8 to align with Kenya’s development goals. He related that initially SDG 3 did not explicitly state anything about vaccines, however, they knew it was important to have that appear in the SDGs, so that it did not get lost at the county level. And he felt that they were influential in getting Target 3.8 to include “and vaccines for all.”

Kenya is currently developing the Vision 2030 Third Medium Term Plan (MPT III), as well as county-integrated development plans. Key informants reported that they are integrating the SDGs through participatory planning processes at the national and local levels. At the national level, the government brings together different actors including departmental heads, members of civil society, and donors. This process was also documented in Kenya’s Roadmap to Sustainable Development Goals (Government of Kenya, 2016b, p. 8). Similarly, civil society members view the MTP III process as a means to localize the SDGs in the Kenyan context.

Avenues for Public Participation in the Planning and Localization Process

Public engagement in planning processes is a constitutional requirement in Kenya (Government of Kenya, 2010, Article 174), which was rolled out in the County Government Act of 2012, the County Financial Management Act of 2012, and the County Public Participation Guideline of 2016. Most respondents agreed that there were avenues for public participation in the planning and localization processes. In most policy formulation and review processes, the government was the convener. CSO and donor partners worked in task forces, and they also had opportunities to provide feedback online and via email. The Roadmap to Sustainable Development Goals also notes the centrality of mapping stakeholders and engaging the public in the localization process (Government of Kenya, 2016b, p. 6).

Kenya’s Public Participation Guideline lays out the process of meaningfully engaging public in decision-making. A local government official explained that the process starts with sensitizing communities on the government’s broad development agendas, so the public knows the parameters within which they can frame their priorities. Then the consultative meetings start from the village level, identifying and prioritizing community needs (Government of Kenya, 2016a). Another county-level official explained the budgeting process in similar terms. He indicated that they first prepare a draft budget, which is then taken to the community. However, this is just a guide. Then they go from village to village to ask people if this draft shows what they need. If these are not their needs, there is discussion, and the people pick their priorities.

Although public participation structures are not equally developed across all the counties, increased public awareness of the constitutional right to participation has resulted in the public’s demand for more meaningful participation. A national CSO leader explained that, at a recent public forum on the budget, participants refused to provide comments until they had had an opportunity to read and internalize the lengthy documents provided to them. They simply left the forum with the documents. He opined, “That is the kind of empowerment that we require from the public” (National CSO Actor 5).

County governments also invite CSOs to participate in the planning processes, as required by the County Government Act. Some counties, like Makueni, have elaborate public participation structures, while others are works-in-progress. A national CSO leader explained, “in the planning process, the public is usually consulted and even during our efforts as CSO, we encourage the public, through our members, to be part and parcel of this process” (National CSO Actor 5). This participation process discussed by informants correlates with that prescribed in the key documents reviewed (Government of Kenya, 2012, 2013, 2016a).

Local Health Priorities and SDG 3

On the central research question, the evidence indicates that Kenyan health policy and planning has continued to reflect local health priorities rather than defaulting to the health SDG targets and indicators. Most respondents reported that local communities made the final decisions on what is prioritized, after they have been sensitized on the county’s broad development agenda. At the county level, the planning process focuses on local priorities first and foremost, before incorporating the national policies and the SDGs. And local needs determine the local priorities. Integration of the SDGs and national policies comes as a secondary step and only if they align with the local needs and priorities. A local government official explained,

[T]he guiding principle may not be the UN document, the guiding principle is the local situation. But in the process of delivering the local situation, you find that one or two or three aspects fits into the bigger picture of national strategy and the world structure. (County Government Official 8)

Local officials view the ideas for expansion of health services as emerging from local community needs. One local government official explained that when they open a new health facility, it is not because the World Health Organization (WHO) recommends that a facility be located within 5 km. It is because the people say that they are too far away from the closest facility, and then the politicians decide there must be a new facility there. Similarly, the county health budget is based on local needs and so may well exceed global standards.

A county CSO leader affirmed that it is the communities themselves, not the government that decides which projects go forward. He explained,

In this county, we do what is called the bottom-up approach. The priority comes from the citizens. We go from the village level to the sub-ward level, to the sub-county level before coming to a headquarters level. But the process is driven from the citizens; they are the ones who prioritize what is most pressing for them. (County CSO Actor 15)

CSO leaders generally believe that public priorities are meaningfully integrated into county and national policy and planning documents.

The planning process is both bottom-up and top-down as local health needs are collected first and then they are aligned with national policy and the SDGs. The process of developing county health plans starts at the community level. Community health workers work with communities to identify health needs, which are then combined into a facility plan, which might have two or three communities linked to it. Facility plans are then consolidated into sub-county plans and then into county plans. At the national level, a forum composed of the Health Cabinet Secretary and the County Executive Committee for Health (CEC Health) makes national policy decisions. The CEC Health is the link between the county and the national planning processes. It incorporates issues arising from counties, as well as the SDGs and other global agendas. In implementing the policies, counties integrate these national policies and plans with local needs and priorities as part of the planning process that includes input from community health volunteers and community health extension workers. In addition, respondents noted that the health information derived from data routinely collected at the facility level is also used as a basis for decision-making, policy formulation, planning, and resource allocation.

Just as the informants indicated that Kenya’s health policy and planning is based primarily on local priorities, the documents examined also supported this conclusion. For example, the Implementation of the Agenda 2030 for Sustainable Development in Kenya, the voluntary national review report, states that Kenya is implementing the development goals that were prioritized in the Vision 2030 Medium-Term Plans before the adoption of the SDGs (Government of Kenya, 2017a). The report explains,

To start the implementation of the SDGs in Kenya, it was found necessary to establish the extent to which the SDGs converge with Kenya’s own development objectives as set out in the Kenya Vision 2030 and therefore identify which SDGs are relevant to Kenya’s development context. This was done by mapping each of the 17 goals with Vision 2030 within the second Medium Term Plan. The mapping indicates that the Kenya Vision 2030 is well aligned to the global development framework. (Government of Kenya, 2017a, p. 5)

The report also says that “sub national governments are now implementing the relevant SDGs targets at the grass root level hence more targeted interventions and strategies” to fast-track development and reduce regional social and economic inequalities (Government of Kenya, 2017a, p. 13). Relatedly, Annex I of the voluntary national review report presents the “SDG Indicators Framework for Kenya,” which shows that Kenya has chosen to focus on specific SDG indicators that are relevant to the needs of its populations across the 17 goals. For example, the “SDG Indicators Framework for Kenya” shows that Kenya will report on only 3 of the 11 indicators for SDG 6 (water and sanitation) but 13 of the 14 indicators for SDG 5 (gender equality) (Government of Kenya, 2017a, Annex I).

In regard to SDG 3—“Ensure healthy lives and promote well-being for all at all ages”—the voluntary review report states:

The progress on health goals is anchored on the Kenya Health Policy, 2014–2030 and the Kenyan Health Sector Strategic and Investment Plan (KHSSP, July 2014–June 2018) that have six policy objectives and seven strategic objectives which provide the policy framework to progress towards attainment of vision 2030 goal for the health sector. (Government of Kenya, 2017a, p. 23)

The voluntary review report does not cover all SDG 3 targets and indicators. It lists 16 of the 27 SDG 3 indicators as part of the “SDG Indicators Framework for Kenya” (Annex I) and reports data specifically on only 10 indicators in this early review (Annex II). Importantly, all the indicators that are listed in the “SDG Indicators Framework for Kenya” were already in the Kenya Health Policy 2014–2030. Both the evidence from the key informants and the voluntary national review report—the Implementation of the Agenda 2030 for Sustainable Development in Kenya report—indicate that the SDGs have not changed the Kenyan health agenda; rather, Kenya is implementing those SDG 3 targets and indicators that align with its local and national priorities.

On the other hand, health policies, strategies, and plans must align with the SDGs as this is a requirement for donor funding and a substantial amount of health funding, 27 percent of Kenya’s health budget, is from overseas donors (The Word Bank, n.d.). For example, most of the resources to address Malaria, TB, and HIV come from the Global Fund. Similarly, county government officials know that when Kenya is seeking donor funding for maternal healthcare, for example, government planning documents must include maternal healthcare as a priority. If the funders do not find maternal healthcare in the plans, they will not provide the funding. Officials at local and national levels understand that donors will only fund health initiatives that are in sync with the SDGs and also in the national and county plans.

Discussion

Many development experts are in agreement that the MDGs helped rally the international community, governments, and civil society leaders to focus on achieving the limited number of measurable and time-bound goals. While the MDGs had some positive impacts on human development, they have been faulted for being rigid and narrow, promoting vertical approaches to poverty eradication, and focusing only on the global south countries (Fukuda-Parr, 2014; Fukuda-Parr et al., 2014; Langford & Winkler, 2014; Unterhalter, 2014). The nature of the MDGs made them easily confused for national policy planning tools and thereby potentially undercutting and diverting attention from national and local priorities. The SDGs, on the other hand, are comprehensive, interconnected, “global in nature and universally applicable to all countries, whilst accounting for national variations in development and capacity” (World Health Organization [WHO], 2018). That said, the SDGs are still global goals and there is concern that, like the MDGs, they might override national and local agenda.

Horn and Grugel (2018) observe that the SDGs are open to interpretations to fit national and local specific needs and should be seen as an adaptable tool for global development. Their study in Ecuador demonstrated that middle-income countries might be using the SDGs selectively, choosing the ones that are relevant for them (Horn & Grugel, 2018). Although Kenya is a lower middle-income country, we found that, like Ecuador, it engages with the SDGs selectively “with an emphasis on those goals and targets which are considered of domestic importance” (Horn & Grugel, 2018 p. 73). That said, unlike Ecuador, Kenya engages with the SDGs framework more extensively, which may be because the SDGs align so closely with Kenya’s development plan Vision 2030 (Government of Kenya, 2007).

Both the informant interviews and policy documents reviewed evidenced that, while the SDGs and other global goals inform national and local development planning, they have not dictated or overridden the national and local policy priorities. Kenya acknowledges that the SDGs “should not be seen as a one-size fits all for responding to the development needs of all countries” therefore, each country should “localize the SDGs at the national and/or sub-national levels to fit the existing development contexts of these areas” (Government of Kenya, 2016b, p. 8). Kenya’s unique engagement with the SDGs is further demonstrated in what Kenya chose to report on in its voluntary national review report. As noted in the findings on SDG 3, Kenya chose to report not only on some SDG targets and indicators but also on all its health objectives in the Kenya Health Policy 2014–2030 (Government of Kenya, 2014) and Kenya Vision 2030 (Government of Kenya, 2007).

Kenya has a comprehensive robust development plan—Kenya Vision 2030—that was developed in 2007 and is in sync with the SDGs, as is Kenya’s health policy, which is based on Kenya Vision 2030. Like the SDGs, Kenya Vision 2030 is broad and counties make individual decisions on what areas of Kenya Vision 2030 they will implement, depending on their population’s needs. The similarities between Kenya Vision 2030 and the SDGs may have resulted from Kenya’s extensive participation in the SDG formulation process, which saw many of Kenya’s priorities (and those of other countries similar to Kenya) included, as noted by one of the informants. While the national and local development plans and policies may be similar to the SDGs, they are based on locally identified needs and not on the SDGs and other global goals. For example, informants in both Makueni and West Pokot counties reported that the expansion of the healthcare services emerged from the local community needs even though they matched the WHO standards. For both counties, we found that the local needs determine the local priorities. In many instances, those needs matched with the national and global goals.

After the community goals are identified, county technical teams may then identify which national and global goals align with the identified local goals. For example, in Makueni County, as reported by one of the key informants, women complained of walking long distances to access maternal healthcare. Although skilled maternal healthcare services were free, many women delivered at home under the care of untrained traditional birth attendants and in unsanitary conditions. This kept maternal and infant mortality high. In an effort to relieve women of the burden of walking long distances to reach skilled maternal services, the county planned “for accelerated construction and rehabilitation of health facilities” (County Government of Makueni, 2013). While this aligns with SDG target 3.1, it was first prioritized as a need at the local level. This is corroborated by the observations of Horn and Grugel (2018, p. 14) in Ecuador, that rather than determining development priorities, the SDGs legitimize “development goals and policies that have already been decided on.”

Finally, studies show that, during the MDG era, low-income countries that were dependent on donor aid were more likely to use the MDGs as a planning framework to ensure that they were compliant with the donor conditions (Sarwar, 2015). Seyedsayamdost (2014, p. 27) found that countries with “higher reliance on ODA, and lower income were correlated with higher proclivity of national plans to be aligned with the MDGs.” Kenya’s medium-term plans, in the early stages of implementation of Kenya Vision 2030, show that Kenya used the MDGs and other global development frameworks, such as Education For All and the Declaration of Alma-Ata on Primary Health Care, as tools for its development plans (Government of Kenya, 2008, 2013).

Moving on to this SDGs era in the context of devolution in Kenya, this study found that now local and national priorities drive development planning. Because the SDGs are broad, they create room for local and national priorities without the need to narrow down so as to adhere to specific donor conditions. This widened playing field makes it easier for the local and the national government to find donor funding that matches their needs, which is more likely to suit both ends. Horn and Gruel (2018, p. 82) observe that the broad nature of the SDGs leaves “patterns and practices of engagement open to state elites to decide.” In both the counties studied in Kenya, the government and CSO leaders pointed out that when the local people identify their needs through public participation, the technical teams align those needs with the national and other global benchmarks for reporting and attracting donor funding. As key informants noted, health policies and plans must align with SDGs in order to attract donor funding. For example, in both counties, the officials reported that technical staff aligned locally identified health needs with the WHO’s six pillars of health system strengthening. In the end, local priorities prevail and can usually be framed in terms of the newer, broader and looser national and international frameworks, allowing for local ownership of health policy and planning.

Conclusion

The adoption of the 2030 Agenda for Sustainable Development in 2015, including the 17 SDGs and 169 targets, is a reflection of the rise in global goal setting that continues to guide and shape international development policy. Like the MDGs implemented from 2001 to 2015, the SDGs are setting the national and local agendas on what is prioritized, funded, and measured. By so doing, they shape narratives and influence policy and planning priorities. This study examined the process through which SDG 3—ensure healthy lives—is translated into national- and county-level policy, planning, and budgeting processes in Kenya, with the aim to learn if global goals—in this case SDG 3 targets and indicators—override local priorities.

This study found that Kenya has made efforts to localize SDG 3 targets in its development agenda at the national and county levels; however, local and national priorities drive development planning. The processes of integrating the SDGs are both bottom-up and top-down, as local needs are collected first and then they are aligned with national health policy and SDG 3. Through public participatory approaches, counties pay attention to local priorities first and foremost, before incorporating the national policies and SDG 3 targets into planning and programming.

Our findings on Kenya’s engagement with the SDGs are consistent with Horn and Grugel (2018, p. 82) findings in Ecuador that domestic needs determine how “national and local governments choose to engage with … global goals and international partners that match and reinforce their own interests and practices.” While the local-level health policy and programming appear to be in sync with the SDGs, which may be because the SDGs cover so much—17 goals and 169 targets—Kenya—at least in these two districts—does not use the SDGs as a planning framework. Rather, it uses the SDGs and other global frameworks to legitimize local and national priorities and to report development progress to global partners and forum.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors wish to thank the Office of Global Programs at the University of Massachusetts Boston for providing partial funding for this study.

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