Table 2 Forms of power and their expression in Kenya

Power over

Power is viewed as ‘zero-sum’ where the more power one person has than the less the other has. Having power involved taking it from someone else and then using it to dominate and prevent others from gaining it.

Power over was typically exerted by state actors at the top of the institutional hierarchy within the county, by the governor, the county executive committee member for health and the members of county assembly, with some county executive committee members for health adopting an authoritarian approach, limiting sharing of knowledge and information.

Power over was demonstrated in interactions between state actors (members of county assembly and governor and county executive committee members).

Power over was demonstrated by state actors (e.g. county executive committee member for health) and other providers, with some technical decision makers feeling unable to challenge decisions which may not be suitable.

“Well just to be frank with you sometimes it is not easy for us to say no okay [to politicians]… my seniors here are politically appointed so at any time now they can change in the cabinet level of the county… sometimes is difficult for us to stand up and change this.” County Health Respondent IDI, Male45

Patronage norms led to misuse of power in some settings, with resources channelled to voters/ citizens from similar tribe as the more ‘powerful’ leaders.

Community members were not informed of all the choices available to them, or of the benefits and disadvantages of those choices limited their access to knowledge.

Power with

Based on mutual support and collaboration to build collective strength. It helps build bridges and promote more equitable relations

Mechanisms for power with have been introduced according to the Constitution, e.g. public participation meetings. However, failure to address norms which limit power within e.g. patriarchal norms, have led to limited active participation from many citizens, leaving these forums open to elite capture and limiting opportunities for power with.

Overall, most county level state actors have made limited attempts to share priority-setting power with actors at other levels.

“The issue of health care in my view is no more in the hands of the health care providers, but rather in the [hands of] policy makers.” County Health Respondent IDI, Male24

Exceptions include: one county where county level actors have plans for broader decentralisation to lower levels; in another county the county executive committee sought to reduce the power imbalance by sharing knowledge with actors from community level to county level, finding common ground and understanding among the interests of actors from all levels.

Power to act

Refers to the potential of every person to shape their life.

Outside of county level technical and political actors, other potential decision makers such as health workers, sub-county actors and community members appear to have limited power to act, with limited meaningful participation.

“So in a way we are feeling there is a gap. It [decision-making] is happening at the county level but they are not involving the most important people... We are not involved in decision-making nowadays in the county government.” CHEW IDI, Male01

Power within

Relates to a person’s sense of self-worth, values and self-knowledge, having the capacity to have hope and affirming dignity and fulfilment.

Power within relates closely with how forces and structures, such as patriarchy and patronage remain unaddressed and as a consequence there has been limited scope for empowerment and increasing citizens power within to enable them to fully engage with priority-setting (see power with above).

“…members of county assembly are not very comfortable with the system [public participation] because they believe it is empowering the citizen so much that they are losing the political grip and that has been the issue across the country.” National Respondent IDI, Male10