Dr Gregory Ganda CEC Health kisumu county Chair, CECs caucus at the Council of Governors/HANDOUT
During a recent visit to one of Kenya’s County Referral and Teaching Hospitals as part of the Kenya Pediatric Scholarship Award Committee, a question arose during a courtesy call on whether the facility should eventually transition into a national hospital.
The reaction in the room was immediate. Not excitement about nationalization, but anxiety about disruption.
Senior county officials spoke candidly about their fears that such a transition could weaken county service delivery and leave them carrying the social burden of healthcare without the corresponding infrastructure and system capacity needed to manage it. That is increasingly the reality confronting counties operating major referral institutions.
Counties operating large referral hospitals increasingly appear caught in a dilemma. Such facilities are enormously expensive to sustain. Yet many county leaders fear that transition to national status could create disruptions whose consequences may ultimately outweigh the financial relief associated with national takeover.
Listening to those concerns, I was reminded of the experience surrounding Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH).
Indeed, similar anxieties existed during discussions surrounding the transition of JOOTRH from a county referral facility into a national teaching and referral hospital, where significant political negotiation and consensus-building were required before the eventual decision was reached.
The transition was historic. It represented ambition, political goodwill, and a shared belief that the people of the Lake Region deserved a stronger, well-financed public tertiary institution capable of advanced training, research, and specialized care.
What is often forgotten, however, is that this transition was not imposed on the county. It was a deliberate county decision following convergence between political leadership, technical experts, universities, specialists, the County Assembly, and the people of Kisumu.
The expectation, therefore, was that this would be an all-inclusive and participatory handover.
Instead, to many within the county system, what unfolded increasingly felt more like an administrative takeover. This distinction matters not for purposes of blame, but because Kenya is likely to witness similar transitions in future, and the lessons emerging from JOOTRH may help prevent similar challenges elsewhere.
More importantly, the disruptions surrounding the transition were not merely administrative or political. The consequences soon became visible within service delivery.
At one point after transition, a policy emerged requiring patients seeking care at JOOTRH to possess active social health insurance registration before accessing services. While the intention may have been financial sustainability, the implementation was abrupt and ultimately shifted pressure onto already strained county facilities.
Patients arrived unable to access care.
Ambulance teams and referring clinicians found themselves stranded with patients they could not hand over because they lacked active cover, while vulnerable populations suddenly found themselves excluded from services.
Another challenge emerged around patient access procedures. Following transition, a registration fee of Sh200 was reportedly introduced into the HMIS system in alignment with practices within other national referral hospitals.
However, the implementation was abrupt and introduced without adequate transition planning or communication within the wider referral ecosystem. In some cases, nurses and frontline health workers referring vulnerable patients reportedly found themselves personally paying the fee to allow their patients to access admission services.
Many were redirected to, or instead opted to seek care at, Kisumu County Referral Hospital.
The result was an immediate and unplanned surge in patient volumes at the Kisumu County Refferal hospital , which inherited additional pressure without corresponding financing, staffing, or infrastructure support.
As referral patterns shifted abruptly, other county facilities increasingly found themselves managing higher patient volumes and more complex cases without proportional expansion of infrastructure or specialist support.
For many health workers in the region, it was striking to witness a reversal of the traditional referral flow. As JOOTRH became increasingly difficult to access and pressure mounted within Kisumu County Referral Hospital, patients who would ordinarily have remained within the county referral system increasingly found themselves being referred to facilities in neighboring counties because of capacity and access constraints.
The effects extended beyond hospitals into community health systems.
Community Health Assistants administratively attached to JOOTRH transitioned into the new national structure, leaving community units suddenly without supervision.
Human resource planning similarly exposed important gaps. Several specialists sponsored by Kisumu County for speciality and subspecialty training had originally been intended for deployment within the tertiary infrastructure anchored around JOOTRH. Yet because workforce transition planning was inadequately coordinated, many returned into lower-level county facilities despite possessing expertise more suited for a national referral institution.
The asset transfer process also illustrated broader coordination challenges.
One of the most contentious examples involved Victoria Sub-County Hospital. While there had been an understanding that JOOTRH would continue utilizing the facility temporarily during transition, the supporting arrangements were reportedly not adequately anchored within the final framework.
This omission later created uncertainty regarding the facility’s status, with differing interpretations emerging between the hospital and the County Government about its place within the new institutional arrangement. Yet an agreement signed between the Governor and the leadership of JOOTRH had clearly documented the temporary utilization arrangement. In addition, Victoria Sub-County Hospital had already been gazetted as an independent county health facility separate from JOOTRH long before the transition process began.
The result was an unfortunate situation in which a facility that had neither been earmarked for handover nor formally transferred by the county increasingly came to be operationally treated as though it had become part of the national institution.
The oncology program similarly faced risks of disruption. It required intervention from the Office of the Governor, Office of the Principal Secretary, and the County Executive Committee Member, outside the formal transition structures, to ensure continuity of cancer centre development processes and programmes.
Perhaps most significantly, the county government was never formally presented with a comprehensive final transition report, nor was there a definitive ceremonial or administrative handover of the institution and its documentation from county to national government.
That absence still matters symbolically and institutionally.
How then did a transition built on goodwill and shared ambition produce such tensions?
Although the county government was represented within transition structures, many within the county health system felt that broader county leadership and the wider health sector ecosystem were insufficiently engaged during critical decision-making processes.
The transition also appeared to expose the lingering mistrust that often exists between national and county governments.
The county had proposed an oversight structure consisting of representatives from the County Executive, County Assembly, community, and Ministry of Health to provide political and policy guidance throughout the process. That structure was never operationalized in the manner originally envisaged.
The absence of such a mechanism reduced opportunities for wider consultation and ongoing political oversight beyond the technical transition structures.
One of the major issues raised during public participation involved governance representation after nationalization. Kisumu County had proposed retaining institutional representation within governance structures even after transition. This was never about political control. It reflected a simple health systems reality: even as a national referral hospital, JOOTRH would continue operating within Kisumu County’s broader health ecosystem. Its referral pathways, staffing decisions, and patient access policies would inevitably affect county hospitals and primary healthcare facilities.
Encouragingly, there are already signs that some of these gaps are being recognized. The decision by His Excellency President William Samoei Ruto to support the strengthening and development of Kisumu County Referral Hospital following requests made by Kisumu leadership during his visit to the region was an important and timely intervention. That support reflects recognition that the successful transition requires parallel strengthening of county systems that continue carrying a substantial share of the healthcare burden.
Ultimately, the lessons emerging from the JOOTRH experience should not discourage future collaborations between counties and the national government. Rather, they should help Kenya design more coordinated, transparent, and health-system-sensitive transition frameworks in future.
Today, JOOTRH stands as one of the region’s most important referral, teaching, and research institutions, and its transition remains a landmark moment in the evolution of specialized healthcare in western Kenya.
But as Kenya continues debating the future of tertiary healthcare and county-national partnerships, one lesson is increasingly clear: A hospital may be nationalised through law, but successful transition requires trust, planning, coordination, and genuine partnership with the health system it leaves behind.
