title: Crises and Resilience at the Frontline-Public Health Facility Managers under Devolution in a Sub-County on the Kenyan Coast.
abstract: BACKGROUND
  Public primary health care (PHC) facilities are for many individuals the first point of contact with the formal health care system. These facilities are managed by professional nurses or clinical officers who are recognised to play a key role in implementing health sector reforms and facilitating initiatives aimed at strengthening community involvement. Little in-depth research exists about the dimensions and challenges of these managers' jobs, or on the impact of decentralisation on their roles and responsibilities. In this paper, we describe the roles and responsibilities of PHC managers-or 'in-charges' in Kenya, and their challenges and coping strategies, under accelerated devolution.
  
  
  METHODS
  The data presented in this paper is part of a wider set of activities aimed at understanding governance changes under devolution in Kenya, under the umbrella of a 'learning site'. A learning site is a long term process of collaboration between health managers and researchers deciding together on key health system questions and interventions. Data were collected through seven formal in depth interviews and observations at four PHC facilities as well as eight in depth interviews and informal interactions with sub-county managers from June 2013 to July 2014. Drawing on the Aragon framework of organisation capacity we discuss the multiple accountabilities, daily routines, challenges and coping strategies among PHC facility managers.
  
  
  RESULTS
  PHC in-charges perform complex and diverse roles in a difficult environment with relatively little formal preparation. Their key concerns are lack of job clarity and preparedness, the difficulty of balancing multidirectional accountability responsibilities amidst significant resource shortages, and remuneration anxieties. We show that day-to-day management in an environment of resource constraints and uncertainty requires PHC in-charges who are resilient, reflective, and continuously able to learn and adapt. We highlight the importance of leadership development including the building of critical soft skills such as relationship building.
authors.affiliation: Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box 230-80108, Kilifi, Kenya.
authors.forename: Mary
authors.initials: M
authors.lastname: Nyikuri
authors.affiliation: Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box 230-80108, Kilifi, Kenya.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Tsofa
authors.affiliation: Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box 230-80108, Kilifi, Kenya.|Health Economics Unit, University of Cape Town, Observatory 7975, Cape Town, South Africa.
authors.forename: Edwine
authors.initials: E
authors.lastname: Barasa
authors.affiliation: Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box 230-80108, Kilifi, Kenya.
authors.forename: Philip
authors.initials: P
authors.lastname: Okoth
authors.affiliation: Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), P.O. Box 230-80108, Kilifi, Kenya.|The Ethox Centre, Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom.|The Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom.
authors.forename: Sassy
authors.initials: S
authors.lastname: Molyneux
mesh_terms: D003151:Community Health Centers; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D007630:Kenya; D008297:Male; D011216:Practice Management, Medical