title: Navigating institutional complexity in the health sector: lessons from tobacco control in Kenya.
abstract: BACKGROUND
  This research examines the institutional dynamics of tobacco control following the establishment of Kenya's 2007 landmark tobacco control legislation. Our analysis focuses specifically on coordination challenges within the health sector.
  
  
  METHODS
  We conducted semi-structured interviews with key informants (n = 17) involved in tobacco regulation and control in Kenya. We recruited participants from different offices and sectors of government and non-governmental organizations.
  
  
  RESULTS
  We find that the main challenges toward successful implementation of tobacco control are a lack of coordination and clarity of mandate of the principal institutions involved in tobacco control efforts. In a related development, the passage of a new constitution in 2010 created structural changes that have affected the successful implementation of the country's tobacco control legislation.
  
  
  CONCLUSIONS
  We discuss how proponents of tobacco control navigated these two overarching institutional challenges. These findings point to the institutional factors that influence policy implementation extending beyond the traditional focus on the dynamic between government and the tobacco industry. These findings specifically point to the intragovernmental challenges that bear on policy implementation. The findings suggest that for effective implementation of tobacco control legislation and regulation, there is need for increased cooperation among institutions charged with tobacco control, particularly within or involving the Ministry of Health. Decisive leadership was also widely presented as a component of successful institutional reform.
  
  
  CONCLUSIONS
  This study points to the importance of coordinating policy development and implementation across levels of government and the need for leadership and clear mandates to guide cooperation within the health sector. The Kenyan experience offers useful lessons in the pitfalls of institutional incoherence, but more importantly, the value of investing in and then promoting well-functioning institutions.
authors.affiliation: Faculty of Medicine, School of Physical and Occupational Therapy, McGill University, Hosmer House, 3630 Promenade Sir William Osler, Montreal, QC H3G 1Y5, Canada raphael.lencucha@mcgill.ca.
authors.forename: Raphael
authors.initials: R
authors.lastname: Lencucha
authors.affiliation: International Institute for Legislative Affairs, House No. 3, Mariposa Apartments (No. 23), Ngong Rd, Opp Jamhuri Telephone Exchange (Posta), P.O. Box 1542-00200, Nairobi, Kenya.
authors.forename: Peter
authors.initials: P
authors.lastname: Magati
authors.affiliation: Economic and Health Policy Research, American Cancer Society, Atlanta, GA 30303, USA and Political Science, Marquette University, Milwaukee, WI, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Drope
mesh_terms: D003299:Cooperative Behavior; D003906:Developing Countries; D006076:Government; D006291:Health Policy / Q000331:legislation & jurisprudence*; D006801:Humans; D007407:Interviews as Topic; D007630:Kenya; D011050:Policy Making; D019460:Tobacco Industry / Q000331:legislation & jurisprudence / Q000458:organization & administration*
keywords: Government; health policy; institutions; policy implementation; tobacco