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County leadership were ill prepared in human resources for health management capacity, leadership structures, and organizational arrangements when the Government of Kenya devolved health service delivery including management of the health workforce to the 47 counties. This resulted in acute shortages and imbalanced health worker distribution with no proper administrative systems – all leading to recurring health worker industrial unrest, and disrupted service delivery. This technical brief shares approaches, results, adaptive lessons and recommendations from IntraHealth International efforts to strengthen health workforce leadership, management and governance in the public health sector.