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Health policy options that focus on efforts to maximize the positive and minimize the negative impact of decentralized health system governance

June 22, 2022

Yohannes Mekuria
  Department of Medicine, Adama General Hospital and Medical College


Decentralization is the transfer of authority or the distribution of public planning, management, and decision-making from the national to sub-national levels(1).

The concept “decentralization” refers to a wide range of power transfer structures and accountability mechanisms. Policies range from transferring limited powers to lower management levels within current health management structures and financial methods to massive sectoral reform attempts that reorganize even the most basic services(2–4).

Decentralization is the process of reorganizing power so that institutions of government at the national, regional, and local levels share responsibility under the solidarity principle, improving the overall effectiveness and quality of the governance systems while enhancing the power and capabilities of sub-national levels(5,6).

Decentralization in the Health Sector

Decentralization is a key concept in health system development. To attain “Health for all” and to advance primary healthcare, decentralization of health system structure and management is a critical issue for many nations(7,8).

Decentralization in the health care system refers to the formal transfer of authority and responsibility to decide on the management, production, distribution, and/or financing of health services, typically from a smaller to a larger number of actors who are geographically or organizationally distinct(2,6,9).

In actuality, decentralization of the health system can take many different forms, depending on the organizational style of the national health system as well as the general political and administrative structures and goals of the government. Decentralization is currently being encouraged in many nations as a means of enhancing the performance and results of national health care systems as part of reforms in the health care delivery system(7,10,11).


Pillars of decentralization

Deconcentration (the mildest form of decentralization): is the transfer of some administrative duty and power from central government offices to the regional offices of central government ministries. Comparable to regional, provincial or local governance(1,10).

Devolution (the highest form of decentralization): whereby central government entities cede power, responsibility, and resources to local governments. When it comes to enhancing local responsiveness to health planning and cross-sectoral integration, this type of decentralization has the most promising advantages. These days, most nations, including Ethiopia, employ decentralization of this kind(1,7).

Delegation: delegating duties to regional or local groups independent of the central government, such as arm’s length organizations, while maintaining indirect control of the central government. On behalf of the federal government, non-governmental organizations normally carry out specific service obligations in the health sector (such as the implementation of primary health care campaigns)(4,8).

Privatization: is occasionally brought up as a method of decentralization (in the health sector). It entails the transfer of administrative duties from the government to nonprofit organizations, for-profit businesses, or volunteer associations(4,7).

Impacts of Decentralization

Decentralization is viewed as the most significant factor in raising efficiency, promoting equity, and addressing local health needs and situations. Decentralization offers many benefits, even though it is not the answer to every problem. Some of the positive impacts of decentralized health system governance are(3,6,12):

Some of the positive impacts of decentralized health system governance include: needs in the community are better identified and met participation, empowerment, and decision-making in the community are all quick, improved healthcare program implementation, and a more logical and unified health care system that accommodates to local interests, local units learn the abilities needed to tackle difficulties.

Ownership development in local units and functions improves; increased access, utilization, and accountability, and inequalities between rural and urban areas are reduced. Control, supervision, and coordination that are effective and greater integration of the work of various governmental and private entities, as well as in an emergency, immediate response and action are in place

Decentralization is a delicate political topic since it involves the distribution of authority and the allotment of resources. Certain adverse impacts of decentralization that must be considered are(5,11,13):

  • It increases the administrative cost
  • It may weaken the ministry ofhealth
  • It can create inequity between localgovernments
  • It may lead to a coordinationproblem
  • Maintaining global standards is
  • Extra infrastructure cost is
  • Complexity in the coordination of decentralized
  • It may lead to an absence of uniformity at the organizationallevel



Health policy options to maximize the positive and minimize the negative impacts of decentralized health system governance

Different countries have different decentralized health systems, and they often vary over time as governments change and institutional and human capability rises(3). Nevertheless, the following are some health policy strategies to maximize the advantageous effects and reduce the unfavorable ones of decentralized health system governance:

Access to Information and Communication

Increasing the community’s access to health information, improving literacy and awareness levels, and appointing service boards, may help to enhance the community’s trust in health services. To make well-informed and meaningful decisions, local communities need information on the prices of services, the available delivery methods, and the resources.

There must be binding and credible mechanisms to allow communities to express preferences so that incentives exist for community participation. Several studies have found that having access to health information increases the use of mother and child health services and lowers newborn, under-five, and maternal death rates. Communities must have access to information about public sector performance to respond and hold officials and politicians accountable.

Empower Local Participation and Decision making

Local agents are frequently regarded as ‘black boxes,’ with resources handed to them and regulations imposed, but it is unclear what factors affect their decisions. Investing in select case studies of local agents would be extremely beneficial in improving the processes through which governmental principals attempt to steer local agents through sanctions, incentives, and investments in popular engagement.

It would be beneficial if healthcare reforms included local communities and non-governmental actors in bottom-up planning, targeting, and program preparation.

Finance and Health Expenditures

We must have more detailed information on what precisely local agents are doing with health resources and a consistent and routine reporting system for finance should be in place.

Analyze how local governments finance, health costs, whether through their resources, transfers from the federal government, or shared revenues and identify areas where local budgets may require supplementation. Local governments may have the little revenue-generating capacity and hence will continue to rely on intergovernmental transfers from the federal government. Intergovernmental transfers should be calculated openly and honestly, ideally via a clear, concise, and verifiable formula.

Capacity Building

Changes in the duties and responsibilities of various actors in the health sector, notably local government health officials, should be followed with training and capacity-building strategies. Train government health care personnel and civil servants in decentralized planning and management abilities, as well as whole-system stewardship at the central level.

Capacity building at all levels is critical for implementing the various frameworks required for efficient and effective decentralization.

A clear line of Accountability Development

Clear lines of authority should be balanced with clear mechanisms of accountability of legislative and judicial systems, financial management systems, sanctions, codes of conduct, standards of care, electoral procedures, market forces, and enforcement organizations.

Involve civil society in the oversight of service delivery quality, accessibility, and affordability. This is especially true for the health sector, which is a public benefit and a vital government function to society. Transparency and accountability in local government can improve healthcare quality.


Quality Improvement

Evidence from Latin American countries undergoing decentralization processes suggests that enhancing health care quality would require more than simply shifting assets and personnel to municipal administrations.

It may necessitate more fundamental changes in the public sector’s role, such as an expanded involvement of the private sector in the supply (rather than financing) of health care and a shift in the government’s focus on finance from inputs to outputs.

Assurance of Equity or Allocative efficiency

Careful resource allocation and distribution based on local needs, allowing local organizations to better satisfy the needs of specific populations, and provision of resources to marginalized regions and groups

There should be better matching of public services to local preferences and improved patient responsiveness.

Authority of Central Government (Ministry of Health)

While decentralization generally implies a reduced role for the central government, it may end up weakening the ministry of health in service delivery; certain functions are likely to be best carried out at the central level – research and dissemination of research findings, epidemic control, national public goods, health information, standards, regulations, and accreditation. Decentralization still necessitates strong central monitoring and enforcement capacity for regulations and standards.

Assess Impact of Decentralization

Long-term evaluation of the influence of decentralization on health status outcomes is critical. To monitor and assess the practical aspects of the decentralization process, research institutes should be involved. Systematic quantitative assessments of factors for efficiency, quality, equity, and financial soundness, in particular, are required.


Decentralization does not ensure better outcomes for the health system or a more efficient health sector. The effectiveness of decentralization processes is influenced by a variety of factors, including local managerial and technical capability, accountability systems, transparent and clear legal frameworks that outline the division of responsibilities, and enough funding to carry out mandates and address local priorities. Authority and accountability must be balanced with the necessary capacities, skills, and information flows for decentralization to be successful.



  1. Linda E. Decentralization , deconcentration and devolution : what do they mean ? 1. 2004;(April):27–30.
  2. Saltman RB, Bankauskaite V, Vrangbaek K. D e c e n t r a l i z a t i o n in h e a l t h c a r e.
  3. Hutchinson PL, Lafond AK. Monitoring and Evaluation of Decentralization Reforms in Developing Country Health Sectors. 2004;
  5. Panda B, Thakur HP. Decentralization and health system performance – a focused review of dimensions , difficulties , and derivatives in. BMC Health Serv Res [Internet]. 2016;16(Suppl 6):1–14. Available from: http://dx.doi.org/10.1186/s12913-016-1784-9
  6. Strategic I, Conference M, Eren E. Decentralization in health services and its impacts : SWOT Analysis of Current Applications in Turkey. 2013;99:711–8.
  7. Tidemand P. DRAFT NOTE ON Health Sector Decentralisation. 2010;(November).
  8. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana , Zambia , Uganda and the Philippines : a comparative analysis of decision space. 2002;17(1):14–31.
  9. Development EF, Development NF, Development IF, Development CF, Development A. Effective Management of Decentralized Health Systems. 2012;(November).
  10. Tolera H, Gebre-egziabher T, Kloos H. Public Health Service Delivery in a Decentralized System : Public Health Service Delivery in a Decentralized. 2019;19(2).
  11. Makokha RO. Does Decentralization Improve Provision of Health Services ? Evidence from Kisumu and Makueni Counties in Kenya. 2017;1(1710748):1–63.
  12. Human Resources for Health Decentralization ’ s impact on the health workforce : Perspectives of managers , workers and national leaders. 2004;11:1–11.
  13. Tsofa B, Molyneux S, Gilson L, Goodman C. How does decentralisation affect health sector planning and financial management ? a case study of early effects of devolution in Kilifi County , Kenya. 2017;1–12.

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