Challenges with decentralisation in practice

If you have experienced a health system caught in the ‘decentralisation pendulum’, or seen the effects of disagreements between national and subnational health system levels over decision space and accountability, you will know first hand that these can greatly reduce the effectiveness and efficiency of the health system, and demoralise the health workforce. While there is great potential to strengthen the health system by changing the decision space of subnational health system levels, these changes must be done carefully, be well resourced, and consider ways to prevent or mitigate the unintended consequences of such a realignment of power.

While decentralisation approaches often focus on increasing decision space at ‘higher’ subnational levels (e.g. province, district, state, county) they may also increase accountability and responsiveness at the level of individual communities, and it is this important part of the health system which we will now explore. As we do so, reflect on how the decision space at these ‘district’ type levels will impact on how a community health system functions.