Decentralisation and Health Services Delivery in 4 Districts in Tanzania: How and Why Does the Use of Decision Space Vary Across Districts?

Document Type : Original Article


1 Department of History, Political Science & Development Studies, Dar es Salaam University College of Education, Dar es Salaam, Tanzania

2 Institute of Development Studies, University of Dar es Salaam, Dar es Salaam, Tanzania


Decentralisation in the health sector has been promoted in low- and middle-income countries (LMICs) for many years. Inherently, decentralisation grants decision-making space to local level authorities over different functions such as: finance, human resources, service organization, and governance. However, there is paucity of studies which have assessed the actual use of decision-making space by local government officials within the decentralised health system. The objective of this study was to analyse the exercise of decision space across four districts in Tanzania and explore why variations exist amongst them.
The study was guided by the decision space framework and relied on interviews and documentary reviews. Interviews were conducted with the national, regional and district level officials; and data were analysed using thematic approach.
Decentralisation has provided moderate decision space on the Community Health Fund (CHF), accounting for supplies of medicine, motivation of health workers, additional management techniques and rewarding the formally established health committees as a more effective means of community participation and management. While some districts innovated within a moderate range of choice, others were unaware of the range of choices they could utilise. Leadership skills of key district health managers and local government officials as well as horizontal relationships at the district and local levels were the key factors that accounted for the variations in the use of the decision space across districts.
This study concludes that more horizontal sharing of innovations among districts may contribute to more effective service delivery in the districts that did not have active leadership. Additionally, the innovations applied by the best performing districts should be incorporated in the national guidelines. Furthermore, targeted capacity building activities for the district health managers may improve decision-making abilities and in turn improve health system performance.


Main Subjects

  1. Rondinelli DA. Government Decentralization in Comparative Perspective:Theory and Practice in Developing Countries. ‎Int Rev Adm Sci. 1981;47(2):133-145. doi:10.1177/002085238004700205
  2. Mills A, Vaughan JP, Smith DL, Tabibzadeh I. Health system decentralization: concepts, issues and country experience. Geneva: World Health Organization; 1990.
  3. Peckham S, Exworthy M, Greener I, Powell M. Decentralizing Health Services: More Local Accountability or Just More Central Control? Public Money & Management. 2005;25(4):221-228. doi:10.1080/09540962.2005.10600097
  4. Mills A. Decentralization and accountability in the health sector from an international perspective: What are the choices? Public Adm Dev. 1994;14(3):281-292. doi:10.1002/pad.4230140305
  5. Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med. 1998;47(10):1513-1527.
  6. Bossert T, Chitah MB, Bowser D. Decentralization in Zambia: resource allocation and district performance. Health Policy Plan. 2003;18(4):357-369.
  7. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan. 2002;17(1):14-31.
  8. Bossert TJ, Bowser DM, Amenyah JK. Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala. Health Policy Plan. 2007;22(2):73-82. doi:10.1093/heapol/czl041
  9. Bossert TJ, Mitchell AD, Mazumdar S, Belli P. Decentralization of health in the Indian state of West Bengal: analysis of decision space, institutional capacities and accountability. Washington, DC: World Bank; 2010.
  10. Marchal B, Denerville E, Dedzo M, De Brouwere V, Kegels G. Decentralisation, decision spaces and human resource management at hospital level: High commitment human resource management approaches used by the management team of Ghana’s Cape Coast Central Regional Hospital. Antwerp: Institute of Tropical Medicine; 2005.
  11. Bossert TJ. Empirical Studies of an Approach to Decentralization: “Decision Space” in Decentralized Health Systems. In: Faguet JP, Paschi C, eds. Is Decentralization Good for Development? Perspectives from Academics and Policy Makers. Oxford: Oxford University Press; 2015.
  12. Bossert T, Cakir V, Bowser D, Mitchell A. Morocco Decentralisation Study: Summary of Preliminary Findings. Harvard School of Public Health and John Snow Incorporated; 2003.
  13. Sumah AM, Baatiema L, Abimbola S. The impacts of decentralisation on health-related equity: A systematic review of the evidence. Health Policy. 2016;120(10):1183-1192. doi:10.1016/j.healthpol.2016.09.003
  14. Bossert TJ, Mitchell AD. Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan. Soc Sci Med. 2011;72(1):39-48. doi:10.1016/j.socscimed.2010.10.019
  15. Bossert TJ, Mitchell AD, Janjua MA. Improving Health System Performance in a Decentralized Health System: Capacity Building in Pakistan. Health Syst Reform. 2015;1(4):276-284. doi:10.1080/23288604.2015.1056330
  16. Roman TE, Cleary S, McIntyre D. Exploring the Functioning of Decision Space: A Review of the Available Health Systems Literature. Int J Health Policy Manag. 2017;6(7):365-376. doi:10.15171/ijhpm.2017.26
  17. Kigume R, Maluka S, Kamuzora P. Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning, allocation, and use of financial resources. Int J Health Plann Manage. 2018;33(2):e621-e635. doi:10.1002/hpm.2511
  18. Kigume R, Maluka S. Health Sector Decentralisation in Tanzania: Analysis of Decision Space in Human Resources for Health Management. BMC Health Services Research; Forthcoming.
  19. Kigume R, Maluka S. Health sector decentralisation in Tanzania: How do institutional capacities influence use of decision space? Int J Health Plann Manage. 2018. doi:10.1002/hpm.2587
  20. United Republic of Tanzania (URT).  Local government Reform Programme: Policy Paper on Local Government Reform. Dar es Salaam: URT; 1998.
  21. Shivji IG, Peter C. Village Democracy Initiative Report. Dar es Salaam: The Presidents’ Office - Regional Administration and Local Government; 2003.
  22. Ministry of Health and Social Welfare [MoHSW]. Tanzania National Health Accounts (NHA) 2009/10. Dar es Salaam: Government of United Republic of Tanzania, Department of Policy and Planning, MoHSW; 2011.
  23. Ministry of Health and Social Welfare [MoHSW]. Tanzania National Health Accounts year 2010 with sub-accounts for HIV and AIDS, malaria, and reproductive and child health. Dar es Salaam: Government of United Republic of Tanzania, Department of Policy and Planning, MoHSW; 2012.
  24. Ministry of Health and Social Welfare [MoHSW]. Forth Health Sector Strategic Plan 2016–2020 (HSSP IV). Dar es Salaam: Government of United Republic of Tanzania, MoHSW; 2015.
  25. Yin RK. Case Study Research: Design and Methods. Thousand Oaks, CA: Sage Publications Inc; 2003.
  26. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  27. United Republic of Tanzania (URT). The Community Health Fund Act. Dar es Salaam: United Republic of Tanzania; 2001.
  28. Prud’homme R. On the dangers of decentralization. Policy Research Working paper. Washington, DC: World Bank; 1994.
  29. Bossert TJ, Larranaga O, Giedion U, Arbelaez JJ, Bowser DM. Decentralization and equity of resource allocation: evidence from Colombia and Chile. Bull World Health Organ. 2003;81(2):95-100.
  30. Tresch RW. Optimal federalism: Sorting the functions of government within the fiscal hierarchy. Public finance: a normative theory. San Diego: Academic Press; 2002.
  31. Maluka SO, Bukagile G. Implementation of Community Health Fund in Tanzania: why do some districts perform better than others? Int J Health Plann Manage. 2014;29(4):e368-382. doi:10.1002/hpm.2226
  32. Joseph C, Maluka SO. Do management and leadership practices in the context of decentralisation influence performance of community health fund? Evidence from Iramba and Iringa districts in Tanzania. Int J Health Policy Manag. 2016;6(5):257-265. doi:10.15171/ijhpm.2016.130
  33. Maluka SO, Bukagile G. Community participation in the decentralised district health systems in Tanzania: why do some health committees perform better than others? Int J Health Plann Manage. 2016;31(2):E86-e104. doi:10.1002/hpm.2299
  34. Asante A, Iljanto S, Rule J. Strengthening Health Management and Leadership at the District Level: What can we learn from high performing districts in the West Java Province of Indonesia? Sydney, Australia: Human Resources for Health Knowledge Hub; 2012.
  35. Zon H, Pavlova M, Drabo KM, Groot W. Municipal health services provision by local governments: a systematic review of experiences in decentralized Sub-Saharan African countries. Health Policy Plan. 2017;32(9):1327-1336. doi:10.1093/heapol/czx082
  36. Boyne G. Scale, performance and local government reorganization: An analysis of the non-metropolitan districts. Public Money & Management. 1996;16(3):55-60. doi:10.1080/09540969609387934
  37. Peckham S. Decentralisation - A Portmanteau Concept That Promises Much but Fails to Deliver? Comment on “Decentralisation of Health Services in Fiji: A Decision Space Analysis.” Int J Health Policy Manag. 2016;5(12):729-732. doi:10.15171/ijhpm.2016.88
Volume 8, Issue 2
February 2019
Pages 90-100
  • Receive Date: 11 February 2018
  • Revise Date: 26 September 2018
  • Accept Date: 29 September 2018
  • First Publish Date: 01 February 2019