Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning, allocation, and use of financial resources

Abstract

While decentralisation of health systems has been on the policy agenda in low-income and middle-income countries since the 1970s, many studies have focused on understanding who has more decision-making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision-making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The findings of this study indicated that the decentralisation process in Tanzania has provided authorities with a range of decision-making space. In the areas of priority setting and planning, district health authorities had moderate decision space. However, in the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision-making space. The districts, nevertheless, had wider decision-making space in mobilising and using locally generated financial resources. However, the ability of the districts to allocate and use locally generated resources was constrained by bureaucratic procedures of the central government. The study concludes that decentralisation by devolution which is being promoted in the policy documents in Tanzania is yet to be realised at the district and local levels. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans.

Health sector decentralisation in Tanzania: How do institutional capacities influence use of decision space?

“…As reported in other papers, the decentralisation process in Tanzania has provided authorities with a range of decision‐making space to be utilised at the local level . The decentralisation process in Tanzania has provided decision space to district health managers, to health service providers, and to community members in identifying the needs of the communities and prepare plans and budgets as well as in the implementation of health plans and budgets.…”

“…The findings of the study indicated that local government authorities, including the health departments, had narrow decision space in the allocation and utilisation of financial resources provided by the central government to finance district health services . The districts depended on the Health Basket Fund and Health Block Funds to finance district health services.…”

“…This means that the local governments, including health facilities and the communities, had little room to add other identified local priorities. Nevertheless, district health managers and the health facilities had wide decision space in identifying specific interventions and activities within the broader national‐level priorities …”

“…The districts, thus, had little room to allocate funds beyond these determined ceilings and cost centres. The districts, nevertheless, had wide decision‐making space in mobilising and using locally generated financial resources …”

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

“…A number of studies, drawing from the decision space framework, have assessed the extent of autonomy enjoyed by local decision-makers in countries that have decentralized or devolved their health systems [12][13][14][15][16][17]. Most have attempted to come up with an overall or summative assessment of local decision space yet, in practice, decision-making for health services often involve multiple actors, each of whom may be wielding varying degrees of influence into the decision-making process.…”