The promise and reality of decentralization: a critical appraisal of Sierra Leone’s primary health care system

Abstract

Postwar reconstruction in Sierra Leone was accompanied by an ambitious donor-promoted decentralization programme aimed at making delivery of the country's failing social services more efficient. A decade after the 'decentralization' of health services, this article examines systemic failures that have resulted in de-concentration rather than devolution of the health system. It identifies four factors that have contributed to a dysfunctional decentralized provision of primary health care. First, is an inconsistent political and legal framework that blurs and distorts delineations of authority between central and subnational government institutions. This leads to three further challenges that interact to create an ineffective public health sector: the central government is resistant to devolution, partly due to a culture of accumulation; local-level interventions are uncoordinated; and there is limited accountability for frontline health workers. As a result, citizens' health needs are unmet. Sierra Leone is plagued by some of the worst maternal and child mortality rates in the world, and faced the most intractable outbreak of the 2014-2015 Ebola epidemic. Drawing on participant observation and interview data, this article suggests that building a resilient decentralised primary healthcare system will largely depend on the willingness of the centre to meaningfully devolve power and resources to subnational governments, and establish a mutual accountability mechanism in which 'actors' at all levels are held accountable.

Are health systems interventions gender blind? examining health system reconstruction in conflict affected states

“…The Sierra Leonean government also undertook significant reform, by introducing a national decentralization policy that included the health sector [ 49 ] and a “Free Health Care Initiative” (FHCI) to provide free health services to pregnant women, lactating mothers and children under five. However, decentralization was plagued with systemic failures, clearly evident during the 2014–6 Ebola Virus Disease (EVD) outbreak with local responses undermined by failures at the national level [ 50 – 52 ]. The Ebola outbreak further weakened Sierra Leone’s health system, with maternal health services heavily affected.…”

Government–donor relations in Sierra Leone: who is in the driving seat?

“…However, despite the intensity of the relationship, it was not all plain sailing from the end of the civil war in 2002 up to the start of this study in 2010. While decentralisation and a large free healthcare initiative were both presidentially backed and rolled out on time, in 2004 and 2010 respectively, studies show these expensive projects have considerable flaws (Conteh 2016). In 2007, DFID went so far as to suspend budget support, stating that this was a benchmarks-informed decision.…”

“…); and the politically instrumental purposes served by the donor-supported decentralisation programme (Conteh 2017). Agency in government needs emphasis, as the availability of donor funds fosters a sense of moral hazard and allows the government to channel resources to other uses such as infrastructural projects and public and political goods, and from which officials can obtain personalised transactional gains (Conteh 2016).…”

“…Most officials, wherever they are in government, face multiple and shifting stresses and incentives. In Sierra Leone, a small state where donors have indeed had more sway, there are pressures to follow many donor lines, contrary pressures to be seen to be resistant to other donor lines, and obligations -in what is still to a significant degree a patron-cliental system -to patrons above and to ethnoregional support bases, family, kith and kin below (Conteh 2016). Presidential, ministerial and lower echelon actions at any one time reflect a calculation concerning these shifting imperatives and thus explain to a considerable degree the level of success or failure of any given reform and the overall limited returns of aid programmes (Harris 2013: 153-7;Tavakoli et al 2014: 6-7).…”

The Promise and Reality of Public Sector Reform – A Case Study of the Implementation of Trinidad and Tobagos Health Sector Reform

“…In order for successful implementation to be achieved, there is the need for support of and commitment to the reform, regardless of its nature, from within central government (Conteh, 2016). For instance, if decentralisation is used, central government officials must be willing to transfer the functions and responsibilities that they previously performed to implementing bodies.…”