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Decentralization and Management Strengthening at the Local Level

Background and Strategy

In many instances decentralization is a highly politicized process and frequently it is initiated outside of the health care sector. The Project’s experience demonstrates that there is frequently confusion around decentralization and that problems arise if actors do not understand the decentralized context and lack capacity to perform the new roles they must play. For example, local level health units are not accustomed to handling finances; unless new systems and training are provided to help them manage money in a decentralized system, financial mismanagement is likely to occur.

In countries that are pursuing decentralization policies, PHRplus commonly (i) works with a range of actors to develop consensus about the nature and scope of decentralization, (ii) assists governments at all levels to help clarify new roles within a decentralized system, and (iii) builds capacity to perform these roles. As decentralization takes very different forms in different countries, its consequences are by no means certain; thus, PHRplus also advocates for and provides support to the monitoring of decentralization processes.


  • Consensus building: in Benin, PHRplus has supported the Ministry of Health (MOH) effort to build consensus to aid a smooth transfer of authority and finances to the local level. PHRplus will help to sustain the political will needed to proceed with policy implementation, as well as with communicating the policy throughout the country. Similarly, PHRplus will continue to provide El Salvador’s MOH with technical assistance in the areas of communication and strategic advocacy to support the decentralization process in that country.

  • Clarification of roles: in Benin, PHRplus will provide support to the MOH to develop/improve texts related to decentralization and to clarify roles and responsibilities at all levels of the health system. In Albania, PHRplus is helping to clarify the implications of decentralization processes for the health sector.

  • Management strengthening at the local level: PHRplus is working in Albania, the Democratic Republic of the Congo (DRC), Honduras, El Salvador, and Malawi to strengthen management at the local level. In DRC, PHRplus continues to collaborate with the USAID-funded SANRU III project to improve financial accounting and management of resources at the health zone level. Similarly, in Albania and Malawi, PHRplus is providing assistance to strengthen local level planning, budgeting, and reporting in order to increase sustainable financing of primary health care services. In El Salvador, where the government has committed to a significant and rapid decentralization process, PHRplus is providing technical assistance to implement and strengthen the decentralized units (SIBASIs), and to implement management contracts between the centeral level and the SIBASIs. In Honduras, PHRplus is supporting health planning at the local level and management strengthening.

  • Monitoring decentralization: PHRplus is working in Albania and El Salvador to help cast light on the effects of decentralization. In Albania, it has initiated a detailed evaluation study on the impact of a bundle of interventions including decentralization, management strengthening at the local level, and quality assurance (see section 9). In El Salvador, PHRplus conducted a facility and management survey, and will use this as a baseline to monitor the decentralization process. The application of the National Health Accounts methodology at the regional level in Ethiopia promises to provide a further tool that can be used to help monitor decentralization processes.

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