Has decentralisation enhanced health service delivery (HSD) to the poor in Ethiopia? What factors enabled or inhibited improvements in health services between 1996 and 2006? This study finds that the Health Sector Development Programme (HSDP), which used decentralisation strategies, was largely successful. Subnational institutional and management capacity was a key factor in successful implementation. However, limited community voice and involvement limited the programme’s impact: a carefully-synchronised balance between supply- and demand-focused interventions is important. Health sector decentralisation is likely to be more effective as part of a broader government decentralisation policy across sectors. The coordinated provision of sufficient critical inputs (facilities, health workers, drugs) is essential.
The 20-year Health Sector Development Programme (HSDP) began in 1997 in the context of a national policy to decentralise and democratise HSD. It was largely successful in improving HSD outputs and health outcomes. Regional health bureau had budgetary authority and autonomy, and used district-level (woreda) governments and their health offices to implement the HSDP. Results varied across the regions:
- Decentralisation to regional level was associated with improved health outcomes and HSD outputs, although the improvements were from a very low baseline level.
- Decentralisation at the district level was premature: gains had not been consolidated at regional level and the woredas had weak management capacity.
- The expansion of the HSD network and human resources for primary care services was successfully implemented and even exceeded planned targets. However, drug availability was problematic.
- Despite the stated objective of targeting the poor (most of whom live in rural areas), much of the progress in health indicators was in urban areas.
- The Information, Education, and Communication component did not create demand for services. The diversity in culture, ethnicity, religion, and language of the population made it difficult to adapt IEC materials to different needs.
- The financing strategy succeeded in mobilising additional resources from donors and increasing per capita health spending. However it resulted in an increased health sector dependency on donor financing.
- Decentralisation was often influenced by clientelistic centre-region relations – a problem compounded by the lack of community voice – thus creating the risk of elite capture.
Few of the programme’s interventions aimed at enhancing public transparency around health budgets, or strengthening citizen voice in relation to HSD. The HSDP also failed to define indicators that could measure its impact on the poor, despite this being a stated objective. Other lessons include:
- Sequencing in implementation makes HSD decentralisation more manageable. Time should be allowed for initial gains to be consolidated at regional levels before moving to district or lower levels.
- Strengthening institutional capacity plays a key role in the effectiveness of programme implementation.
- Focusing human resources development on nurses and midwives helps to improve primary health care and increase user uptake of local services.
- Synchronising the completion of health facility construction works with related inputs is important for efficiency.
- It is relatively easy to increase health facilities and build system capacity, but difficult to create demand and change behaviour among users. Balancing supply and demand interventions is critical.
