Decentralisation, governance and health-system performance: “where you stand depends on where you sit”

It is often argued that when decentralisation is accompanied by adequate mechanisms of accountability service delivery will improve. From a governance perspective, it is generally argued that decentralisation of the health sector is the right thing to do as long as the underlying conditions of good governance exist and/or decentralisation will strengthen those conditions. From a health-systems perspective, however, the rationale for decentralisation is less clear. From this perspective, the appropriate degree of decentralisation and the necessary mechanisms of accountability depend upon the achievement of health system goals.
From a health-systems perspective, policies of partial decentralisation may be a better option than full decentralisation if this results in improved functioning of the health system. Based on evidence from six countries (Bolivia, Chile, India, Pakistan, Philippines, Uganda), this study finds that a balance between centralisation of some functions, along with improved mechanisms of accountability is needed to achieve health system objectives.