Poorly designed decentralization programmes indirectly increase the gap between people and health systems. These programmes have reduced access to services, reduced equity in health systems or reduced the coverage of public health programmes (Owino & Munga, 1997; Gilson et al., 1994).

Decentralization is an explicit policy measure to shift authority, to devolve legal powers and controls, such as the hiring and firing of personnel, to a lower level of the health system. Despite this, there is weak evidence of the promised benefits in accountability or increased public participation (Gilson et al., 1994; Gaventa & Robinson, 1998).