The unfortunate results of decentralization policies seem to relate to a number of unaddressed defects in their design.

• Local level planning is linked with centrally imposed budgets, with little room for local discretion (Gilson et al., 1994).
• There are inadequate, specific measures to enhance accountability, community participation or intersectoral coordination (Lauglo & Molutsi, 1995).
• At local level health information systems and survey skills are weaker so local political elites and bureaucracies make decisions that are less evidence based.
• Health authorities are poor at communicating to lower lever service providers and communities so they do not have an adequate understanding of the content or implications of decentralization (Community Working Group on Health, 1997).
• The boards are appointed by central government, with little accountability to the public. In practice they have few delegated responsibilities, particularly over revenue raising and retention, financial controls and staffing, so weakening their ability to make significant impacts on hospital performance (Bennett et al., 1995; Smithson et al., 1997).