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
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
et al., 1995; Smithson
et al., 1997).