Abstract:
Decentralisation by devolution has emerged as a strategic
approach in developing countries to enhance public
healthcare service delivery through increased local
responsiveness and community participation. However,
this shift presents a paradox: while aimed at empowering
local authorities, decentralisation often exacerbates existing
disparities, hinders effective resource allocation, and
complicates cohesive healthcare policy implementation.
This study examined the interplay between efficacy and
accountability in decentralised health systems, drawing on
case studies from Uganda, Kenya, Ghana, Indonesia, Brazil,
South Africa, and Tanzania, employing a systematic
literature review and mixed-methods approach. Key
findings indicated that decentralisation can improve local
healthcare service delivery, but its effectiveness is
frequently constrained by governance capacity and
resource allocation challenges. The research highlights the
importance of strengthening local governance capabilities,
fostering community engagement, and addressing
contextual factors like local government competencies and
fiscal resources. Limitations include a reliance on English-
language publications, potentially excluding valuable
insights from other languages, and the selected case studies
may not represent all decentralised healthcare experiences.
The study recommends comprehensive capacity-building
initiatives, stronger accountability frameworks, and active
community involvement to ensure equitable healthcare
outcomes. By acknowledging the paradox of
decentralization, policymakers can better design and
implement reforms, ultimately enhancing health service
delivery in developing.
