Navigating the Paradox of Decentralization by Devolution: An Evaluation of Public Healthcare Service Delivery in Developing Countries

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.