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Decentralization in Zambia: resource allocation and district performance.

Thomas Bossert1, Mukosha Bona Chitah, Diana Bowser

  • 1Harvard School of Public Health, Boston, MA 02115, USA. tbossert@hsph.harvard.edu

Health Policy and Planning
|December 5, 2003
PubMed
Summary

Zambia

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Area of Science:

  • Public Health
  • Health Systems Research
  • Health Policy and Management

Background:

  • Zambia initiated health sector decentralization in the mid-1990s.
  • Decentralization aimed to improve health service delivery through local governance.
  • Assessing the impact of decentralization on health system performance is crucial.

Purpose of the Study:

  • To evaluate the extent of decentralization ('decision space') granted to Zambian health districts.
  • To analyze resource allocation choices made by local health authorities.
  • To assess health system performance indicators under decentralization.

Main Methods:

  • Analysis of 'decision space' for district health officials regarding expenditures, user fees, contracting, targeting, and governance.
  • Examination of resource allocation formulas and internal resource distribution guidelines.
  • Review of health system performance indicators (utilization, immunization, family planning) from 1995-98.

Main Results:

  • Districts had moderate decision-making power, with limitations on salaries, allowances, and revenue generation (e.g., local taxes).
  • Funding allocation formulas based on population and hospital beds led to equitable per capita spending.
  • Districts showed varied adherence to internal resource allocation guidelines, with some over-allocating to district offices and under-allocating to hospitals.
  • User fees contributed minimally to total expenditures, with wealthier/urban districts generating more revenue.
  • Little variation in performance indicators was observed, except for a decline in immunization coverage.

Conclusions:

  • Zambian health districts possessed a moderate degree of autonomy within a decentralized system.
  • Resource allocation showed some inequities despite efforts towards equal per capita spending.
  • Decentralization did not demonstrate a clear positive or negative impact on overall health service performance during the study period.

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