Title:
More Roles, Less Power? Decentralization and District Health Management Teams Performance in Health Service Delivery. A Synthesis of Evidence from Malawi, Ghana, and Uganda
Authors:
Kalanga, Alinafe
Place:
Amsterdam, The Netherlands
Publisher:
KIT - Royal Tropical Institute [etc.]
Year:
2025
PAGE:
x, 50
Language:
En
Subject:
Health and Poverty
Keywords:
Decentralization; District Health Management Teams; Health Systems; Sub- Saharan Africa; Health Service Management
Abstract:
Decentralization is widely regarded as a strategy to strengthen governance, accountability, and responsiveness in the health systems globally, including across sub-Saharan Africa. This thesis synthesizes evidence on how decentralization has influenced the performance of the District Health Management Teams (DHMTs) in Malawi, Ghana, and Uganda. The main aim is to draw key lessons from both successes and challenges encountered and to generate practical recommendations for improvement. Using a structured literature review guided by Regmi et al.’s (2010) analytical framework, the study analyzed the decentralization effects on management structures, processes, and service delivery outcomes. The findings show that, despite decades of reforms, DHMTs in all three countries still lack genuine control over finances and staff, as central authorities retain most of the decision-making power. While some local successes, such as improved maternal health in Malawi, community outreach in Uganda, and immunization gains in Ghana, highlight potential benefits, these were usually supported by donors or strong individual leaders, rather than by a systemic change. The challenges outweigh the purported benefits of decentralization, as issues persist. Unpredictable and delayed funding, staff shortages, poor infrastructure, and weak or symbolic community participation limit the effectiveness of DHMTs. Rural and underserved areas are the most affected. The evidence suggests decentralization has focused more on changing formal roles than on delivering real power and resources to district teams. To achieve meaningful improvements, the study recommends that real financial power and human resources authority be devolved to DHMTs, with adequate funding and clear accountability structures.
Organization:
KIT - Royal Tropical Institute, VU - Vrije Universiteit Amsterdam
Institute:
KIT (Royal Tropical Institute)
Country:
Malawi, Ghana, and Uganda
Region:
Sub-Saharan Africa
Training:
Master of Science in Public Health and Health Equity
Category:
Research
Right:
@ 2025 Kalanga
Document type:
Thesis/dissertation
File:
eHue04cKWB_20251216115915292.pdf