LOCAL-GOVERNMENT DECENTRALIZATION AND THE HEALTH SECTOR IN TANZANIA

An evaluation of primary-level health care undertaken in Tanzania 1989-91 found that district health managers felt powerless to address health care performance weaknesses, although the district is the unit to which government management functions have been decentralized. In order to understand the managers' views, this article analyses the pattern of decentralization within the health system from their perspective. It reviews the historical development of government structures and the theory and practice of decentralization within Tanzania. The matrix of accountability for health care has become very confusing, with multiple and cross-cutting flows of authority within and between levels of the system. District health managers have limited authority to take management action, such as managing resources, in ways that would begin to address problems of inefficiency and poor quality of care within primary care. District health management also suffers from weak resource allocation and financial management procedures. The main obstacles preventing more effective management are: resource constraints; conflicts between the demands for central control and local discretion; limited institutional capacity; and political and cultural influences over the implementation of decentralization. Evaluation of past experience suggests that future policy influencing the organizational structure of government health services must be developed cautiously, recognizing the critical importance of complementary action to develop both institutional capacity and political and economic support for the health system.