This document provides an overview of decentralizing health services in Malawi. It discusses progress made so far in decentralizing functions like finance, procurement, and service delivery to district levels. It identifies gaps in policies, laws, and implementation and makes recommendations. Key points include clarifying roles and responsibilities at each level, ensuring coordinated support from central, regional, and district structures, establishing city health directorates, building financial management capacity, and providing guidelines for partner involvement. The document also examines challenges in decentralizing human resources and the architecture for managing health workers in a decentralized system.

1. Decentralisation of the
Health Sector
Dr Richard Tambulasi and Bakhethisi Mlalazi
Presentation to the Mid-Year Review
MHSP-TA
27 April 2015

2. Presentation outline
• Introduction and background
• Decentralised health services delivery
• Resourcing for health at district level
• Human resource for health
• Governance in the decentralised framework

3. Introduction and background
• Review of issues related to decentralisation of the
health sector
• Objective is providing Technical Assistance to support
the implementation of HSSP for enhanced health
service delivery
• Focus on : General Background on Decentralisation,
Service Delivery, Human Resource , Resourcing , and
Governance

4. Introduction and Background continued
• Methodology: chiefly an in-depth qualitative analysis
carried, data gathered through in-depth interviews
conducted with key informants both at policy making
and implementation levels .
• Acknowledgements: Decentralisation Group based at
the MOH - Chair Mr Masache, and the Director of
Planning Dr Kabambe and all members of the DEG for
rich feedback and support

5. Why Decentralisation
• To enhance health service delivery
• Find local solutions for local health problems
• Increased resource mobilisation for health
• Improve primary level and secondary level service
delivery

6. Why Decentralisation
1. Second Health Plan 1973-1998 to Fourth Heath Plan,
National Health Policy Framework of 1995, Joint Program of
Work for a Health Sector Wide Approach 2004-2010, HSSP
2011-2016, Republic Constitution 1995, The Local
Government Act, 1998, Decentralisation Policy 1998
2. MOH Devolution guidelines 2004, MOH guidelines for the
management of devolved health sector 2004, MLGRD
guidebook on decentralisation 2005, Draft Health policy

7. Progress so far for devolution of functions
• All the sectors have not fully devolved their functions to
the councils
• Human resources management still centralised
• The ministry of health has done some strides:

8. Progress so Far for Devolution of Functions contn.
1. Finance: Health is the only ministry that has devolved to
districts more than 80% of all “sector funds”. Health, has
deconcentrated about 40% of its budgetary resources
– Some challenges: DHO in some cases not signatory and inter-
borrowing happens without his/her knowledge
2. Procurement: The council has one procurement committee
at the district level and all sectoral committees were
dissolved
– infrequent meetings lead to leads to delays in purchasing

9. Gaps and inconsistences in policy, legislation and
implementation
• Conflict on the role of zonal offices in a decentralised set up
among MOH, MLGRD and DHRMD
• No articulation of the responsibility allocation for district
hospital
• Policy and guidelines do not spell out the operationalization
of division of labour on service delivery between cities and
district assemblies.

10. Gaps and Inconsistences in Policy, Legislation and
Implementation
• There seems to be no agreement between the MOH and
MOLGD on the implementation modality of decentralisation:
big bang approach vs incremental approaches
• Some laws preserve centralisation, while others promote
decentralisation. The Public Health Act (1948) s 142; Vs Local
Government Act S10 and S 25).

11. Institutional and Legal Framework of Decentralisation in Other
Countries and Lessons for Malawi
• Cases Reviewed: Uganda, South Africa, Tanzania, Norway
1. Clear division of responsibilities among levels of health
service to avoid duplication, role confusion and ensure
value for money.
2. Coordination, partnership and agreement between the
Ministry of Local Government and Ministry of Health on
critical aspects of local government
3. Synergies between laws, legislation and policies to avoid
conflict.

12. Institutional and Legal Framework of Decentralisation in
Other Countries and Lessons for Malawi cont
4. Regional level structures are not against decentralisation but
complement it. Role of Zones in the Malawian context
5. Decentralisation is a process: It can be implemented in a
phased manner with districts and sectors that are seen to be
ready to start first and the rest can follow
6. There is no one blue print for decentralisation. It is rather
context specific.
7. Decentralisation is not a magic bullet to effective service
delivery.

13. Decentralised Health Services Delivery
Levels of care delivery
1. Community 2. Primary 3. Secondary 4. Tertiary
The Proposed Decentralised Services Delivery
1. Directorate of Health and Social Services to do the following:
a. preventive health services; (c) curative services;
b. social welfare services ; (d) Manage waste disposal
2. District hospitals to be managed by a separate team from the
rest of the district with Hospital Management Team

14. Issues and Recommendations on Support structures for
decentralization framework
1. Primary Health Care system
a. Clarify various functions and roles of the Directorate of Health
and Social Service to avoid overloading of services and
overlooking of critical health issues.
b. reinvigorate health planning function at the district level:
Directorate of Planning and Development at the district level
should have planning desk officers responsible for health
c. Primary health services: MOH consider establishing the deputy
directorate responsible for primary health care within the
curative directorate at the central MOH so as to have a
dedicated person to provide professional advice on primary
health services to the councils.

15. 2. Secondary health care
• The district hospital though managed by the Hospital management
team will need to be provided with technical leadership in health
delivery by the: Directorate of Health and Social welfare, Central
Hospital, Zonal office
3. Tertiary health care
• According to Decentralisation policy and Local Government Act,
not part of the decentralisation agenda
• Central hospitals will need to have autonomy to deliver tertiary
level services and remove the current inefficiencies
• Since the central hospital has health experts it should be able to
provide technical advice and supervise the district hospitals and
directorate of health and social welfare at the district level.

16. Recommendations on Health Service Delivery in Cities
• The health issues for district and city are not homogenous and hence
there is need to establish a function Directorate of health and social
welfare at both the District and City Councils.
• The district council director will have jurisdiction over the District
while the City one will be responsible for the city. Thus all the health
centres and facilities within the City will have to be managed by the
City.
• City Director of health will need to have his own budget and vote.
Thus the city council will need to be receiving finances for the
population of the city as it is currently the case with the district
council.
• Proper guidelines will need to be drawn in-terms of coverage of
service delivery for the city and rural directorates

17. Recommendations on Health Service Delivery in
Cities cont.
• City Director of health will need to have his own budget and
vote. Thus the city council will need to be receiving finances
for the population of the city as it is currently the case with the
district council.
• Proper guidelines will need to be drawn in-terms of coverage
of service delivery for the city and rural directorates

18. RESOURCING FOR HEALTH AT DISTRICT LEVEL
Currently, local councils in Malawi generally obtain their finances
from four main sources as follows:
1. Locally generated revenue, Government grants;
2. Donor and project funds for specified activities; and
3. Fund-raising from well-wishers

19. Challenges of Resourcing for Health
• Resources are not evenly distributed in all the districts.
• Partners do not follow local levels plan when coming up with
activities
• Some cases the few available providers are over concentrated in
one health problem
• Providers get over concentrated in one corner of the district
• Some partners do not disclose their budgets to the District
Council for proper planning.
• Capacity challenges in financial management: but capacity follow
resources !!!

20. Recommendations
• The SWAp arrangement should be decentralised so that partners
provide resources for health at the local level to ensure that
resources are available
• District councils need to ensure that projects at the district level are
well distributed in-terms of areas of need and location
• District Councils need to ensure that partners provide funding in
relation to the district health implementation plans
• MOH need to provide policy guidelines on availability of partners
within a district to avoid a situation where one district is over
concentrated with resources while others are resource constrained
• Capacity building in finance management

21. Recommendations cont.
• District Councils need to ensure that partners provide funding
in relation to the district health implementation plans
• MOH need to provide policy guidelines on availability of
partners within a district to avoid a situation where one
district is over concentrated with resources while others are
resource constrained
• Capacity building in finance management

22. HUMAN RESOURCE FOR HEALTH
Context of staff devolution
Staff devolution being considered in the context of
–Progress in implementation of decentralisation
–Public sector reforms – creation of a public service
–Desired end state is a PS, that is harmonised and allows
for effective performance and professional growth
–Staff devolution is still at the discussion stage, so the
health sector can join in the dialogue and influence
direction and events

23. Architecture of HR Management in public service
• Several institutions, complex relationships
• Key Commissions in considering decentralisation –CSC, LASCOM,
HSC
• Commission responsibilities - conditions of service, recruitment,
promotion, discipline
• DHRMD responsible for establishment, deployments, payroll
• Classification of staff according to services
• Movement between services is restricted
• Key role for LASCOM in devolution, but it has constraints

24. Decentralised service delivery structures
• Key concerns, Health and HRM
• Proposed Directorate of Health and Social Welfare offers positives
in service delivery
• Necessary to review proposed functions and structure to reflect
best practice
• The functioning of the Appointments and Disciplinary Committee
• The responsibility burden responsibly of the HR function will need
extensive review
• Recommendation for reviewed functions and new structures

25. Envisaged staff devolution
Process
• MoLGRD will coordinate, working with DHRMD
• Devolution will be based on the 2004 functional review and
recommended establishment
• Piloting of establishment data and HRMIS in 6 Districts
• MoLGRD will fill non-established posts by June 2015
• No date set for devolution as yet, need for government approval
• Once go ahead is given, MoLGRD will engage with devolving sectors
and District Councils
• There will be a functional review after staff have been devolved to
the Districts

26. Envisaged staff devolution Issues
• Proposed dialogue before devolution is good
• Timescales envisaged by MoLGRD (December 21015) are not
realistic
• Decentralisation will impact on jobs in District Councils and
Ministries
• Recommendations
– Coordination of devolution
– Strengthen District Councils and LASCOM before devolution
– Overall functional review and job regarding

27. GOVERNANCE IN THE DECENTRALISED
FRAMEWORK
Governance in decentralisation
• Governance is a key concern in decentralisation
• District - wide structures
• Health specific governance structures

28. Issues in functionality of District wide structures
• Impact of 2010 amendments, and role of MoLGRD
• Understanding roles and responsibilities
• Calibre of elected officials
• Support staff vs elected officials
• Role relationships among elected officials
Recommendations
• Clarification of roles and responsibilities
• Development of specific skills
• Facilities

29. Some broad observations
• Mandates need to be reviewed in the light of decentralisation
• Improved communication and coordination would improve
effectiveness
• More emphasis needed on advocacy
• Capacity development required across the board
• Lack of resources is impacting functionality and effectiveness
• There are CSO networks that can be harnessed to improve
functionality

30. Recommendations
• MoH should develop guidelines for health specific structures
(collaborate with District Councils) as a legacy to the
decentralisation process
• Intensive, prolonged and coordinated capacity building is
required to improve functionality and effectiveness

31. END