Decentralisation and health services delivery in Tanzania: analysis of decision space and organizational capacities.

While decentralisation of health systems has been on the policy agenda in low‐income and middle‐income countries since the 1970s, many studies have focused on understanding who has more decision‐making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision‐making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The study also investigated the variations in actual use of decision-making by district health managers and how organizational capacities influence the use of decision space available in the decentralised health system. In-depth interviews were conducted with the Ministry officials, Regional Health Management Teams, District Executive Directors, District Planning officials, Council Health Management Teams, and Health facility officials. In addition, focused group discussions (FGDs) were conducted with Ward Councilors. Lastly, relevant policy documents and guidelines were reviewed. Data were analyzed using Thematic Approach. The study found that decentralisation process in Tanzania has granted local level authorities with a range of decision-making space to be utilised. In the areas of priority setting and planning, human resource utilisation and management, services delivery, and governance, district health authorities had moderate decision making space. In the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision making space. The districts, nevertheless, had wide decisions making space in mobilizing and using locally generated financial resources. However, within the decentralised health systems in Tanzania, some districts were able to make effective use of the range of choices they were formally granted by the central government while others were unaware of the range of choices they could utilise. However, the ability of the districts to allocate and use locally generated resources was constrained by the limited financial resources and bureaucratic procedures of the central government, particularly in the procurement of medicines and medical supplies. In addition, the ability of the community members to participate in planning, priority setting and governance of the district health system was constrained by limited capacity in terms of knowledge and skills. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans. Also the central government should reduce bureaucratic procedures required to disburse funds to district councils. Further, the district councils and the Ministry of Health should strengthen capacities of health service providers and members of health committees and boards. Lastly, in order for the decentralized health system entities to make better use of the available decision space, there is a need to forge sustainable partnerships with other key actors in the district.