Rethinking Health Decentralization Programming: Experience and Lessons from Uganda

Decentralization was instituted more than twenty years ago in Uganda as a means to make government more responsive to citizen needs and increase availability of health services at the community level. Unfortunately, the goals of decentralization have not fully been met. The constraints limiting the positive impact of decentralization include lack of financial and human resources at the district government level. The United States Agency for International Development (USAID) unveiled an innovative program last year, “Strengthening Decentralization for Sustainability” (SDS), to help address these two critical constraints. SDS provides tools and training to district management staff and financial incentives in the form of direct cash grants to district governments with the willingness to increase availability of community health services. Additionally, SDS helps district governments coordinate the work of other donor health projects operating within their borders, putting them in the driver seat to prioritize health needs. A major implication is that SDS could change the way donors work to improve community health outcomes in decentralized environments. By working directly with central and districts governments instead of civil society and providing them with resources they need to implement health programs that are of their own design, donors may be able to achieve longer lasting and sustainable results. This presentation will describe the SDS methodology, results to date, and potential for influencing the design of future donor health programs in decentralized governance systems.