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 heal th care performance weaknesses, although the district is the unit to w hich 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. I t 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 multip le and cross-cutting flows of authority within and between levels of t he system. District health managers have limited authority to take man agement action, such as managing resources, in ways that would begin t o address problems of inefficiency and poor quality of care within pri mary care. District health management also suffers from weak resource allocation and financial management procedures. The main obstacles pre venting 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 th e implementation of decentralization. Evaluation of past experience su ggests that future policy influencing the organizational structure of government health services must be developed cautiously, recognizing t he critical importance of complementary action to develop both institu tional capacity and political and economic support for the health syst em.