Decentralization and Governance of Universal Health Coverage

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Derick Brinkerhoff

Derick Brinkerhoff

Distinguished Fellow, International Public Management at RTI. Dr. Brinkerhoff is co-editor of the journal Public Administration and Development, and serves on the editorial boards of Public Administration Review and International Review of Administrative Sciences. He also holds an associate faculty appointment at George Washington University's Trachtenberg School of Public Policy and Public Administration, and has an EdD in Administration, Planning and Social Policy from Harvard University. Derick can be reached at
Derick Brinkerhoff

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Decentralization is frequently recommended as a governance remedy for a wide variety of ills, for example: a means to deepen democratic governance and citizen empowerment, a pathway to improve administrative and service delivery efficiency and effectiveness, and/or a political palliative to calm restive regions seeking increased autonomy.  As a governance specialist, I’m frequently asked, “does decentralization work?”  And since I’ve focused extensively on governance in the health sector, that question often relates to how decentralization might help solve a health systems problem.

As the international health community considers the governance dimensions of universal health coverage (UHC), the question narrows to the relationship between decentralization and UHC. My answer would begin with, “it depends,” which is admittedly an unsatisfying response. But for complicated policies like decentralization and UHC, the proverbial devil is in the details. The definitions of the terms are often fuzzy. The motivations for pursuing them are typically mixed and occasionally contradictory. The operational contents of the policies—frequently ambitious packages of reforms with serious implementation challenges—often have unpredictable outcomes. The contextual influences—historical, institutional, socio-economic, and cultural factors—are varied and highly complex.

Community members attend a local governance meeting in Rangunia, Chittagong, Bangladesh.

Decentralization in general concerns the allocation of power, authority, resources and responsibilities between central and local governments. Decentralization is commonly categorized as political, fiscal, and administrative along a continuum from deconcentration (limited local discretion) to the fullest form of decentralized autonomy, called devolution.  UHC is defined as a situation where “all people can obtain the health services they need, of good quality, without suffering financial hardship.” These broad definitions leave lots of room for specifying how decentralization and UHC governance might interact.

One approach to identifying a more helpful answer is to consider how decentralization influences the accountability relationships that are central to UHC among government entities (e.g., health and finance ministries, parliaments, insurance agencies), providers (public, private), and citizens.

Bill Savedoff and his colleagues identified five governance dimensions in their assessment of country experience with managing mandatory health insurance: coherent decision-making structures, transparency and information, consistency and stability, stakeholder participation, and supervision and regulation.  The table below captures how each of these dimensions factor into accountability for UHC and are influenced by decentralization.

Governance dimension Importance for accountability for UHC Selected decentralization influences
Coherent decision-making structures ·       Responsibility for decision-making matches roles, authority, resources

·       Institutions have appropriate capacities to exercise responsibility

·       Assignment of roles, responsibilities, and resources across levels of government strongly affects quality and consistency of decision-making

·       Mismatched assignment increases risks of incoherence, conflicts, and poor UHC performance and results

·       Sub-national governments offer increased opportunities for officials to make public commitments to UHC

·       Financing formulas and intergovernmental transfers strongly impact decision-making at central and sub-national levels

Transparency and information ·       Information is available and accessible on UHC performance, processes, and outcomes

·       Top-down (e.g., audits) and bottom-up (e.g., citizen report cards) information informs decisions

·       Sub-national entities may face incentives to increase use of information for local accountability

·       Information flows upward may increase coherence of central management of UHC

Consistency and stability ·       Agreed-upon and formal rules and procedures (e.g., legal frameworks)

·       Predictable and credible application

·       Political settlement supports UHC

·       Devolution may reduce consistency and introduce instability, and may create multiple political settlements

·       Local government experimentation with different approaches to UHC may contribute to innovation and improved performance

Stakeholder participation ·       Representatives from government, business, unions, and beneficiaries provide input into UHC design and operations

·       Participatory structures and processes enable broad representation and mitigate power differentials


·       Creates multiple venues for stakeholder engagement, so increased options for input, dialogue, and bargaining

·       Can create increased incentives for stakeholder participation

·       Multiple venues can build capacity and support empowerment

·       Increased risk of capture at the local level

Supervision and regulation ·       Regulatory regimes with clear rules and procedures enable integrated financial and health care quality supervision

·       Regulatory and supervisory capacity supports effective oversight and enforcement

·       May increase citizen engagement in oversight of providers through social accountability mechanisms

·       May increase risk of inconsistent application of regulations across local jurisdictions, or of regulatory capture

·       Weak local government capacity for supervision and regulation may limit effectiveness

This table is just a start at understanding how decentralization can influence UHC governance, and demonstrates that these influences are both positive and negative. Clearly, how decentralization is designed and implemented plays an important role in whether on balance it is a plus or a minus for effective UHC. Further, I haven’t included anything specific about differences in governance across various forms of UHC; for example, direct public provision, single-payer, state-managed markets, or competitive markets. While much about decentralization and UHC remains to be unpacked, approaching the “does decentralization work” question with some finer grained specifics helps further this important dialogue.


This is the third in a series of blogs on pursuing Universal Health Coverage authored by RTI experts on Global Health Hub. You may also be interested in reading “Does Governance Help Achieve Universal Health Coverage?” and “How do political considerations shape Universal Health Coverage?,” both by RTI’s Taylor Williamson.