Decentralization and primary health care: some negative implications in developing countries

Int J Health Serv. 1994;24(3):459-75. doi: 10.2190/G1XJ-PX06-1LVD-2FXQ.


Decentralization is a highly popular concept, being a key element of Primary Health Care policies. There are, however, certain negative implications of decentralization that must be taken into account. These are analyzed in this article with particular reference to developing countries. The authors criticize the tendency for decentralization to be associated with state limitations, and discuss the dilemma of relating decentralization, which is the enhancement of the different, to equity, which is the promotion of equivalence. Those situations in which decentralization can strengthen political domination are described. The authors conclude by setting out a checklist of warning questions and issues to be taken into account to ensure that decentralization genuinely facilitates the Primary Health Care orientation of health policy.

PIP: Many developing countries favor decentralization within the context of primary health care (PHC). Decision makers should consider some negative implications of decentralization, however. These implications center around the tendency for decentralization to be linked with privatization and limitations on the role of the state, achieving equality while promoting decentralization, and use of decentralization as a strategy of political control and domination. Decentralization means transfer of authority, functions, and/or resources from the center to the periphery within a specific sector. Privatization is transfer of the same from the public sector to the private sector. Some people confuse the two and argue incorrectly that privatization is a form of decentralization. Privatization supporters should justify privatization on its own arguments and not on those of decentralization. Some organizations (e.g., World Bank) promote decentralization as a market surrogate strategy, but this view does not foster community participation within PHC or a more coordinated approach to addressing health problems. Decentralization must include strengthening lower level management capacity. It cannot successfully provide PHC if the local government is restricted to operate by being vulnerable to locally dominant groups or private capital investment. There must be some degree of centralization in resource allocation and planning for PHC. The proposed form of decentralization should promote and not hinder policies of equity. For example, the burdens of funding PHC should not fall mostly on the poor or the sick. Policy makers need to consider whether the proposed form of decentralization will or will not provide more for those in the greatest need. Decentralization should not create a tendency toward blame diffusion, a decentralization of conflict, and a policy of divide and rule. Decentralization policy should not form a process of centralization.

MeSH terms

  • Developing Countries*
  • Health Planning
  • Health Services Needs and Demand
  • Politics
  • Primary Health Care / economics
  • Primary Health Care / organization & administration*
  • Privatization