Decentralisation and Health Service Governance in Zambia

Abstract
Decentralisation is a tool that’s advocated for to govern health services by academic literature and development agencies. Its popularity stems from the notion that decentralisation increases local capacity by delivering efficient administrative and decision-making systems. Advocates of decentralisation further postulate that decentralisation allows for government to be closer to the people and is, therefore, a more responsive tool in improving delivery of social services and addressing poverty at local levels. Despite its popularity, critics of decentralisation often suggest that its success is dependent on the type of decentralisation that is implemented in specific contexts and how the implementation strategies relate to in-country institutional arrangements and capacities. In spite of its critics, decentralisation has over the years continued to dominate the development agenda in both developing and developed countries, especially in the health sector. In Zambia, since 1992 governments have implemented health sector decentralisation with varying degrees of success.
Therefore, this thesis seeks to examine why and how health sector decentralisation has been implemented in Zambia since 1992. Drawing on conceptual literature and historical understandings of decentralisation processes, the research uses the health policy triangle framework (HPTF) developed by Walt and Gilson (1994); to understand the content, context, processes and actors involved in Zambian national decentralisation processes between 1992 and 2018. The thesis uses two specific examples of decentralisation processes – the health reforms of 1992 to 2006; and the devolution agenda that started in 2002 to date.
Based on textual analysis of policy documents and on qualitative field research conducted in Zambia between February 2018 and August 2018 – forty-three (43) interviews conducted in total - the thesis makes contributions through a number of original insights and conclusions related to the practice of decentralisation for health service governance in Zambia. First, it shows how policy ideas come to the forefront of policy agenda and how and why these ideas come to be widely accepted in local policy practice in Zambia. Second, it locates the ensemble of actors and how they come to interpret policy ideas. Third, it demonstrates how actors’ interactions shape policy interpretation and implementation. Lastly, it shows how international policy agenda engulfs local policy practice in Zambia and how the conglomerate of international ideas, ideologies and actors plays out within the Zambian context.