Many countries in Africa are in varying stages of decentralizing their political structures, giving greater political responsibility to counties or provinces. In this model, budgeting and delivery of health services often fall to local government. Generally, this movement is expected to produce greater access to health care services, as local populations can better engage their local policymakers and hold them accountable. But significant challenges to realizing this potential exist, and little data exist on its impact on health equity, efficiency, accountability, or quality. For health advocates, decentralization dramatically shifts their playing field from the national to subnational level, and they must adapt in real time.
In response, PATH organized an Advocacy Learning Lab on decentralization in Nairobi, Kenya, on February 13 and 14, 2019. The Lab convened 125 attendees from seven African countries, prioritizing the participation of stakeholders operating in subnational contexts, including advocates, nongovernmental and civil-society organizations, policymakers, duty-bearers, donors, and implementing partners. Sessions were carefully designed to facilitate an exchange of ideas and support planning for real-world scenarios. Participants brought challenges and learnings from their local contexts and explored how the decentralization of political structures is impacting the delivery of health care—in both positive and negative ways—across many African countries. They also discussed the role local advocates can play in ensuring the quality of care continues to improve.
Throughout the two days, Learning Lab participants shared examples of successful advocacy initiatives and discussed how their lessons could contribute to future work and motivate action at the subnational level. Photo: PATH/Dan Ewur.
Several high-level policymakers were in attendance, including H.E. Dr. Wilber Ottichilo, governor of Kenya’s Vihiga County, and Michael Iga Bukenya, member of Parliament and chairperson of Uganda’s Parliamentary Health Committee. Governor Ottichilo opened the Learning Lab with a discussion about the role decentralization plays in Kenya and how it makes decision-making easier and reduces the bureaucracy and bottlenecks associated with a centralized system.
In his keynote address, H.E. Dr. Wilber Ottichilo, governor of Kenya’s Vihiga County, said the primary objective of decentralization is to devolve power, resources, and representation to be closer to the people. Photo: PATH/Dan Ewur.
Participants spent the two days engaged in discussions on topics ranging from financing health at the subnational level to capitalizing on people and partnerships to move forward health agendas. In a session about using data for decision-making, panelists discussed the role advocates play in demanding the generation of high-quality data and ensuring it is packaged for decision-makers. This is especially important at the subnational level, where policymakers have an expanded mandate and need targeted, accurate data to guide prioritization and decision-making.
PATH's Chief Data Officer Jeff Bernson speaks during a panel discussing advocates’ roles in ensuring policymakers are equipped with the appropriate data to make informed policy decisions. Photo: PATH/Dan Ewur.
If the world wants to achieve the ambitious goal of universal health coverage by 2030, accelerated action is needed at the district, county, and provincial levels where increasing responsibility lies, but advocacy pathways are less defined. Advocates and decision-makers must work together to understand emerging challenges and opportunities associated with decentralization.
As a way of continuing the conversation, an online Knowledge Gateway site was set up to enable participants to remain engaged in discussions on health advocacy in decentralized settings. The collaborative platform will be used to continue and expand on the in-person Learning Lab and is open to anyone interested in sharing ideas, lessons learned, and tools for how to best navigate health advocacy in decentralized settings. To join, visit the sign-up page.
To learn more about PATH’s Advocacy Learning Lab: Decentralization, read the meeting report.
The Advocacy Learning Lab: Decentralization convened 125 attendees from seven African countries, prioritizing the participation of stakeholders operating in subnational contexts. Photo: PATH/Dan Ewur.
The Advocacy Learning Lab: Decentralization is the second in PATH’s south-to-south learning series, dubbed Advocacy Learning Labs. With support from the Bill & Melinda Gates Foundation, PATH convened 75 stakeholders in August 2018 for a Learning Lab on the topic of accountability. Read more about PATH’s Advocacy Learning Lab: Accountability in Health.
