Abstract
Background: Decentralisation in the health sector has been promoted in low- and middle-income countries (LMICs) for
many years. Inherently, decentralisation grants decision-making space to local level authorities over different functions
such as: finance, human resources, service organization, and governance. However, there is paucity of studies which have
assessed the actual use of decision-making space by local government officials within the decentralised health system.
The objective of this study was to analyse the exercise of decision space across 4 districts in Tanzania and explore why
variations exist amongst them.
Methods: The study was guided by the decision space framework and relied on interviews and documentary reviews.
Interviews were conducted with the national, regional and district level officials; and data were analysed using thematic
approach.
Results: Decentralisation has provided moderate decision space on the Community Health Fund (CHF), accounting
for supplies of medicine, motivation of health workers, additional management techniques and rewarding the formally
established health committees as a more effective means of community participation and management. While some
districts innovated within a moderate range of choice, others were unaware of the range of choices they could utilise.
Leadership skills of key district health managers and local government officials as well as horizontal relationships at
the district and local levels were the key factors that accounted for the variations in the use of the decision space across
districts.
Conclusion: This study concludes that more horizontal sharing of innovations among districts may contribute to more
effective service delivery in the districts that did not have active leadership. Additionally, the innovations applied by the
best performing districts should be incorporated in the national guidelines. Furthermore, targeted capacity building
activities for the district health managers may improve decision-making abilities and in turn improve health system
performance.