Zambia’s ambitious process of decentralization after 1995 is examined in this study using the “decision-space” analytical approach in national level data analysis and in field case studies of nine districts. The study found that the “deconcentrated” system allowed local choice at the district level over a “decision space” that permitted moderate choices over expenditures, fees, contracting, targeting and governance. It allowed very little choice over salaries and allowances and ruled out contributing local tax revenues to the system. The study recommended consideration of expanding local choice over hiring and firing and salaries as anticipated in the original legislation.
The analysis of local expenditures showed that the allocation formula appears to have favored poorer districts and that although the revenues from fees were low, the wealthier districts were much more successful than poorer districts in raising fee revenue. These findings suggest that more transparency in the allocation formula and monitoring of local fee collection should be implemented by the Ministry of Health and the Central Board of Health.
The case studies found that decision-making processes tended to involve local participation as programmed; however, in the crucial decisions made after budget cuts, the community was not consulted. Confusion over the status of district boards and failure to encourage communication between district boards and neighborhood and facility committees limited participation and should be addressed. To the extent that the studies were able to evaluate performance of the decentralized system, little variation was found in key indicators—suggesting that decentralization did not lead to the deterioration of a system that might have suffered from general economic decline and a rise in HIV/AIDS.