2.3 A brief overview of Malawi decentralization legislation and processes

Designing for scale: in other words, thinking beyond the pilot and the proliferation of often smallscale, vertical projects that are probably implemented in a limited area - and work from the outset to understand what works.

While not mentioned, this would ideally include attention to the District level; any pilot would build in scale-up strategies from the beginning.

The 2021 World Development Report, entitled Data for Better Lives, does not discuss in any detail the role or remit of decentralized structures (health or other) in the context of building effective, democratic systems with strong governance. It does, however, note the following (NB: without specific reference to decentralized or sub-national structures, unless these are implicitly subsumed under 'government agencies'):

'When government agencies, civil society, academia, and the private sector securely take part in a national data system, the potential uses of data expand and so does the potential impact on development. In fact, the more integrated the system and the more participants involved, the higher is the potential return...Higher degrees of integration require close coordination and shared governance between participants, but such integration is otherwise compatible with a decentralized data architecture...Even though most countries are far away from the aspirational goal of a well-functioning data system, setting sights on this target can provide countries with guidance on the next steps in developing such a system. ' (p. 16)

A 2018 report entitled Transforming Health Systems Through Good Digital Health Governance notes that Digital health has been acknowledged as a key building block for UHC and the healthrelated Sustainable Development Goals. However, it argues that while much work is being undertaken across the global South, a holistic approach to digital health, which requires good governance for successful implementation and sustainability throughout the health system, continues to be lacking in many countries.

Thus: Good governance is needed at all levels—local, district, provincial, and national—throughout the health information system. This, in turn, supports equitable access and delivery of quality, affordable health services. (Marcelo et al. 2018; p. 4)

Such efforts to entrench good governance in the Malawian digital health context should surely require engagement with and by District health structures, in order to optimize buy-in, ownership and the development of a 'knowledge culture' 4 for planning and service delivery. Relevant here is that in order to develop a knowledge culture, which is a process-driven incremental build, there needs to be support to such activities as well as training; the evidence throughout the independent evaluation is that training on its own is insufficient to increase appetite for, and use of, digital data for planning and to achieve improved service delivery and health outcomes.

Again, it is important to note that no one project can hope to achieve all such outcomes, because there needs to be a national, systemic process running alongside to address decentralization in its broadest sense.

2.3 A brief overview of Malawi decentralization legislation and processes

The box below homes in on the health sector and the extent to which overarching national legislative instruments and reports and also sector strategies address decentralization and decentralized systems and structures.

4 Here 'knowledge culture' refers to a group of behaviours, including responsiveness towards the use of data, positive evidence of individual and organizational practices to support data use, senior staff members actively promoting data use and encouraging users, all of which can develop and sustain evidence-based planning and service delivery.

Literature review 5

• The 1998 Malawi Local Government Act, the key instrument in terms of legislative foundations for decentralization, refers to devolution.

• Political decentralization stalled in 2005. There has at best been 'piecemeal' fiscal + administrative decentralization since then. The 2010 amendments to the 1998 LGA 'clawed back' many aspects of decentralization (p. vii re. both formal + informal recentralization of power and functions). There is lack of coherence/read across between District Development Plans +

District Health Implementation Plans. (O' Neill, Cammack et al 2014)

• The 1998 LGA left 'referral Health Facilities' within the ambit of the central MoH, but did not clearly define what is meant by a referral Health Facility. The 2010 Local Government (Amendment) Bill undermined decentralization + the management of public sector reform. The major lesson provided by Malawi is that there is no automatic relationship between [partial/incomplete] decentralization + efficient public service delivery + development. (Hussein 2012)

• The 2017 National Health Plan II and accompanying Health Sector Strategic Plan II identify the importance of improved governance + strategies to achieve more effective cooperation with stakeholders. The partial implementation of decentralization is viewed as a cause of poor governance in the health sector.

• The current Malawi Health Sector Strategic Plan II 2017 - 2022 (the HSSP II) includes little specific consideration of decentralization. It is unclear whether there has been any coherence between the development of the HSSP II + iterations of the National Decentralization Programme.

• Furthermore, the 2020 Malawi Voluntary National Review Report for the SDGs contains minimal discussion of decentralized/District health structures or their role in work towards achievement of the

SDGs. Thus the section on SDG3 contains no mention of Districts' role in its achievement, or of the importance of data disaggregated by District and contextual priorities.

• HSSP III is currently under development - there is said to be impetus for achieving one single data reporting system (rather that the existing proliferation of donor-supported mechanisms in addition to

DHIS2). In addition, a 'SWAp revival' concept note is under development. There is apparently genuine appetite to ensure HSSP3 applies a more integrated approach to health service delivery, away from programme silos.

The literature review reveals a range of frequently voiced concerns linked to decentralization in Malawi and elsewhere. The points raised in the quotes are echoed in this report.

'Stakeholders view governance challenges as a significant barrier to achieving a more effective and equitable health system. Three categories were identified: accountability (enforceability; answerability; stakeholder-led initiatives); health resource management (healthcare financing; drug supply); influence in decision-making (unequal power; stakeholder engagement)...The partial implementation of the government policy of decentralization was viewed as a cause of poor governance in the health sector.' (Masefield et al 2020)

'The decentralization agenda remains incomplete, even nascent, in Malawi. Genuine decentralized government requires effective coalitions between central and local state and nonstate actors.' (Mohmand & Loureiro 2017).

The following quotes (the first from a Kuunika partner representative) are more specific to decentralization of health data architecture and systems.

'Disjointed planning and asymmetric access to information... Despite the mandate to create periodic District Development Plans (DDPs) and District Implementation Plans (DIPs) with associated budgets, funding and resource allocation decisions are mostly determined centrally... Most plans go underfunded and tough decisions must be made about what will get prioritized...After submission to national level, plans are often returned with a prescribed budget

5 For details of all references see Annex 1.