The promise and reality of decentralization: a critical appraisal of Sierra Leone’s primary health care system

Post-war reconstruction in Sierra Leone was accompanied by an ambitious donor-promoteddecentralization programme aimed at making delivery of the country’s failing social servicesmore efficient. A decade after the ‘decentralization’ of health services, this article examines systemic failures that have resulted in de-concentration rather than devolution of the health system. It identifies four factors that have contributed to a dysfunctional decentralized provision of primary health care. First, is an inconsistent political and legal framework that blurs and distorts delineations of authority between central and subnational government institutions. This leads to three further challenges that interact to create an ineffective public health sector: the central government is resistant to devolution, partly due to a culture of accumulation; local-level interventions are uncoordinated; and there is limited accountability for frontline health workers. As a result, citizens’ health needs are unmet. Sierra Leone is plagued by some of the worst maternal and child mortality rates in the world, and faced the most intractable outbreak of the 2014–2015 Ebola epidemic. Drawing on participant observation and interview data, this article suggests that building a resilient decentralized primary health care system will largely depend on the willingness of the centre to meaningfully devolve power and resources to subnational governments, and establish amutual accountability mechanism in which actors at all levels are held accountable.