Health sector reform and organizational issues at the local level: Lessons from selected African countries

Experiences with health sector reform in four countries in Eastern and Southern Africa (Botswana, Tanzania, Mozambique and Zambia) are discussed. While the aims and options for reform are similar, the context and the approaches taken are different. The paper identifies district level organizational issues arising from decentralization, the introduction of user fees, and privatization, with particular reference to implications for planning and resource allocation and human resource management. Findings suggest that reform requires comprehensive rather than selective approaches, and that inadequate attention has been given to analysing the preconditions for, and implications of, reform efforts and to ensuring consistency. The need for differentiated approaches to reform, and for tailoring reform to the capacity in the system to own and manage reform, is stressed.