Turning decentralisation from policy ambition into a working system.
Malawi's Comprehensive Health Sector Devolution Plan.
An institutional-architecture case — a system, not a summary.
Founder experience · Ministry of Health & Sanitation consultancy · 2026
Overlaid at every tier
Who does what, at every tier — the devolution architecture.
The problem
Decentralisation is national policy, but the operating question is unanswered: who actually does what — functions, financing, drug budgets, human resources, accountability — between the Ministry of Health, Local Government Authorities and the Ministry of Local Government? Without that architecture, devolution stalls.
Why it was hard
It sits across multiple institutions with overlapping mandates, contested financing and HR arrangements, and weak intergovernmental coordination — a governance-design problem, not a technical one.
The approach
- 1
Conducted policy and institutional analysis of the National Decentralization Policy, Local Government Act and health-sector frameworks.
- 2
Assessed the status of devolved functions — financing, HR, drug-budget management, service delivery and coordination.
- 3
Ran structured consultation with Ministry of Health directorates, the local-government ministry, Local Government Authorities, District Health Management Teams, partners and civil society.
- 4
Designed the governance architecture — functions to devolve versus retain, reporting lines, accountability, financing and HR — with a monitoring and evaluation framework.
What was created
Inception Report
Situational Analysis
Draft Devolution Plan
Stakeholder Consultation / Validation Report
Final Devolution Plan
A devolution governance architecture and M&E framework
What changed
Delivered the plan and architecture that operationalise health-sector devolution, validated with the Ministry of Health Senior Management Team. Adoption and rollout sit with the Ministry.
Frameworks & methods
What this demonstrates