Abstract-Key policy questions on decentralization in health relate to whether and in which ways health sector decentralization can improve health outcomes. Focusing on a maternal, neonatal, and child health program in Pakistan, this study examines relationships between three dimensions of decentralization: the degree of local decision-making choice ("decision space"), individual and institutional capacities, and local accountability. Additionally, these relationships are examined at two points in time to assess whether "capacity building" interventions, as well as any changes in decision space, are related to improvements in health sector performance as measured by improved administrative processes and indicators of health coverage in important primary care services. The study is based on surveys administered in 2006 and 2009 to local health sector decision-makers in 15 districts in Pakistan-ten of which received capacity-building assistance from the US government-funded maternal and child health project (PAIMAN), and five control districts not receiving capacity-building interventions. Findings indicate that while local authorities in both districts reported using wider decision space by 2009, institutional capacities in PAIMAN districts improved to a higher degree than in comparison districts. Officials in neither set of districts reported significant changes in their accountability to local elected officials, although those districts with more decision space and institutional capacities mobilized greater local support for health programs. Extending findings from an earlier study focused on similar questions, there were strong synergies among the dimensions of decentralization for different health sector functions, as well as some evidence of associations between stronger institutional capacities/wider decision-space and improvements in health coverage and in better administration of the health system. Findings suggest that targeted capacity-building activities at the district level may contribute to improved decision-making abilities and, in turn, improved health system performance.
Keywords: decentralization; Pakistan; capacity building; maternal, neonatal, and child health; accountability.