Improving Local Health Systems for Global Health Results

Will localizing public health systems improve health outcomes? The Urban Institute hosted an expert roundtable event in June 2014 to try and answer this question, bringing together technical experts, practitioners, funders and researchers to highlight opportunities for improving health outcomes at the local level.

The post-2015 Sustainable Development Goals are increasingly focused on “inclusive development,” an effort to ensure that resources for social welfare reach poor, marginalized and base-of-the-pyramid communities. This awareness presents an opportunity to better localize health interventions and strengthen global health outcomes by bringing together the knowledge, resources and expertise of two growing practice areas: public health services and decentralized local governance. But there are significant gaps in today’s research.

The group identified key opportunities and challenges in developing these local health systems, as well as shared priorities for new research. Some of the most significant challenges in developing better interventions are both technical and political:

  1. Financial and performance data is often unavailable at the local level,
  2. The data that does exist is rarely credible or effectively verified,
  3. The relationships and motivations of local institutions cannot be ignored,
  4. The donor community is missing the last mile of decentralization where local governments interact with service providers such as health facilities and schools, and
  5. External donor financing is not a sustainable fix to under-resourced local services, and many LGAs face tremendous difficulty in maintaining the same level of resources and staff when foreign support ends.

Many local governments lack capabilities like adequate reporting systems or sufficient training to manage the information, but systemic problem like political obstacles and poor internal incentives can discourage even the most ambitious technical solutions.

What should funders and development partners take away from this?

Considering these obstacles, the development community could contribute to lasting and systemic improvements by focusing on four areas:

  • Improve the basic ability of local authorities and stakeholders to track, record and manage valuable data like public expenditures and service performance to inform decision-making;
  • Collect operational data from local government authorities to develop case-sensitive and cross-cutting insights about the difficulties and opportunities of devolving public services;
  • Recognize that external performance programs like results based financing (RBF) will inevitably change incentives and relationships within government structures, and they cannot be simply layered on top of dysfunctional systems; and 
  • Identify local constraints and administrative “bottlenecks” in service delivery, and consider how new health and public finance systems can be best integrated within existing systems.

What is Urban doing to help?

The Urban Institute is documenting intergovernmental structures and financing for service delivery in 31 countries through the Local Public Sector Initiative (LPSI) and Urban Service Delivery framework. We’re spearheading a global research effort on “localizing” public services and how they contribute to the post-2015 development agenda. And in eastern Africa, the Urban Institute is investing in new research on strengthening local health systems and inter-governmental finance for service outcomes.

As our methodology expands to new countries, we are leveraging our access to service information and generating new insights into health systems performance. This data will provide strategic guidance to governments and donors on how to prioritize public services and develop more targeted reforms for the greatest social impact.

Learn more about the Urban Institute’s work improving local service systems with the links below, or by watching video coverage of the June event. A full agenda of the event is available for more information.


Panel 1

Presentation: Improving health outcomes through improved governance and finance: the state of knowledge and practice

Damien de Walque

Panel / Roundtable Discussion: Improving health outcomes through improved governance and finance

Ken Leonard (Chair), Tom Bossert, Damien de Walque, Rena Eichler 


Panel 2

Presentation: Strengthening the intergovernmental context for achieving inclusive and sustainable local health services

Jamie Boex

Panel / Roundtable Discussion: Strengthening the intergovernmental context for achieving inclusive and sustainable local health services

Serdar Yilmaz (Chair), Jamie Boex, Eunice Heredia-Ortiz, Francois Vaillancourt


Panel 3

Panel / Roundtable discussion: State of Practice, Filling Knowledge Gaps and Moving from Knowledge to Implementation

Laura Pavlovic (Chair), Jeremy Kanthor, Ken Leonard, Serdar Yilmaz


Learn More:

Given the vast scale of the global development challenge, it is increasingly clear that the Millennium Development Goals (MDGs) are pursued in a manner that is excessively top-down in nature and that the distance between central government authorities and their citizens is too large for central authorities to effectively empower the people over the public sector. This paper explores to what extent local public entitieswhether in the form of elected local governments or through deconcentrated local departments of the national government-can contribute to achieving poverty reduction and development outcomes.

Localizing the MDGs: Unlocking the Potential of the Local Public Sector to Engage in Development and Poverty Reduction

UI is setting out build on LPSI’s initial findings by analyzing the role of the local public sector on global development outcomes in health and education from 2000 through 2010 for approximately 60 developing and transition countries, with support from the Development Partner Working Group on Decentralization and Local Governance (DELOG). 

Urban Institute's Local Public Sector Initiative branches out