Thomas J. Bossert, Ph.D.

Harvard T.H. Chan School of Public Health


The author’s 1998 article on decentralization focused on the element of choice as the major issue of decentralization – granting authority and responsibility for choice to administrative and elected officials at peripheral levels of organizations and governments – and introduced the concept of “decision space” to describe the range of choice allowed to local authorities for different functions (financing, service delivery, human resources, governance).  This approach was based largely on principal agent theory focusing on how central authorities can circumscribe local choice by establishing rules over choice and by providing incentives for making choices that would achieve central objectives. 

This chapter reviews this approach and discusses its evolution in empirical studies first focusing on defining the formal decision space (in Ghana, Uganda, Zambia and  Philippines) and then expanding to surveys that assess the actual or informal decision space that officials reported they were able to exercise (Nicaragua and Morocco). 

In a more recent phase of research, the author has now expanded the scope of study to examine two additional concepts – institutional capacity to make good decisions and accountability to local elected officials – and the interaction among decision-space, capacity and accountability.  Preliminary findings on studies using this approach in Pakistan and India are presented.

In conclusion, the chapter reviews the importance of refined definitions of decentralization to assessing what form is most effective in achieving policy makers’ objectives.


Bossert, Thomas J. and Joel C. Beauvais, Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy and Planning 17(1): 14-31.

Bossert, Thomas J., Mukosha Bona Chitah and Diana Bowser. “Decentralization in Zambia: Resource Allocation and District Performance.” Health Policy and Planning 18 (4): 3587-669.

Bossert, Thomas J., Osvaldo Larrañaga, and Fernando Ruiz Meir. “Decentralization of health systems in Latin America.”  Pan American Journal of Public Health Vol. 8, Nos. 1/2:  84-92.

Bossert, Thomas J. (1998), “Analyzing the decentralization of health in developing countries: decision space, innovation and performance.” Social Science and Medicine 47: 1513-27.

Bossert, Thomas J., Osvaldo Larrañaga, Ursula Giedion, Jose Arbelaez and Diana Bowser. “Decentralization and Equity of Resource Allocation: Evidence from Colombia and Chile.” Bulletin of World Health Organization, 2003, 81 (2) pp. 95-100

Bossert, Thomas J., Diana Bowser and Leonor Corea. Studies of decentralization of the health system in Nicaragua: Final Report. Harvard School of Public Health and Management Sciences for Health. September 2001.

Bossert, Thomas J., Volcan Cakir, Diana Bowser, and Andrew Mitchell. Morocco Decentralization Study: Summary of Preliminary Findings. Harvard School of Public Health and John Snow Incorporated. 2003.

Bossert, Thomas J., Diana M. Bowser and Johnnie K. Amenyah. “Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala,” Health Policy and Planning 2007/ 22: 73-82.

Bossert, Thomas J. and Andrew D. Mitchell (2011). “Decentralization and local decision-making: Decision Space, Institutional Capacities and Accountability in Pakistan.” Social Science and Medicine 72 , pp. 39-48.

Bossert, Thomas J., Andrew Mitchell and Muhammad Anwar Janjua. “Improving decentralization for health in Pakistan” submitted for publication in World Development 2011

Bossert, Thomas J., Andrew Mitchell, Prarthna Dayal and Madhu Sharma. Decentralization of Health in the Indian States of Uttar Pradesh and Orissa: Analysis of Decision Space, Capacities and Accountability. World Bank. February 2008

Bossert, Thomas J., Andrew Mitchell, Sumit Mazumdar, Paolo Belli. Decentralization of Health in the Indian State of West Bengal: Analysis of Decision Space, Institutional Capacities and Accountability. World Bank, January 2010.

Bossert, Thomas J., Andrew Mitchell, Nathan Blanchet. Governance and Decentralization of Health Systems in Vietnam: Analysis of Provincial Organization, Decision Space/Accountability and Capacity. World Bank, 2010

Brinkerhoff, Derrick W. (2004). “Accountability and health systems: toward conceptual clarity and policy relevance.” Health Policy and Planning 19(6): 371-9

Channa, A. and J.P. Faguet. 2012. “Decentralization of Health and Education in Developing Countries: A Quality-Adjusted Review of the Empirical Literature.”  LSE/STICERD Working Paper No. EOPP 38.

Faguet, J.P. 2014. “Can Sub-National Autonomy Strengthen Democracy in Bolivia?” Publius: The Journal of Federalism, 44(1): 51-81.

Faguet, J.P. and Z. Ali. 2009. “Making Reform Work: Institutions, Dispositions and the Improving Health of Bangladesh.” World Development. 37: 208–218.

Faguet, J.P. and F. Sánchez. 2014. “Decentralization and Access to Social Services in Colombia.” Public Choice, 160(1-2): 227-249.

Faguet, J.P. and F.B. Wietzke. 2006. “Social Funds and Decentralization: Optimal Institutional Design.” Public Administration and Development, 26(4): 303-315.

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King, Gary, Emmanuela Gakidou, Kosuke Imai, Jason Lakin, Ryan T Moore, Clayton Nall, Nirmala Ravishankar, Manett Vargas, Martha María Téllez-Rojo, Juan Eugenio Hernández Ávila, Mauricio Hernández Ávila, Héctor Hernández Llamas. “Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme” The Lancet, 2009; 373: 1447–54

Mitchell, Andrew and Thomas J.Bossert. “Decentralization, Governance and Health System Performance: ‘Where you stand depends on where you sit’. ” accepted for publication by Development Policy Review.

Peckham, S., Exworthy, M., Powell, M., & Greener, I. A. N. (2008). Decentralizing health services in the UK: a new conceptual framework. Public Administration, 86(2), 559-580. 

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