Table 2 Criteria used for assessing decision space at local levels for the purpose of qualitative analysis (adapted from Bossert [21])

a. Planning

Local decision-makers prioritise and develop their own health plans

Local planning possible only if with assistance from the central level

Local planning already taking place, but only optimal if accompanied by significant assistance from the central level

Local planning optimal despite minimal involvement of the central level

Local decision-makers implement the plans that they developed

Implementation possible only with central level support

Implementation being done but only completed if central level support is available

Full implementation possible even without central level support

b. Financing and Budget Allocation

Local decision-makers have their own sources of income to finance health services

Financing mostly dependent on central sources of funds

Mixed financing, such that local sources of financing are augmented with central sources

Financing mostly provided by local sources of funds

Local decision-makers spend the budget allocated for health services

Spending mostly restricted by guidelines imposed by the central level

Some of the budget controlled by the local level, and some regulated by the central level

Spending mostly follows how local decision-makers wish to use the budget

c. Programme Implementation and Service Delivery

Local decision-makers implement their own health programmes and services

Local programmes and services mostly follow only what is promulgated from the central level

Local programmes and services follow nationally mandated programmes but also include locally initiated and innovative programmes that address local needs

A good number of innovative programmes and services implemented at local levels with little supervision from the central level

Local decision-makers deliver health services with good quality

Local programmes and services implemented with poor quality

Local programmes and services implemented with good quality when central level provides additional support and training

Local programmes and services implemented with good quality despite minimal central level involvement

d. Management of Facilities, Equipment and Supplies

Local decision-makers put up the number and type of health facilities needed in their areas

Local facilities built and upgraded mostly through central support

Some facilities built and upgraded by the local level but still a large number of constructions or renovations provided by the central level

Local facilities built and upgraded mostly through the local level’s own efforts and resources

Local decision-makers ensure functionality of these facilities with adequate equipment and supplies

Local facilities mostly rely on central support for equipment and supplies

Mixed, such that equipment and supplies are provided by both the local and central levels

Local facilities adequately equipped and supplied from the local level’s own efforts and resources

e. Health Workforce Management

Local decision-makers hire (and fire) the health workforce needed by the local population

Local levels unable to hire the workforce needed

Local levels able to hire some of the workforce required, but central level augments many vacancies through deployment of its own staff

Local levels able to hire most of the workforce on their own

Local decision-makers support the career development of the health workforce

Few opportunities at local levels to support the career development of their workforce

While local levels can support the career development of their workforce, a big chunk of training is still provided by the central level

Training and support for the career development of the workforce sufficiently provided by local levels

f. Data Monitoring and Utilisation

Local decision-makers collect the relevant indicators

Data collection delayed and poorly validated, unless the central level requires and enforces it

Local levels collect the data in a timely and accurate manner when assistance is provided by the central level

Timely and accurate data collection despite minimal intervention from the central level

Local decision-makers use the data to inform actions

Utilisation of the collected data for actions at local levels not practiced

Local levels collect the data, but central level provides guidance on how to use the data

Data clearly used for actions by the local levels themselves