Considerations at the sub-national/district level

The sub-national/district level of a health system should be defined in accordance with local jurisdictions. It typically encompasses geographical areas within the country, such as provinces, regions, districts or counties, which provide some health administrative functions for specific populations. The extent of responsibility varies from country-to-country based on the division of roles among the various entities and authorities within the country. For example, in centralized health systems, the central government plays a strong role that is supported by proximal administrative points (e.g., province, district, county, etc.) to facilities. However, in decentralized systems, the central government generally supports the sub-national levels in applying consensus guidance, policy and regulations from the national level. How these are applied is determined at sub-national level. There are also autonomous systems, which provide their support independently of the central government. In addition to these types of system differences, health system fragmentation may also exist, separating certain programmes or functions of the health system from one another and resulting in discoordination. All these parameters need to be considered carefully when planning the use of tools for activities at the sub-national level.

This section of the Toolkit contains further information and links to tools that support the following functions at the sub-national/district level:

These functions may also be important in addressing and carrying out key actions to implement a plan in a given district, or the most proximal responsible administrative post to referral hospitals for a specific area. The Quality health services: a planning guide provides further detail on the following key actions to consider at the district level, when supporting efforts to improve quality of care:

• Align district commitment to national quality goals and priorities.
• Develop district structures and an operational plan (where they already exist, update them based on learning from health facilities and national direction).
• Orient health facilities to district and national-level quality goals and priorities.
• Respond to facility needs in reaching selected aims and ensure functioning support systems for quality health services.
• Maintain engagement with the national level.
• Adapt any quality intervention packages to the district-level context.