Health decentralization : a double-edged sword of power transfer to districts

SOS Médias Burundi

Bujumbura, January 13, 2026 – By entrusting district administrators with the appointment of district medical officers and directors of municipal and district hospitals, the Burundian government is taking another step in implementing the new administrative division. Presented as a lever for decentralization and bringing health services closer to the population, this reform nevertheless raises questions about its implications for the technical independence of the health sector and the quality of care.

The reform, formalized after the legislative and district elections of June 5, 2025, has profoundly reshaped Burundi’s territorial organization. The number of provinces has been reduced from 18 to 5, the number of districts from 119 to 42, while the number of administrative zones has increased from 339 to 447. The number of villages has also increased, from 2,910 to 3,037. These changes reflect the stated commitment to bringing the administration closer to citizens and strengthening decentralization.

The chief medical officers of health districts, as well as the directors of communal and district hospitals, will now be appointed by the district administrators. The decision was announced by the Secretary General and Government Spokesperson, Jérôme Niyonzima, following the Council of Ministers meeting held last week in Bujumbura, Burundi’s commercial capital.

A reform aligned with the new administrative divisions

Each district is now comprised of one or two health districts, each covering a specific population and a geographical area encompassing several administrative zones. An administrative zone can only fall under the jurisdiction of a single health district, in order to avoid overlaps and ensure a coherent organization of health services.

Decentralizing to bring services closer

The Council of Ministers recommends that the chief medical officers of health districts and the directors of municipal and district hospitals be appointed by the district administrator, in accordance with the spirit of decentralization. However, administrators retain the option of recruiting these officials from outside their district, if necessary, to address shortages of qualified personnel.

Risks of interference highlighted

While the reform aims to strengthen local accountability and adapt health services to district realities, it is not without its critics. Observers are concerned about the risk of political or administrative interference in a technical sector where decisions should be based on professional criteria, experience, and performance. The politicization of appointments could weaken health governance and, ultimately, affect the quality of care provided to the population.

Outdated signs and incomplete decentralization

The Council of Ministers also recommended the removal of unnecessary signs and the updating of names on administrative buildings. Despite the new administrative divisions and the restructuring of ministries, many old signs remain visible, creating confusion and access difficulties for the public.

In several localities, the old signs indicating the boundaries of districts and administrative zones remain in place, complicating citizens’ wayfinding and sometimes forcing them to walk long distances to access administrative services, contradicting the stated objective of bringing public services closer to the people.

A reform awaited on the ground

While the new administrative divisions aim to bring the administration and social services closer to the population, many challenges remain. For many observers, the success of healthcare decentralization will depend not only on the transfer of power to districts, but above all on the transparency of appointments, adherence to professional criteria, and the State’s ability to support the reform with concrete measures that benefit citizens.