Table 1.

Threats and protective measures influencing the success of devolution reforms

	Threat	Protective measure
Context	This political process occurs within and is influenced by the social, economic and political context. Historical norms may permit nepotism and corruption, may continue and thrive unless challenged by transparent and strong accountability mechanisms.	The ‘handing over’ of responsibilities between levels is a political process, influenced by the unique social, economic and political context within which reforms occur. Ideally reform process should be carefully planned out in advance and take place over time. Knowledge and recognition of the context and introductions of actions to challenge existing norms should be put in place to ensure distribution of funds which takes into consideration the underlying county poverty level and ability to raise sufficient local revenue.
Process	Resistance to the reform process by central government actors, may contribute to ineffective implementation and failure to build capacity for local government.	Strong and committed political leadership at national and sub-national levels, with willingness to share power, authority and financial resources.
	Lack of clarity on roles and responsibilities by actors will hinder transparency and contribute to confusion within the priority-setting process.	Clear understanding at each level of rights, expected standards, roles and responsibilities
Actors	Limited administrative and management capacity within local government, may deepen inequalities between formerly marginalized and non-marginalized areas	Actions planned in advance of reforms to build adequate institutional capacity for administrative, technical, organizational, financial and human resource management across the system and at individual level.
	Failure to address power imbalances between actors within counties may lead to entrenchment of influence in favour of local elites and continued exclusion of vulnerable individuals from priority-setting processes.	Accountability measures should be established in advance, which are responsive to local civil society preferences, while still ensuring improved population health and health sector performance.
Content	If poorly planned, devolution may contribute to the selection of priorities which increase disparities.	If well planned with needed capacity and accountability measures in place there is opportunity to reduce inequities and promote UHC.