Strengthening district health systems to achieve Malawi's decentralisation objectives: lessons learnt from Malawi's Blantyre Prevention Strategy.

The Alma-Ata 'Health for All' Declaration of 1978 emphasised community participation in health systems and the need to 'bring health care as close as possible to where people live and work'. Since then, decentralised approaches that leverage the proximity of local governments to their populations have emerged as the preferred model for health systems over fully centralised structures. The district health system, particularly in low- and middle-income countries, has evolved as a key framework to advance the Alma-Ata vision and strengthen health system governance in decentralised settings. However, implementation has often been hindered by limited local capacity, raising a persistent question: how can district health systems be strengthened to achieve decentralisation objectives? Using Malawi's ongoing Blantyre Prevention Strategy (BPS), a systems-based project designed to build local capacity at district and city levels for HIV prevention, as a case study, this paper-reviews policies and frameworks guiding health sector decentralisation in Malawi and examines how BPS is contributing to strengthening the district health system and supporting broader decentralisation efforts in Malawi's health sector.