Decentralization Efforts Research Articles

Strategi Pengembangan Desa Wisata Berdasarkan Rencana Induk Pembangunan Kepariwisataan Daerah Tahun 2015 – 2025 Dinas Pariwisata Kabupaten Sleman, Provinsi Daerah Istimewa Yogyakarta

The Sleman Regency Government is one of the regions that enjoys the results of the tourism sector. According to data from the Sleman Regency Tourism Office (Dispar), in 2023 more than 60% of income in the tourism sector will come from cultural tourism, including village tourism and visits to temples and museums. Until semester 1 of 2023, the realization of PAD for Sleman Regency specifically in the tourism sector has reached IDR 164.8 billion or the equivalent of 54.72% of what was targeted. The issuance of Regional Regulation no. 11 of 2015 concerning the Tourism Development Master Plan (RIPK) shows the important role of Tourism Villages and the strategy of Sleman district in organizing tourist areas. The aim of this research is to analyze the Tourism Village development strategy based on (RIPK) Sleman Regency. The research method in this study uses qualitative research by collecting data through interviews, observation and literature study. The results of this research show firstly that the empowerment efforts carried out by the Sleman Regency Tourism Office have been carried out for years and have proven successful. Second, the tourism village program which is pro-poor can be said to be successful. Third, decentralization efforts can be said to be successful. This is realized through several programs that have been well implemented by the government. Fourth, participation efforts from tourist villages in Sleman Regency can be said to be successful. This is realized through community involvement in MUSREMBANG and supervision in terms of managing tourist villages. The five supports for women in developing tourist villages in Sleman Regency can be said to be successful because women have received great benefits. Sixth, self-sufficiency can be said to be successful through collaboration and innovation which is the key to the success of tourist villages. Seven, The integration of development programs has been realized through efforts, namely the construction of physical buildings, poverty training, and empowerment efforts through training have also been carried out

Early Childhood Education And Village Corruption: An Evidence From Indonesia

This study explores the relationship between early childhood education (ECE) exposure and corruptive behavior among village leaders in Indonesia, particularly in light of the decentralization efforts that began in 2014 with the Village Fund Initiative. The objective is to determine whether village leaders who were exposed to ECE in their early years are less prone to engage in corrupt practices when managing public funds. The research utilizes a staggered difference-in-difference approach, comparing corruption cases between leaders exposed to ECE and those who were not. The study collected data from the Indonesian village census (PODES) between 1993 and 2018, focusing on Java Island. The corruption cases were sourced from the Indonesian Supreme Court, specifically analyzing the behavior of village heads elected post-2014. The methodology allowed for a quasi-experimental design by leveraging the timing of village elections as a key variable. The results ECE exposure did not universally reduce corruption across the sample. In fact, corruption surged among early-treated groups who experienced the program in the 1990s, suggesting that ECE alone is not a strong deterrent to corruption. However, for later-treated groups, ECE exposure did lead to a reduction in corrupt behavior, pointing to an adaptation effect as village leaders observed peers being prosecuted for corruption. In conclusion, while early childhood education plays a role in shaping governance outcomes, its impact on reducing corruption is nuanced. The findings suggest that integrating anti-corruption education into the ECE curriculum could strengthen governance at the village level, particularly when combined with robust law enforcement mechanisms

‘Grand designs?’ Investigating the cultural and spatial logics of Channel 4’s media hub workspaces in Leeds, Bristol and Glasgow

This article explores the evolving spatiality of media production through an analysis of recent developments in UK broadcaster Channel 4’s move to a multi-site operating model. Historically, media buildings have served as landmarks of power and influence, embodying the aspirations and identities of media organisations and, as such, offer a fruitful lens for the specific exploration of the spaces of contemporary media production. Through a detailed analysis of Channel 4’s decision-making process, site selections and the significance of the chosen buildings within areas with an urban regeneration focus, the study investigates the complex interplay between media industry dynamics, regional development policies, and wider political and economic forces. Drawing on a range of academic literature and evidence from media, industry and policy reporting, the article highlights the strategic motivations behind Channel 4’s decentralisation efforts, positioned by the organisation as an effort to address diversity in terms of nations and regions representation but significantly shaped by political factors. However, it also raises critical questions about the long-term sustainability, economic viability and cultural impact of these relocation decisions. The article discusses how Channel 4’s regional media spaces and decentralisation reflect the impermanence and crisis facing Public Service Media, emphasising the shifting power dynamics within the media landscape and the need for adaptive strategies in an increasingly volatile industry environment. By examining the evolving investment in media buildings, this research contributes to a growing body of research seeking to understand the complex dynamics shaping contemporary media landscapes and urban environments.

The Discourse of Decentralization in Thailand: A Study of Political, Administrative, and Financial Aspects

The decentralization process in Thailand has been shaped by political history, economic policies, and institutional changes, but remains hindered by a centralized authority and entrenched patrimonial culture. Despite post-1997 reforms aimed at enhancing local democracy, decentralization efforts have faced challenges from political instability, limited resources, and national reluctance to relinquish control. This research employs critical discourse analysis to examine how political, administrative, and financial discourses affect power dynamics, social structures, and governance. Findings reveal ongoing struggles between national and local entities, reflecting broader societal attitudes. The study underscores the need for innovative legal and institutional reforms to address regional disparities, promote good governance, and foster equitable development in Thailand.

Land Regulation and Local Service Provision: Can Economic Growth and Environmental Protection Be Achieved Simultaneously?

This study examines the impact of China’s industrial land approval reform (ILAR) on the provision of subnational services. Utilizing the 2011 pilot reform policy approved by the State Council, we utilize a staggered Difference-in-Differences (DID) method to determine the reform’s impact on local economic growth and environmental protection. The findings reveal that the reform enhances local economic development and decreases pollution levels. Additionally, the reform significantly decreases land resource misallocation in pilot cities, enhancing productivity. We also find that local governments allocate more land to the tertiary sector through this reform, achieving industrial upgrading. The optimization effects are more pronounced in cities with higher fiscal pressure. Based on these findings, we recommend that policymakers sustain decentralization efforts and consider further incentives for cities under fiscal stress. We fill a gap in the literature by linking land use regulation with subnational service provision, contributing to the understanding of the socioeconomic benefits of decentralization and local government service levels.

Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia

BackgroundMulti-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia.MethodsA qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance.FindingsThe principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.ConclusionsPrincipled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

지역 문예회관 활성화에 미치는 영향요인 분석: 지역 특성 요인의 유의성 검증

This study aims to analyze the factors that influence the revitalization of local cultural and arts centers, which have been established to foster regional cultural development and enhance the cultural lives of local residents, within the context of past decentralization efforts and recent emphasis on balanced regional development. Specifically, the study examines the significance of various social and economic conditions affecting local area, such as population decline, regional extinction, aging populations, youth outmigration, and economic slowdown, on the revitalization of local cultural and arts centers. By investigating the causal relationship between the current limitations of local areas and the activation of local cultural and arts centers, the study seeks to propose future strategic directions for regional cultural policies to enhance the vitality of these centers. The research employs a panel regression analysis on data from 53 local cultural and arts centers in small and medium-sized cities, using performance-related data from 2016 to 2020, as detailed in the Board of Audit and Inspection's report on the Status of Population Structure Change III(Local Administration). The analysis reveals that higher operational expertise, achieved through the residency of professional performance groups and the employment of specialized personnel for performance planning and related projects, as well as higher operational capacity for hosting and planning both fine and popular art performances, positively impact the revitalization of local cultural and arts centers. However, regional characteristics were found to have no significant causal relationship with the activation of local cultural and arts centers. Consequently, to enhance the activation of cultural and arts facilities, including local cultural and arts centers, local areas should not remain constrained by their current physical limitations or social and economic issues. Instead, efforts should focus on developing regional culture through the branding of cultural and arts facilities, facilitated by necessary changes in systems and policies that allow for the continuous infusion of professional personnel and high-quality art programs into local cultural and arts centers.

Enacting Decentralized Authority: The Practices and Limits of Moving Beyond Hierarchy

Decentralization as an organizing principle has drawn growing interest from scholars and practitioners because of its perceived suitability for contemporary market conditions and alignment with employees’ evolving work expectations. However, efforts to decentralize authority face significant obstacles and often end in failure. I propose that existing research on decentralization has struggled to generate insight into how such barriers can be overcome because it has treated decentralization as a static outcome imposed by organizational designers. In contrast, this article treats decentralization as a dynamic and situated achievement that must be continually enacted, and it leverages ethnographic data from a decentralization effort in order to build theory on the organizational practices that support enactments of decentralized authority. I find that successful enactments of decentralized authority were supported by practices that established clear boundaries of authority and focused collective attention on these boundaries, as well as by practices that depersonalized collective attributions of the source of authority. At the same time, the practices were difficult to sustain because they were cognitively, emotionally, and temporally demanding. Through this study, I show that decentralization is not merely a one-time structural change but an ongoing collective process that requires navigating and neutralizing the structural and psychological forces pulling organizations back toward hierarchy.

Party Politics in West Bengal: Historical and Contemporary Dynamics

Party politics in West Bengal is a complex and ever-evolving phenomenon deeply rooted in the state's socio-cultural history. This overview explores the dynamic landscape of party politics in West Bengal, tracing its historical evolution and examining the key players, ideological underpinnings, electoral strategies, and socio-economic factors that have influenced voter preferences over the years. From the pre-independence era's freedom struggle to the contemporary political dynamics dominated by the All-India Trinamool Congress (AITC) and Bharatiya Janata Party (BJP), West Bengal's political journey reflects its vibrant cultural mosaic and socio-political complexities. This paper also discusses the current scenario in West Bengal, highlighting the role of various political parties in recent local and assembly elections. The methodology involves a comprehensive review of academic papers and journals on various aspects of West Bengal's politics, governance, and societal dynamics. While existing literature touches on governance-related aspects like healthcare policies, decentralisation, and power sector reforms, there is a research gap in integrating these elements to provide a holistic assessment of West Bengal's governance model. The paper identifies this research gap and calls for a more comprehensive study that explores the interplay of political decisions, decentralisation efforts, and policy reforms in shaping the state's development and governance outcomes.

The Decentralised Governance in Kenya: Implications on Citizen Participation in the Local Governance

Abstract This study sought to examine the extent to which decentralisation efforts have affected citizen participation in local governance in Kenya. Survey research designs was employed. 371 questionnaires were administered and 16 interview conducted with key stakeholders. The findings revealed that decentralisation influences citizen participation in devolved Governance. 77.3% of the respondents agreed decentralization had promoted political entrepreneurship while 75% contended that decentralization had influenced citizen participation in development of policies and legislation. Moreover, 57.2% of the respondents felt that citizen participation in decentralized policy-making was high while 69% of the respondents were satisfied that decentralization had made it possible for citizens to participate in county budgeting. Only 49% approved the effectiveness of decentralization in promoting citizen participation in participatory budgeting and planning process. The national and county governments should put in place measures to safeguard the independence of the counties in realizing the objective of citizen participation in governance.

Is GRDP a mediating factor in enhancing local tax revenues due to ICT development in Indonesia?

Purpose: This study aims to investigate whether the Gross Regional Domestic Product (GRDP) of the information and communication sector mediates the relationship between Information and Communication Technology (ICT) development and local tax revenue enhancement across districts and municipalities in Indonesia. Design/Methodology/Approach: This study uses a quantitative approach to examine how ICT growth, access, infrastructure and utilization affect local taxes and regional levies using panel data from 2017 to 2021.The GRDP of the information and communication sector is incorporated as a crucial moderating variable. Findings: The findings reveal that the GRDP of the information and communication sector plays a vital moderating role in the relationships between ICT factors and local taxes and levies. ICT development benefits local tax systems through increased efficiency, transparency, reduced disparities and enhanced accessibility. Effective ICT infrastructure enables digital fiscal transactions, increasing revenues while improving collection efficiency and reducing income disparities among provinces. High ICT utilization supported by technological proficiency enables local governments to enhance local taxes and levies. Practical Implications: An increase in the GRDP of the information and communication sector leads to higher tax revenues for local governments, funding public services and infrastructure development. Additionally, it attracts investments from other sectors, boosting regional levies and promoting overall regional economic development. The study highlights leveraging the GRDP of this sector as a strategic factor to enhance local tax revenue and regional levies across Indonesian provinces contributing to fiscal decentralization efforts.

Education in Sri Lanka: A Historical, Administrative, and Contemporary Overview with Emphasis on Secondary Schooling

Aims: This research aims to comprehensively explore the historical evolution, administrative intricacies, and current state of secondary education in Sri Lanka, with a particular focus on the post-independence era. It seeks to provide valuable insights into the challenges, initiatives, and policy measures that have shaped the educational landscape in the country.
 Study Design: The study adopts a historical research design, meticulously tracing the trajectory of education in Sri Lanka from ancient times through the colonial periods to the contemporary era. It places a particular emphasis on the post-independence period, scrutinizing administrative reforms, decentralization efforts, and the structure of secondary schooling.
 Place and Duration of Study: The research is conducted in Sri Lanka, encompassing various regions and educational institutions across the country.
 Methodology: Grey literature, including historical documents, archival records, and unpublished reports, serves as a pivotal source for this study. Government reports, policy documents, and contemporary educational sources are analyzed to provide a nuanced understanding of the challenges and initiatives in Sri Lanka's education system. Internal memos, working papers, and non-peer-reviewed literature are utilized to dissect administrative structures, policy measures, and curriculum development.
 Results: The research reveals the intricate historical journey of education in Sri Lanka, highlighting the impact of colonial rulers on the traditional education system. Post-independence challenges and initiatives, such as decentralization efforts and administrative reforms, are scrutinized. The contemporary education system, including diverse school categories and the flow of education from preschool to tertiary levels, is comprehensively analyzed. Key policies, such as free education, medium of instruction, and compulsory education, are detailed to showcase the government's commitment to inclusive and accessible education.
 Conclusion: In conclusion, this study provides a holistic understanding of the multifaceted dimensions of education in Sri Lanka. By examining historical roots, administrative intricacies, and the current state of the secondary education sector, the research sheds light on the enduring pursuit of knowledge and enlightenment in Sri Lanka's educational journey. The findings offer valuable insights for scholars, policymakers, and those interested in the dynamic evolution of education in the country.

"New Regionalism" and Its Implementation in Ukrainian Legislation: The Terminology and the Political Implications

This paper investigates the terminology associated with "New regionalism" and its integration into Ukrainian legislation, analyzing its political and administrative implications. "New regionalism" is a contemporary administrative-territorial reform, with a focus on the principle of subsidiarity, which minimizes central authority intervention in local affairs. While not explicitly present in its regulations, certain subsidiarity elements are part of Ukrainian law. The study explores the adoption and implementation of "New regionalism" principles and terminology within the country's legal discourse. The second aim of the study was to examine how "New regionalism" could potentially influence the political dynamics and administrative structures, particularly in the context of decentralization efforts. By employing systematic and comparative methodologies alongside principles of dialectical analysis, the study offers insights into the evolving landscape of Ukrainian political and administrative terminology alongside its structures, which might play a crucial role in the context of the Russian-Ukrainian conflict.

Home nursing in clinical trials: Result from semi-structured qualitative interviews.

There is a need to transition from conventional (on-site) clinical trials (CTs) to trials conducted within the comfort of a patient's home or community (decentralized CT) through e-consent, remote data monitoring, and telemedicine consults. This shift in trial procedures will positively impact recruitment rates, compliance and participant retention, protocol deviations, and delays or missed visits. Home nursing in CTs (HNCTs) will be an important component of this decentralization effort. A few limitations may impact the implementation of HNCT in India. In this regard, the workstream conducted semi-structured qualitative interviews with experts from diverse domains of CT conduct (researchers from academia and industry, clinicians, investigators, nursing staff, patient research advocates, institutional ethics committee, or institutional review board members, legal experts, and trial participants) to collect their understanding, perspectives, and the ground realities about HNCTs in India. The current review puts forth the key areas that would facilitate the establishment of HNCTs in India and provides recommendations for the same.

Community Participation in Planning Social Infrastructure Delivery in Ghana’s Local Government: A Case Study of Shai Osudoku District

The unintended consequences associated with non-inclusive participation are a key structural challenge facing Ghana’s decentralisation efforts over the past 25 years. This article uses a social transformation framework to examine the planning process in the delivery of social infrastructure. The qualitative descriptive design that draws from the naturalistic paradigm provided an in-depth exploration of stakeholder participation in planning social infrastructure delivery. Results suggest that the planning process is initiated by the district assembly within a legal framework and for which local participation is by invitation. The article argues for the setup of a local management team as part of the structure for social infrastructure delivery.

Decentralization of Environmental Governance in Pakistan and its Impact on Sustainable Development

Environmental governance is a key instrument towards sustainable development that requires full information, sound decision-making procedures, implementation of rules and their execution according to internationally accepted standards. While Pakistan has made progress in devising legislations and laws to manage major environmental issues, it is still not as close to its target of achieving sustainable development despite several decades of efforts at environmental regulation and governance. This paper evaluates the post-18th Amendment scenario regarding the achievement of sustainable environment through better environmental governance in Pakistan. The country is facing serious environmental challenges of ever-increasing environmental pollution, losing fertile lands, depleting fragile water resources and poor human development. Pakistan ranks 161 among 192 countries regarding its Human Development Index (HDI) because of its dismal performance in the fields of education, health, and income. In 2022, Pakistan’s Environmental Performance Index (EPI) ranking was 176th among 180 countries with a score of 24.6. Despite decentralization efforts, Pakistan has failed to achieve considerable improvement in environmental governance and management. To address these issues, there is a need to review the pros and cons of the 18th Amendment in the constitution of Pakistan objectively and modify it if needed. To facilitate inter-provincial and inter-sectoral coordination, different institutions, and statutory bodies relevant to environmental governance formed after the 18th Amendment should be made functional to devise comprehensive and collaborative strategies for sustainable development.

Decentralization in Public Policy and Governance of Public Services in Alaska, USA

Public policy is developed through a process of policy analysis, debate, and decision-making, involving various stakeholders such as government officials, civil society organizations, and citizens. . Effective decentralization requires careful planning, institutional design, and monitoring and evaluation to ensure that it promotes good governance and produces positive outcomes for citizens. Effective governance structures and processes are necessary to develop and implement effective public policies, while well-designed public policies can help to promote good governance by fostering transparency, accountability, and participation. The research used the descriptive research design. The target population was 40 public officers in Alaska, USA. Questionnaires were utilized to gather the data. The study found that decentralization in the public policy and governance of public services in Alaska, USA have significant effects on the efficiency, effectiveness, and responsiveness of the system. By transferring decision-making authority and responsibilities from central government entities to local or regional authorities, decentralization allows for increased local autonomy and tailored decision-making. Local authorities, such as municipalities or regional governments, have a better understanding of the specific needs and priorities of their communities. The study concluded that decentralization in public policy and governance of public services in Alaska has the potential to enhance local responsiveness, citizen engagement, and overall effectiveness of public service delivery, while also necessitating careful attention to address potential challenges and ensure equitable outcomes.  The study recommended that effective implementation of decentralization in the public policy and governance of public services requires strengthening governance structures, capacity building, fostering citizen participation, ensuring equitable resource allocation, and continuous monitoring and evaluation. Decentralization requires solid institutional capacity at all levels of government to ensure that policies are effectively implemented and resources are efficiently utilized. Monitoring and evaluation are critical to assessing the effectiveness of decentralization efforts and identifying areas for improvement Keywords: Decentralization, public policy, governance, public services, USA

Evaluating TB diagnosis and care in the Union of the Comoros.

The Union of the Comoros has experienced a persistent notification gap in TB cases despite several strategic changes, including molecular diagnosis and contact investigation. We therefore performed a TB patient pathway analysis (PPA) under the National Tuberculosis Programme (NTP). To assess the alignment of healthcare-seeking behaviour and TB service availability to clarify the reasons for these missing cases. Three primary data sources, including a national list of health facilities, TB surveillance data and care-seeking behaviour data, were analysed at the national and regional levels to determine access to TB diagnosis and the initial point of care-seeking. Summary data were visualised using the standardised PPA Wizard programme, and the analysis was completed using demographic and socio-economic data. At the initial point of care-seeking, 18% of patients had access to TB services, available only in nine centralised public health facilities. Furthermore, 30% of patients initially consulted in the informal sector and 45% in the formal public or private sector in health facilities, both of which lacked the capacity for TB diagnosis or first-line treatment. The concentration of and limited access to TB services at the intermediate and central levels of care indicate a need for decentralisation efforts.

Fiscal Decentralization, Taxation Efforts and Corporate Green Technology Innovation in China Based on Moderating and Heterogeneity Effects

Corporate green technology innovation is an effective way to achieve regional sustainable development goals (SDGs). Based on fiscal decentralization as a green function that empowers provincial governments with fiscal powers that are highly relevant to regional sustainable economic decision-making, this paper focused on the impacts of fiscal decentralization on corporate green technology innovation, as well as the moderating roles of taxation efforts. Taking China’s listed corporations from the period of 2005 to 2019 as the research sample, we constructed green technology innovation indicators at the corporate level. The empirical results were as follows: firstly, fiscal decentralization significantly promoted corporate green technology innovation on the whole; secondly, the synergy effects of fiscal decentralization and taxation efforts were strongly positive, implying a substantial promotion of corporate green technology innovation; thirdly, heterogeneity tests found that the synergistic effects of fiscal decentralization and taxation efforts were more significant in promoting corporate green technology innovation in eastern China, non-state-owned enterprises (non-SOEs) and manufacturing corporations. The above results were proven to be equally valid after a series of robustness tests. We suggest that provincial governments should be granted more fiscal autonomy, and that taxation efforts should be optimized to promote corporate green technology innovation.

Voyaging through the paediatric surgical maze: A multi-centre analysis of inter-hospital referrals to Johannesburg, South Africa

IntroductionPaediatric surgery is a centralised service that is provided at only three public sector hospitals in Johannesburg, South Africa. These centres receive an overwhelming number of referrals from over fifty lower-level hospitals. The aim of this study was to analyse referrals to these specialist centres in order to quantify the unmet referred burden of disease and to identify ways in which paediatric surgical access in the region can be improved. MethodsA prospective descriptive study was conducted over a 1-year period (01/06/21–31/05/22). All inter-hospital referrals from lower-level hospitals to the three Johannesburg-based specialist centres were analysed. Results2394 unique referrals to 3 hospitals were recorded. Five main diagnoses were responsible for 68% of all referrals: neonatal surgical conditions, burns, acute abdomen/bowel obstruction, trauma and symptomatic hernias. 59.7% of all referred patients met criteria for emergency transfer to a specialist unit. 26.7% of these patients, however, were unable to be transferred owing to a lack of bedspace at specialist centres. Transferred patients experienced significant time delays between referral and arrival. Four lower-level hospitals have been identified as possible sites for service expansion. ConclusionA large unmet paediatric surgical burden of disease has been identified. Lower-level hospitals have been identified that may be suitable for the implementation of decentralisation efforts to improve access to paediatric surgery within the region. Level of EvidenceV