In Cote d'Ivoire, decentralization is a process that accelerated following the economic crisis of the 1980s and under pressure from donors. It is based on arguments of efficiency, rationality, responsiveness and its capacity to increase community participation. From the 2000s onwards, devolution has been deepened by the creation of several types of local governments and the transfer and distribution of powers from the state to them. However, the appropriation and implementation of these competencies are lacking, resulting in the fragmentation of the planning and coordination of local health activities, and a weakness in accountability mechanisms and quality of care. In short, the operationalization of the deconcentration/devolution pair in the health sector is a complex process that must be implemented in an incremental, participatory, mixed manner combining top-down and bottom-up approaches. It must take into account the interests of the various stakeholders through a participatory planning process and consensual coordination of local activities.