The findings show that while other African countries successfully implemented such reforms, Malawi has been struggling due to institutional bureaucratic constraints. It is in this regard that after an initial health sector decentralization programme transfer based on learning approaches championed by one donor organization had failed to be implemented due to bureaucratic factors, other donor organizations had to jump in with coercive top-down means to the Government which made the bureaucrats start the actual devolution process, though reluctantly. Thus despite the earlier reform learning interventions, the ultimate move to decentralize health services has been a political one with a push from donors while the Ministry of Health’s (hereafter MOH) bureaucrats have resisted. This chapter therefore contributes to the understanding of the role of international organizations and the importance of contextual factors in the international transfer of public sector reforms.