This report on enhancing human development outcomes through decentralized service delivery in Ethiopia seeks to identify changes in human development outcomes in a period of deepening decentralization and to suggest how the country's decentralized governance structure could be improved to increase access to, as well as the quality of, relevant services. A key message of the report is that the decentralized governance structure helped facilitate improvements in service delivery and human development outcomes, but also, that weaknesses in that structure can derail these gains. The report argues that while policymakers, providers, and citizens must work together to strengthen accountability mechanisms, there is a particular need to strengthen local government and enhance the role of service beneficiaries. The report focuses on key actors and their roles in accelerating progress toward achieving the Millennium Development Goals in Ethiopia. It complements rather than duplicates other recent studies. The report is organized as follows. The first chapter reports on trends in human development indicators and government social expenditures in Ethiopia over the past 15 years. Chapter 2 describes the phasing in of Ethiopia's decentralization plan and presents a framework of mechanisms of accountability for providing services. Chapter 3 examines the scope of decentralization in Ethiopia and the use of intergovernmental transfers. Chapter 4 presents some of the data collected for this report on changes in budget allocation behavior at the woreda level before and after decentralization and the effects on allocations for the social sectors. It also examines changes in key service delivery outcomes at the woreda level. Chapter 5 examines some of the constraints to improved service delivery and proposes ways of increasing resources at decentralized levels, of improving the capacity of local governments and service providers, and of involving citizens in service delivery in a more robust and effective way.