Decentralization

This cross-sectional study was carried out in four states that were selected according to geopolitical and administrative criteria to identify the effects of decentralization on health financing and governance policies in Mexico from the perspective of users and providers. The report discusses the effect of decentralization on health service providers and community involvement. Data collection was performed using in-depth interviews with health system key personnel and community leaders, consensus techniques and document analyses. [adapted from author]

All decentralization initiatives require making changes in the structure of the agency or organization, which means making changes in how the work gets done. It means developing new management systems, training staff in the skills that they will need to perform in their new roles, designing or modifying service delivery systems, and developing strategies for enhancing the long-term sustainability of the program.

This study reviews the experience of decentralization in four developing countries: Ghana, Uganda, Zambia and the Philippines. It uses two analytical frameworks to describe and compare the types and degrees of decentralization in each country. The first framework specifies three types of decentralziation: deconcentration, delegation and devolution. The second framework uses a principle agent approach and innovative maps of decision space to define the range of choice for different functions that is transferred from the centre to the periphery of the system. [from abstract]

Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization — the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization.

Both the advocates and the detractors of decentralization are probably wrong. A thoughtfully designed process of decentralization is not likely to radically improve a health system, nor is it likely to severely disrupt the system. We have evidence that a well-designed decentralization can improve equity of allocations and may have other positive effects such as increased funding of promotion and prevention. Its influence over efficiency and quality is not as clear. These guidelines suggest some mechanisms which can be effective in the design and implementation of decentralization.

This comparative study evaluates the implementation of decentralization of health systems in three Latin American countries: Chile, Bolivia, and Colombia. In terms of the relationship between decentralization and system performance in general, the findings support the conclusion that both the die-hard detractors and the fervent advocates for decentralization are wrong. Decentralization appears to be improving some indicators of equity, such as a tendency toward similar per capita expenditures for wealthier and poorer municipalities, and to be associated with increased and more equitable per capita spending on promotion and prevention.

This document offers some help in addressing decentralization for health sector actors interested in designing decentralization policies and strategies, implementing them, and/or operating within decentralized health systems. [author’s description]

The objective was to examine whether decentralization has improved health system performance in the State of Ceara, north-east Brazil. Decentralization was associated with improved performance, but only for 5 of our 22 performance indicators. Moreover, in the multiple regression, decentralization explained the variance in only one performance indicator; indicators for informal management and political culture appeared to be more important influences. However, some indicators for informal management were themselves associated with decentralization but not any of the political culture indicators.

The general argument for decentralizing health care is the potential for improved service quality and coverage. This note raises the issues to consider if decentralization is to bring about beneficial results. A table summarizes a general framework for assigning responsibilities to central and local levels, while the rest of the note outlines a series of issues to consider. [From author]

Decentralization of political and administrative power, combined with a civil service reform, are increasingly prevalent components of health sector reform. The wider implications of decentralization for human resources development are, however, poorly researched and inadequately understood. This paper analyzes these implications from the experience of the author, her colleagues and published literature. [from abstract]

This article considers some of the effects of health sector reform on human resources for health (HRH) in developing countries and countries in transition by examining the effect of fiscal reform and the introduction of decentralisation and market mechanisms to the health sector. [adapted from abstract]

This paper examines evidence from published literature on decentralization’s impact on the demand side of the human resource equation, as well as the factors that have contributed to the impact. The elements that make such an impact analysis exceptionally complex are identified. They include the mode of decentralization that a country is implementing, the level of responsibility for the salary budget and pay determination, and the civil service status of transferred health workers. The main body of the paper is devoted to examining decentralization’s impact on human resource issues from three different perspectives: that of local health managers, health workers themselves, and national health leaders.

This article discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region. The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. [from abstract]

TEHIP (Tanzania Essential Human Interventions Project) was designed to test how and to what extent evidence can guide decentralized planning of the health sector at District level. From the outset, the evidence set included burden of disease, cost effectiveness, health system capacity, and community voice. The Burden of Disease Tool and the Community Voice Tool have been developed as planned. The Cost-Effectiveness Tool has been designed but left on the shelf due to the need to introduce some new precursor tools that had not been foreseen. These include the District Cost Information Tool, the District Health Expenditure Mapping Tool (both of which have been developed and applied) and a District Intervention Coverage Tool that is under development. Also, for the health system capacity, a number of innovations and new tools have evolved including the District Integrated Management Tool, the District Health Mapping Tool, The Community Ownership Strategy, and Strengthening Health Management and Administration. All together, these tools and strategies can be seen as major “interventions” into the capacities of the TEHIP supported districts and must be understood in that sense when comparing the performance of such districts with those with conventional approaches to planning and resource allocation.

This report presents findings from a survey of 252 primary health facilities and 30 local governments carried out in the states of Kogi and Lagos in Nigeria in the latter part of 2002. Nigeria is one of the few countries in the developing world to systematically decentralize the delivery of basic health and education services to locally elected governments. Its health policy has also been guided by the Bamako Initiative to encourage and sustain community participation in primary health care services. The survey data provide systematic evidence on how these institutions of decentralization are functioning at the level local—governments and community based organizations—to deliver primary health service.

This is the fourth of a series of policy briefs produced by the Community Health Department of the Aga Khan Health Service in Kenya. It focuses on a number of issues related to the management of health facilities: the rational for decentralisation of health services, the role of the community in the management of health facilities, the membership of local management committees, selection criteria and, finally, the involvement of local politicians.

These briefs are primarily intended for directors and managers of community-based health care programmes — whether working within ministries of health, international donor agencies or non-government organisations.