Literature review A. Decentralisation in health care. Decentralization has been promoted by advocates of health sector reform in developing countries...

Literature review

1. Decentralisation in health care.

Decentralization has been promoted by advocates of health sector reform in developing countries for decades. Decentralization is widely promoted in health system reform. Decentralization is one important tool in improving governance. Yet not all government functions can be decentralized.

The concept of decentralization as defined by the field of public administration focuses on the ways by which a national political structure manages the distribution of authority and responsibility of health services. As a result the analysis leads toward recommendations as to how to shift responsibility and authority from the centre to the periphery of the administrative system.

The term “decentralization” has been used to connote a variety of reforms characterized by the transfer of fiscal, administrative, and/or political authority for planning, management, or service delivery from the central MOH to alternate institutions. These recipient institutions may be regional or local offices of the same ministry, provincial or municipal governments, autonomous public service agencies, or private sector organizations. Decentralization has been predicted to improve health sector performance in a number of ways, including the following: (1) improved allocate efficiency through permitting the mix of services and expenditures to be shaped by local user preferences; (2) improved production efficiency through greater cost consciousness at the local level; (3) service delivery innovation through experimentation and adaptation to local conditions; (4) improved quality, transparency, accountability, and legitimacy owing to user oversight and participation in decision making; and (5) greater equity through distribution of resources toward traditionally marginal regions and groups. At the same time, fears have been raised about potential macroeconomic destabilization and the aggravation of interregional disparities in wealth and institutional capacity as a result of decentralization (Prudhomme 1995).

Decentralization is one of the main components of health sector reform in a wide range of countries. It is widely recognized that management, planning, and policy functions in the health sector may be carried out more efficiently and effectively, if they are decentralized (Mills et al, 1990; Collins, 1994).

According to Thomas 2015, Decentralization has long been advocated as a desirable process for improving health systems. Recently, it has been seen as an integral part of broader health reforms to achieve improved equity, efficiency, quality and financial soundness. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve these objectives. We do not have adequate means for analysing the three key elements of decentralization:

• the amount of choice that is transferred from central institutions to institutions

At the periphery of health systems;

• what choices local officials make with their increased range for discretion

• What effect these choices have on the performance of the health system.

Decentralization of health-care services has the potential to improve efficiency of health services and equity of outcomes. The countries which are at different levels of decentralization agreed on the strategic framework and that there was a need to address factors influencing the process of decentralization, including health decentralization as a stand-alone policy; weak local management; ineffective referral care; management of vertical programmes; fragmented health information systems; and low civil society participation.

Potential benefits of decentralization

Decentralization and governance

Decentralization is about governance. The word governance has two meanings. One refers to ‘the complex of institutions and organizations which regulate the life of society. It encompasses rules (formal and customary law, regulations internal to organizations, moral imperatives, contractual obligations, etc.) and social aggregations (the family, church, municipality, professional associations, political parties, banks, commercial enterprises, cooperatives, courts of law, government, and parliament). The other meaning refers to ‘the act of governing’, that is to the way institutions are established (for example how laws are proposed and enacted) and to the way organizations behave, manage their affairs and govern people. Both meanings are encompassed in the term ‘good governance’. An increasing awareness of the importance of good governance was a key feature of the 1990s. This refers to the system that is appropriate to achieving such goals of society as stability, growth, equity, justice, efficiency and the practice of those who run the organizations in such a way as to achieve those goals. In this Sourcebook our concern with good governance is more narrowly focused on the effective provision of agricultural support services. Achieving good governance may require an analysis and reform of the institutions underpinning a country’s political, cultural, and bureaucratic framework. Decentralization, in its broadest sense, thus becomes a central point of the new approach.

Decentralization and improved service delivery

Decentralization also aims at an economic and political system that responds more closely to people’s preferences and requirements. By bridging the gap between suppliers and users of goods and services, decentralization measures are expected to achieve three major objectives:

• Improved efficiency in service provision

• More transparency of service providers

• Better accountability to service users.

1. Deconcentration

Deconcentration is generally the most common and limited form of decentralization, and involves the transfer of functions and/or resources to the regional or local field offices of the central government agency in question. Within a deconcentrated system, authority remains within the same institution (e.g., the ministry of health) but is “spread out” to the territorially decentralized instances of this institution (Rondinelli (1981),

De-concentration gives sub-national governments some responsibilities within a sector, but all relevant decisions are made by the ministerial branches. A typical model is for the central line ministries and agencies to have local representatives that manage services within the sub-national governments but respond hierarchically to their own central office. (Rondinelli 1981 and Wallich and Seddon 1999). Under this type of administrative decentralization, local governments typically cannot hire or fire personnel, do not set salary levels, and cannot change the structure of the network of service facilities in place (i.e., number, size, and type of facilities). Local branches and representatives in charge of services simply manage day-to-day operations on behalf of the central ministry and under its watchful eye.

The primary objective may be improving the production efficiency of the administration with an improvement in the impact of the services delivered as a second priority. This may be achieved by introducing administrative and cultural changes within the existing unitary structures, shifting responsibility, decision-making authority and resources for front-line operations only to the managers of local units. Public delivery and public financing coincide within a single administration. Central government personnel and procurement policies apply. In these cases decentralization takes the form of deconcentration.

Deconcentration assigns specific functions and tasks performed by the staff of the headquarters of central administrations to staff posted in peripheral locations within the national territory. Staff, equipment, vehicles, and budgetary resources are transferred to units such as regional and district offices. The managers of these units are given authority for autonomous decision making regarding the operations, which were previously taken at headquarters, or needed clearance from headquarters.

Deconcentration it’s often considered to be the weakest form of decentralization and is used most frequently in unitary states redistributes decision making authority and financial and management responsibilities among different levels of the central Government. It can merely shift responsibilities from central government officials in the capital city to those working in regions, provinces or districts, or it can create strong field administration or local administrative capacity under the supervision of central government ministries. Deconcentration is evident where the bureaucratic hierarchy in a Ministry of Health extends from regional and district levels down to small communities in both urban and rural areas, with the employment of health workers responsible for health education, environmental health and primary care. Front-line health workers forming an extension of the formal health organization are usually referred to as village health workers, whereas those who are paid for by, and accountable to, the local community are usually called community health workers.

Advantages of deconcentration

 Enables ministry officials to provide the support needed by other decentralized institutions. For example, village health committees may need to be supported by field personnel if the level of social organization in the village is low

 Develop the skills of field staff in the collection, management and analysis of epidemiological studies. This enables the field staff to demonstrate that their decisions are more appropriate for their area than decisions taken centrally

 Field offices are also able to gain support for health projects from local government.

 Deconcentration also enables ministry officials to provide the support needed by other decentralized institutions. For example, village health committees may need to be supported by field personnel if the level of social organization in the village is low

Disadvantages of Deconcentration.

Professionalism of the staff of the formal ministerial hierarchy inhibits flexibility, assumes health policy can only be made by experts who have a monopoly of health knowledge, and limits the role of local people to implementation. Thus responsiveness to local needs can be a problem for deconcentrated personnel.

 Intrasectoral coordination may be inhibited by managers having different levels of delegation, institutional jealousies and lack of commitment resulting from unstable employment