DECENTRALIZATION IN HEALTH SYSTEM DEVELOPMENT

Shreejeet ShresthaMPH, M.Sc. Medical Microbiology

WHAT IS HEALTH SYSTEM?

Health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations.

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.(WHO, 2007)

HEALTH SYSTEM DEVELOPMENT (HSD)

Necessitates For The Development Of Health Care Systems

Continuous support to policy and managerial practices for appropriate infrastructure and logistics

Use of technology, information collection and dissemination, organization of health workforce development at national and institutional levels,

Universal coverage and Sustainable financing, and Assured quality and safety in health-care

MEASURES OF HSD Identify and remove health-system bottleneck Monitor the progress and programs in

coverage Intervention packages and health-system

strengthening (Health Care Service Delivery) Address the Human Resources Crisis Strengthen the Health Systems

(Decentralization) Efforts of improve harmonization

WHAT IS DECENTRALIZATION?

According to WHO in 1990, Decentralization is

transfer of authority or dispersal of public

planning, management and decision making from

the national level to sub-national levels

Decentralization shifts decision-making powers to lower-levels of government and entails setting legal and regulatory provision to ensure the: Favorable political environment Good coordinating and cooperating mechanism Initiatives are sustained and required strong political permanence. Entities act in conformity at national standard Citizens have access to local decision making

NEED FOR DECENTRALIZATION

At the past, many countries in the world, particularly the countries

in Asia and Africa strengthened the national and regional

administration by reducing the responsibility of the local

government

But now, many of these countries realized the need to strengthen the

peripheral and local authorities and have adopted decentralization as

one of the major means for implementing the reforms.

NEED FOR DECENTRALIZATION (CONT:)

There are many complex reasons why governments in various countries are beginning to decentralize their services. For exampleDemands for more regional autonomy have

played a major role in Papua New Guinea and Spain

Political ideologies were important in Chile and Yugoslavia

The need to rationalize over burdened and outmoded administration plays a large role in New Zealand and Srilanka

CONCEPTS OF DECENTRALIZATION

On philosophical and ideological level, decentralization

have been seen as an important political ideal, providing

the means of community participation, local self reliance

and ensuring the accountability of the government

officials to the population.

CONCEPTS OF DECENTRALIZATION (CONT: )

Decentralization policies are usually initiated by

central governments and only subsequently are

adopted by the health sectors. This means that the

central government has initiated a national policy by

adopting constitutional changes that set the pattern

for the reforms to be adopted by the different

ministries.

DECENTRALIZATION IN HEALTH SERVICES

Decentralization is one of the main concept for Health

system Development

Decentralization of health system structure and

management is a key issue for many countries in the

achievement of “Health For All” and in the

development of Primary Health Care. (Health System

Decentralization; Concepts, Issue and Country

Experience, WHO, Geneva 1990)

In practice, health system decentralization takes many different

forms, depending not only in overall government political and

administrative structures and objectives, but also on the pattern

of health system organization prevailing in the particular

country.

Decentralization demands a holistic approach, and the

decentralization of health services cannot be looked into in

isolation. As a part of reforms in the health care delivery

system, decentralization is currently being promoted in many

countries as a means to improve the performance and

outcomes of national health care systems.

It is often imputed that health ministries in developing countries

have a reputation of being the most bureaucratic and least

effectively managed institutions. Such centrally managed health

care systems, by and large, are poorly structured, badly led and

inefficiently organized.

Failure of such systems spawned the need for "people centered"

health care systems that build on bottom-up approaches in

planning, allow wider participation of people in needs

assessment, ownership over there sources and facilities and

stewardship of the local bodies.

OBJECTIVE AND RATIONAL FOR DECENTRALIZATION IN HEALTH SERVICES

Objective Rationale

1) To improve technical efficiency

Through fewer levels of bureaucracy and greater cost consciousness at the local level

Through separation of purchasers and provide functions in market-type relations.

2) To increase allocative efficiency

Through better matching of public services to local preferences

Through improved patient responsiveness3) To empower local governments

Through more active local participationThrough improved capacities of local

participation4) To increase the innovation of service delivery

Through experimentation and adaptation to local conditions

Through increased autonomy of local governments and institutions

Objective Rationale5) To increase accountability

Through public participationTransformation of the role of the central

government6) To increase quality of health services

Through integration of the health services and improved information systems

Through improved access to health care services for vulnerable groups

7) To increase equity Through allocating resources according to local needs

Through enabling local organizations to better meet the needs of particular groups

Through distribution of resources towards marginalized regions and groups (through cross –subsidy mechanisms)

DIFFERENT APPROACHES TO DECENTRALIZATION:

Public administration approachLocal fiscal choiceSocial capital approachPrincipal agent approach

PUBLIC ADMINISTRATION APPROACH focuses on the distribution of authority and

responsibility for health services within a national political and administrative structure.

different forms of decentralization:DeconcentrationDelegationDevolutionPrivatization

LOCAL FISCAL CHOICEwas developed by economists to analyze

choices made by local governments using their own resources and inter-governmental transfers from other levels of government.

It has been applied mainly in federal systems where local governments have had a history of constitutionally determined authority and significant locally generated resources.

SOCIAL CAPITAL APPROACHfocuses on explaining why decentralized

governments in some localities have better institutional performance than do governments of other localities.

Applied to health care, this approach suggests that those localities with long and deep histories of strongly established civic organizations will have better performing decentralized governments than localities which lack these networks of associations.

PRINCIPAL AGENT APPROACHproposes a principal (individual or institution)

with specific objectives and agents who are needed to implement activities to achieve those objectives.

Agents also have an advantage allow them to pursue their own interests at the expense of the principal.

HOW CAN WE MAKE DECENTRALIZATION?

Decentralization policies are usually initiated by central governments and only subsequently are they adopted by the health sector byadopting constitutional changes that set the

pattern for the reforms to be adopted by the different ministries

making innovative choices within the decision spaces of local authorities

using local governments own resources and intergovernmental transfers from other levels of government (local fiscal choice model)

HOW CAN WE MAKE DECENTRALIZATION?

equalization funds allocation formulae for intergovernmental

transfers allocation rules that earmark funding for

specific purposes training exercises for local authorities and

communities to achieve institutional performance (social capital approach: Putnam, 1993)

FLOW CHART OF DECENTRALIZATION

CASE STUDIES FOR DECENTRALIZATION

MALDIVES AND DECENTRALIZATION The Seventh National Development Plan states that “the

health policy of the government is targeted to ensure access to primary health care to all citizens in an equitable manner”.

Health Master Plan for 2006-2015, the Government of Maldives has committed itself to provide equitable access to health care for all its citizens.

The government aims to achieve these goals primarily through decentralization of health services and the primary health care approach.

“Act on Decentralization of the Administrative Divisions of the Maldives”, 2010.

This is the Act on the creation of offices, posts, island councils, atoll councils and city councils and the determination of their characteristics, jurisdiction and required principles or rules for the purpose of decentralized administration of the Maldives as stipulated in Chapter 8 of the Constitution.

DECENTRALIZATION IN MYANMARGrowing the needs to involve all relevant sectors at all administrative

levels to mobilize the community more effectively in

health activities health committees had been established in various administrative levels down to the wards and village tracts

These committees at each level were headed by the responsible person of the organs of power concern and include heads of related government departments and representatives from the social organizations as members.

Heads of the health departments were designated as secretaries of the committees.

CASE STUDIES OF NEPAL FOR DECENTRALIZATION IN HEALTH SERVICES During the past few decades, many countries have embarked

on the decentralization of public services. Nepal has also tried to adopt decentralization as a key reform process. 

During the 1990s there was significant progress in the development of health systems under the framework of long-term (1997–2017) health plans and policies, guided by a vision of equitable access and the principles of community participation, decentralization, gender equality, effective services management, and a public–private partnership approach.

Under the guidance of these plans and polices, Nepal has made visible progress in health sector reform despite the nature of difficult topography (hills, mountains).

The main drivers for decentralization in Nepal include: socio-economic inequalities, multi-ethnicity and cultural heterogeneity, poverty, low efficiency of centralized delivery systems and the global phenomenon of decentralization.

As in other countries, two important factors—technical or managerial, and political motives—are major contributing factors behind the decentralization process.

 In the governance system, decentralization and local self-governance have been made operational in Nepal since the 1960s.

In 1999, Nepal enacted a Local Self-Government Act (LSGA) and this Act, whose monitoring committee was chaired by the Prime Minister, laid the foundation for establishing a local self-governance system adopting a broad-based and cross-sectoral approach.

This Act recognized the role of local self governance and devolution of authority and responsibility to make local authorities more responsive and accountable to people.

The rationale for this Act was both philosophical and practical and involved legislation, institutional provision, resources (both financial and human) mobilization and considerations, i.e. autonomy and equality.

One of the major reforms in Nepal's health sector under decentralization was the restructuring of health services.

In 1987, the centre (MoH) underwent change and as a result—Regional Health Directorates were established in five development regions in Nepal.

Restructuring of the district health services (preventive and curative) was considered to be vital for meeting the health needs of local populations.

A unique feature of the health sector in Nepal is that there is a strong community-based health workforce (more than 50 000 female community health workers in addition to 28 000 public health staff) across the country who are mainly responsible for preventive care.

Since 2001/02, over 1435 primary health care facilities (100% in the study district) devolve to the local community management. Government is now in the process of devolve other health care facilities i.e. district hospitals, zonal and regional hospitals to the management of local committees. 

RECOMMENDATIONS AND CONCLUSION

Decentralization is regarded as the most important force in improving efficiency as well as equity and responding to local health conditions and demands.

STRENGTH OF DECENTRALIZATION

Governance Trained local and district managers Formation of DMHT for inter-sectoral collaboration Creation of new posts at sub district level for

monitoring at grass root levelFinancing Retention of taxes by district Autonomy for need-based allocationResources and services Outsourcing leading to regularity, punctuality and

service delivery Procurement of drugs at district level

WEAKNESS OF DECENTRALIZATIONGovernance Lack of administrative capacity and accountability Selection on personal and political choice Lack of power delegation at sub-district level Lack of practical planning at local level Lack of focus on preventive side Lack of evidence based policy making Duplication of power between provincial and

district governments Limited authority on vertical programs Bureaucratic resistance

WEAKNESS OF DECENTRALIZATION

Financing Allocation are not need-based Late release of funds Underpaid health care workers Extra-burden of non-development funds

Resources and services Lack of capable trained health care staffs and doctors Lack of laboratory facilities Transport for emergency referrals Failure to deliver service practically Tertiary service excluded Non-functioning HMIS

CONCLUSION Implementing decentralization in the health sector

has many advantages for the health system development, primary health care and health for-all strategies.

However, decentralization is very sensitive political issue, for it concerns the distribution of power and allocation of resources.

The adoption of a national policy on decentralization is only the beginning of a lengthy process that strong political commitment over many years to achieve the good results.

REFERENCES http://

indonesiahealth.wordpress.com/2010/10/26/objectives-of-decentralization/

http://www.hsph.harvard.edu/ihsg/publications/pdf/No-54.PDF 

http://www.burmalibrary.org/docs14/Myanmar-Health-Care-System.pdf

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