Issues in Program Design
|Contributor: World Bank
Author: Decentralization Thematic Team
Contact: Jennie Litvack
Decentralization & Health Care
What is Decentralization?The term 'decentralization' is used to describe a wide variety of power transfer arrangements and accountability systems. Policies range from the transfer of limited powers to lower management levels within current health management structures and financing mechanisms to extensive sectoral reform efforts which reconfigure the provision of even the most basic services. In the first case, decentralization may later become the driving force for health sector reform; in the latter, it is driven by the wider sectoral reform efforts. The parameters for decentralization -- the speed, the pressures, and the scope of issues to consider -- vary considerably.
The Promise of DecentralizationHealth sector decentralization has become appealing to many because of it has several theoretical advantages. (Mills et al. 1990) These include the potential for:
We Don't Have Much InformationLittle concrete evidence exists to date, however, to confirm that these potential benefits can be realized. Few developing countries have long-term experience with health sector decentralization, and its impact on the management of the sector and on the services it delivers has rarely been evaluated. Thus, the debate whether decentralization does indeed improve equity, efficiency, accountability and quality in the health sector continues without data to inform it. Although anecdotal and country-study evidence confirms that poorly designed and hastily implemented decentralization has serious consequences for health service delivery (Gilson et al. 1994, Kolehmainen-Aitken et al. 1997), we do not have a clear analytical framework to isolate or generalize the factors behind successful and unsuccessful decentralization. (Bossert 1997)
A First Attempt at a FrameworkPast experience shows that achieving the benefits of decentralization depends heavily on policy design. In general, careful attention must be given to health service needs and priorities in deciding which functions and programs to transfer and which to retain under central control. If a function is critical to the attainment of central-level goals and its sustainability at the local level cannot be guaranteed, it should not be decentralized. With this in mind, the table summarizes a general framework for assigning responsibilities to central and local levels, while the rest of the note outlines a series of issue to consider.
1. Local government's freedom to adapt to local conditions must be balanced by a common vision about the goals of the health sector and the purpose of decentralization in furthering these goals. Decentralization policy should include some coordinating mechanism.The prominence of local political interests increases as decentralization transfers more responsibility to this level. While responsiveness to local demands is a benefit of decentralization, it brings two main disadvantages. First, local officials frequently change and may, therefore, be uninformed about key national health policies. Second, local groups may also oppose national policies. One provincial governor in the Philippines banned a donor-funded project in support of family planning services. (It is certainly acceptable and indeed desirable if decentralization enables local governments to design programs according to local preferences; however, services of national priority (e.g., family planning) should be mandated and funded by the central government.
2. Adequate financing and clear delineation of new financial flow mechanisms is essentialIn the preoccupation with defining an essential package of basic health services or a new decentralized health service model, the crucial issue of financing the decentralized health system may be overlooked. A significant financial gap between what is available and what is being planned can compromise the health sector's ability to provide equitable, efficient and good quality services under decentralization. Zambia and South Africa are both facing this issue in their current decentralization efforts. Several guidelines emerge from past experience:
3. Capacity constraints cannot be ignored in either central and decentralized management levels.Ignoring capacity constraints at either central or local levels, or giving inadequate or delayed attention to training staff for their new roles are very serious omissions with predictable effects on health services. Decentralization places a considerable new management burden especially on the lower levels. Qualified health managers are in very short supply in many countries. Furthermore, management training capacity may be insufficient to meet the rapidly expanding training needs. Madagascar, for example, has begun to transfer planning, management and budgetary authority to 111 health districts without having a sufficient number of qualified health managers to serve all these districts. Decentralization changes the roles of the central ministry staff from line management to policy formulation, technical advice and program monitoring. The central-level managers also require systematic retraining and reorientation, which, however, many countries have overlooked. In other cases, staff cuts at the central ministry of health have been so severe that the center's capacity to function effectively is in question. It has been suggested that this is the case in Ethiopia at the moment. In Nepal, initial staff cuts at the central level paralyzed the Expanded Program on Immunization.
ConclusionIn summary, decentralization creates major challenges for health service provision. Active involvement of health managers in the decentralization design, clear national resource allocation standards and health service norms, and an ongoing system for monitoring are essential for guarding equity and quality and for improving efficiency.