Decentralization & Health Care Site Index Main Page	Contributor: World Bank Author: Decentralization Thematic Team Contact: Jennie Litvack

Function	Assignment/Rationale
	Central	Local/Subnational
Program Design	Information dissemination and parameters for priority national programs with externalities that reach beyond individual communities-e.g..Family planning or vaccination programs.	Details of service delivery mechanisms.
Financing	Transferring resources to ensure local government's ability to carry out responsibilities, setting minimum requirements for expenditure on maintenance and training in order to assure consistent quality and sustainability.	Setting user charges/cost-recovery mechanisms, planning expenditure allocations within parameters set by national standards.
Standard-Setting	Central government should carry out functions such as licensing health professionals, registration and quality control of drugs. The capacity for licensure rarely exists at the local level and in countries (such as India) where this fucntion has been decentralized, pharmaceuticals of questionable quality and safely freely cross from states with a poorly managed drug registration system to other better managed states.
Service Delivery	Functions whose execution at the peripheral level is not cost-effective should also be kept central. In many countries, this would include vaccine and pharmaceutical procurement and biomedical equipment maintenance.
	The complex linkages between different services require more planning of appropriate organizational roles, relationships and organizational structures. Serious distortions and hindrances to health service delivery are created, if functional roles and organizational strucutres are devised without full participation of health managers. In the Phillipines, the integrated district health office concept that had taken years to develop was destroyed, when provinces were handed the responsibility for managing hospitals, and municipalities became responsible for primary health care. No linkages were created between these two levels of health service, even though the patient load and quality of service in one are higly dependent on the other. In Bolivia and Zambia, the small size of many local governments has similiarly separated primary care from its secondary referral facilities. In Papua New Guinea, the failure to speecify clearly the new roles and responsibilities for subsidy payments to church-run health services resulted in a severe funding crisis, which forced the churches to close many of their health facilities for a time. Since churches provide about one half of all rural health care in that country and are well integrated with the public sector, large numbers of rural residents were deprived of any access to health services.
Legal Responsibility	The legal and/or regulatory implications of decentrlization for the work of health personnel must be considered to avoid placing health staff at risk. In the Phillippines, the legal protection of local government health staff under a national malpractice legislation has been questioned. In Papua new Guinea, provincial health inspectors after decentralization could no longer legally enforce national legislation concerning the cleanliness of markets, restaurants and work places.