DECENTRALIZATION AND SRH SERVICES

1
DECENTRALIZATION AND SRH SERVICES

• Ranjani Murthy

2
Objectives

• Be acquainted with concepts on decentralization
• Be aware of the global implications of
  decentralization for SRH services
• Be familiar with some strategies for advocating
  SRH services in the process of decentralization

3
DECENTRALISATION

• Decentralisation
• Transfer of authority or power
• Political, fiscal or administrative
• From national to sub-national levels

4
Arguments of advantages of decentralization (may
not use this)

• Local needs can be heard, and so can SRH needs.
• Greater accountability of services to poor, and
  to women.
• Integration across sectors possible- essential
  for SRH outcomes
• Integrated health/SRH services can be better
  provided
• Local resources can be additionally raised and
  used

5
DECENTRALISATION
6
DECENTRALISATION

• Scope of decentralisation
• What and How Much is decentralised varies

7
DECENTRALISATION

• Scope of decentralisation
• What? Decentralisation can cover
• Financing arrangements
• Resource generation, management and allocation
• Prioritisation of services
• Human resource management
• Broader governance

8
DECENTRALISATION

• Scope of decentralisation
• How much? There is a range of choice
• Narrow
• Moderate
• Wide

9
Decentralization and equity

• Important to look at equity between districts,
  sub districts, and between households
• Impact depends on
• Whether there are special funds for resource poor
  areas
• Whether there are mechanisms to transfer funds
  from resource rich to poor areas
• Whether decentralized units impose lower taxes
  and user fee exemptions for poor

10
Decentralization and effectiveness in addressing
health need

• Scope of decentralization
• Depends on priority setting at local level
• Depends on resources generated and transferred
• Whether health personnel management is
  decentralized, and the willingness of the
  personnel to be managed by decentralized units
• How refferal coordination is managed
• Whether elected people are aware of health needs,
  and they prioritise public health interests over
  their individual interests

11
Decentralization and other reforms

• Mismatch between
• Priority setting and decentralization
• Financing reforms and decentralization
• Public private partnerships and
  decentralization

12
Decentralization and accountability

• Can further accountability only if
• Scope of decentralization and resource
  availability
• Marginalised groups are well represented in
  decision making
• Their capacity to strengthened, and that of
  decentralized bodies
• There is flow of information, transparency

13
Decentralization of health, India

• 1.XI Schedule includes the following
•  
•         Health and Sanitation, including
  hospitals, primary health centers, and
  dispensaries
•         Family Welfare
•         Women and Child Development
• 2.      The XI Schedule specifically mentions
•         Public Health
• India, can see devolution (some states),
  de-concentration (mainly) and delegation of
  health services- different states different
  models
• Political most, Kerala higher- fiscal,
  Maharashtra- administrative         

14
Questions for role play

• Identify the actors in the role play
• Who is supportive of decentralization, and who is
  against it? Why?
• Who is supportive of SRH service provisioning,
  and who is against it? Why?
• What is the effect of decentralization on SRH
  services?
• What measures did the sexual and reproductive
  rights and health expert recommend for
  strengthening SRH services?
• What was the outcome of the lobbying by SRRH
  expert?

15
Implications of devolution on SRH
services(Source adapted Rama Lakshminarayanan)
16
Implications of devolution for SRH
17
What can be done

• Increase representation of women as members and
  leaders (not proxy)
• Activation of health committees at GP, PU, ZP
  levels
• Building pressure from women, and youth groups
  from below to demand SRH, monitor allocation to
  health/SRH, local priority setting, health
  expenditure, quality of services, ensure
  equitable financing
• Use religious forums to challenge interpretation
  of texts by local government/conservative forces
• Press for mandatory implementation of national
  SRH package, but adapted to local conditions
• Advocate central resource transfer to poorer
  areas
• Additional central funds for SRH service
  delivery, and mechanisms to track its use
• Local government budget monitoring from a SRH
  lens (also 10 womens component)
• Building capacity of local government on SRH and
  service management
• Strengthening coordination between different
  levels of local government
• Strengthening monitoring and evaluation
  indicators from SRH lens

18
Recommendations on decentralization health

• Devolve powers??, with strengthening the factors
  necessary to make it work
• Make preventive/promotive health care compulsory
• Plan for devolution
• Revamp role of DOH- capacity building of
  different stakeholders- strengthen capacity to
  perform the above role
• Work with health professional associations to
  strengthen capacity of professionals in people
  and management skills
• Allocate adequate resources, transfer to poor
  provinces
• Salary and appointment through LGUs
• Promote Long term planning
• Integrate planning at different levels
• Integrate with other required changes in the
  health sector