Decentralization and Health Systems Reform: Overview

1
Decentralization and Health Systems Reform
Overview

• Dr. Derick W. Brinkerhoff
• Partners for Health Reformplus
• Presentation for
• USAID Global Health Mini-University
• Washington DC
• May 12, 2002

2
Decentralization Purposes

• Decentralization is a policy pursued for a
  variety of purposes
• Political
• Administrative
• Financial.
• Many health sector reforms include
  decentralization as a major component.
• Decentralization is like the elephant and the
  blind men.

3
Decentralization Definitions

• Deconcentration transfer of authority and
  responsibility from central to field offices of
  same agency.
• Delegation transfer of authority and
  responsibility from central agencies to
  organizations outside their direct control (e.g.,
  NGOs, private sector).
• Devolution transfer of authority and
  responsibility from central government to lower
  levels through statutory or constitutional
  measures (e.g., regional and/or municipal
  governments).

4
Thinking about Definitions

• Remember that
• Decentralization is not all or nothing.
• There is not one best way to decentralize.
• The right mix of central and local depends upon
  political, technical, and institutional factors.

5
Decentralization Objectives

• Increase service delivery effectiveness through
  adaptation to local conditions and targeting to
  local needs.
• Improve efficiency of resource utilization by
  incorporating local preferences into
  determination of service mix and expenditures.
• Increase cost-consciousness and efficiency of
  service production through closer links between
  resource allocation and utilization.
• Increase health worker motivation through local
  supervision and involvement of service users in
  oversight, performance assessment, etc.

6
More Decentralization Objectives

• Improve accountability, transparency, legitimacy
  by embedding service delivery in local
  administrative systems.
• Increase citizen participation in health service
  delivery by creating systems and procedures for
  involvement in planning, allocation, oversight,
  and evaluation.
• Increase equity of service delivery by enabling
  marginalized and poor groups to access health
  care providers and to influence decisions on
  service mix and expenditures.
• Increase the role of the private sector in health
  service delivery by separating financing from
  service provision.

7
Health Reform and Decentralization Objectives

• Most reforms contain several of these objectives.
• Many of the objectives are complementary.
• But there can be trade-offs, tensions, and
  conflicts.

8
Decentralizing Health System Functions
9
Critical Issue Mismatch between authority and
responsibility

• Responsibility for managing health workers
  delegated to local units, but center retains
  authority for hiring, firing, and promotion.
• Local units are responsible for health care
  spending, but have no revenue-raising authority.
• Center assigns new responsibilities, but provides
  no additional resources.

10
Critical Issue Tensions and conflicts among
objectives

• Shifts in service mix away from priority services
  toward local preferences.
• How to reconcile?
• Central guidelines, requirements for matching
  funds.
• Set-asides and earmarking.
• Retention of functions at center.

11
Critical Issue Capacity gaps

• Weak local technical and administrative capacity.
• Weak financial capacity risks of corruption.
• Shifting roles of the center less service
  provision, more oversight, regulation,
  stewardship.

12
Critical Issue Tensions between vertical and
horizontal integration

• Vertical programs versus integrated local-level
  services.
• Supervision and oversight.
• Role of the community.

13
Critical Issue Attention to politics and process

• Winners and losers.
• Whose objectives?
• Stakeholder participation.
• Advocacy.
• Conflict resolution and negotiation.

14
Guidance and Lessons Designing Decentralization

• Identify which health system functions that some
  degree of decentralization would improve.
• Identify the objectives of decentralization for
  each of those functions.
• Consider which decisions would be made most
  effectively at central and local levels, by whom.
  Balance with objectives and capacities.
• Map current administrative/financing structure.
  Identify potential sources of tension, conflicts,
  capacity problems, political issues.
• Build in phased implementation, capacity
  building, feedback mechanisms and monitoring and
  evaluation (ME) plans.

15
Guidance and Lessons Implementing
Decentralization

• Identify major stakeholders, clarify winners and
  losers.
• Develop plans for negotiation, compromise,
  advocacy and problem solving.
• Maintain a monitoring system for key policy
  processes and interim results.
• Establish a feedback and decision process to keep
  reforms on track and/or make mid-course
  corrections.
• Where possible, pilot test decentralization
  components that are likely to be problematic and
  where stakeholders do not agree.

16
Guidance and Lessons Evaluating Decentralization

• Establish an ME plan that uses routine
  monitoring information in combination with
  periodic field reviews.
• To avoid unintended consequences, develop
  long-term evaluation design to measure impact of
  decentralization on major objectives and on
  bigger picture health sector objectives.
• Separate results due to decentralization versus
  other factors that may be contributing to that
  result, such as a decline in utilization of
  priority services.