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DECENTRALIZATION

• A transfer of authority to make policies and
  decisions, carry out management functions and use
  resources from central government authorities to
  local government, field administration,
  semi-autonomous corporations, area-wide or
  regional development organisations, functional
  authorities, sub-ordinate units of government or
  specialised functional authorities
• (Cheema Rondinelli, 1983)

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Decentralization

• By
• Dr Arshad Usmani
• Lahore, Pakistan

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Historical Perspectives

• 1950 1960 General strategy for the provision of
  public services in Africa under Colonial
  Administration   
• 1970 1980 Under adoption of Rural Based
  Strategy by Donors Governments,
  Decentralisation considered appropriate for
  effective Management, Planning and Community
  Participation
• 1980 1990 New-Right Thinking approach i.e.
• Privatisation
• Limitation of state role
• Quasi- market in public sector
• Decentralised service provision

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Decentralization Rationale

• A component of Health Sector Reforms (HSR)
  programme
• Scarce financial resources
• Low efficiency quality of health care
• Political will
• Pressure from donors
• To improve PHC services
• (Cont)

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Rationale (Contd)

• Key principle to implement Primary Health Care
  policy because
• Management near to PHC facilities
• Less prior permission from central government
• Increased Community Participation and resource
  mobilisation
• Innovative approach could be adopted without
  involving whole country
• Effective implementation in remote area
• Inter-sectorial co-ordination
• Committed motivated workforce

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Rationale for Decentralization Classical
Agenda

• Decentralization is predicted to improve health
  sector performance
• Improve allocative efficiency
• Improve production efficiency
• Improve quality, transparency, accountability,
  legitimacy
• Greater equity

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Rationale for Decentralization Real Agenda

• Mostly motivated by political concerns
• Part of the democratisation process as
  discredited autocratic central regimes are
  replaced by elected ones under new constitution-
  Latin America
• Spread of multi-party political systems is
  creating demand for more local voices in decision
  making- Africa
• Pressures from regional ethnic groups for more
  control participation in the political process-
  Ethiopia

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Rationale for Decentralization Real Agenda

• Attempts to keep country together by granting
  autonomy to all localities, by forging
  asymmetrical federation- Uganda
• Absence of any meaningful alternative governance
  structure to provide local government services-
  East Europe
• Need to improve service delivery to large
  populations and the recognition of the
  limitations of central administration- East
  Asia
• Pass on responsibility to carry out programs to
  the field because the central levels have run out
  of options to improve health services - Pakistan

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Elements of Decentralization

• Decentralization inherently implies the expansion
  of choices at the local level
• Amount of choice transferred from central level
  to institutions at periphery of health systems
• What choices local officials make with their
  increased discretion and
• What effects these choices have on the
  performance of the health system

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Prerequisites forEffective Decentralization

• System of accountability that relies on
  transparent information, enabling community to
  monitor performance
• Instruments for decentralization -
  constitutional, legal, institutional and
  regulatory framework that allow effective
  equitable services in line with political
  objectives
• Capacity building of local staff to undertake new
  responsibilities, and development of management
  support systems

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Forms of Decentralization

• Different forms are not mutually exclusiveany
  model have characteristics of different types
  superimposed upon one another
• Deconcentration
• Functional
• Prefectoral
• Integrated
• Un-integrated
• Delegation to semi-independent bodies
• Devolution
• Decentralization to local bodies
• Federalism
• Public Sector Market
• Fragmentation

CONTINUUM
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Deconcentration

•  Transfer of functions with in the central
  government hierarchy through the shifting of
  workload from central ministries to field
  officers, the creation of field agencies or the
  shifting of responsibility to local
  administrative units that are part of the central
  government structure (Collins, 1994)

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Deconcentration Salient Features

• Shifting of power from the central offices to
  peripheral offices of the same administrative
  structure
• Semi autonomy to field officers for routine
  decision-making
• Some planning functions according to central
  government guidelines
•  
• Example Many Developing Countries

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A Functional Deconcentration

• Field officers directly linked controlled by
  the ministry 
• Resources, guidelines and decisions about
  recruitment, selection, transfer and promotions
  conveyed from vertical hierarchy 
• Community need not well perceived 
• Example - Ex - District Health System in Punjab
  Health Department

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B Prefectoral Deconcentration

• Field Officers are Sub-ordinate to Prefect
• (Commissioner, Governor)  
• Communication through Prefect.
• Example
• British India before Independence
• Where
• Collector/ District Commissioner exercised powers
  of Finance Judiciary
• Double Control system i.e.
• a. Technical matters of field officers e.g.
  recruitment, pay, training, promotion, transfer
  controlled by the Ministry
  
• b. Performance accountability to the Prefect

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Semi-independent Agencies
Delegation

• Functions are shifted to regions or functional
  development authorities, parastatal organisations
  or special project implementation units
• Independent from central government rules
  regulations in personnel, recruitment, budgeting
  or procurement
• Normal attachment exists with the Central
  Government
• Examples
• Autonomous medical institutions in Punjab
• Social Security Organisations in
  Latin America

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Devolution

• Transfer of functions or decision-making
  authority to legally incorporated local
  governments, such as states, provinces, districts
  or municipalities
• (Collins, 1994)
•   Shifting of responsibility and authority from
  central offices of the ministry of health to
  separate administrative structures still within
  the public administration (provinces, states,
  municipalities)
• (Bossert, 1995)
  Cont.

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Cont.
Devolution

• A Devolved Unit has
• Budgetary allocation
• Freedom of Revenue generation Expenditure
• Elected members
• Conducive to Community Participation 
• More Accountability to people
• Example  
• LGP 2000 in Pakistan

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Decentralisation to Local Bodies With Mixed
Central and Local / Regional Representation

• Local bodies (District Development Councils) or
  regional bodies are decentralised units formed by
  locally elected members and central government
  representatives 
• Semi-autonomous bodies
• Dependent on central government for financial
  resources planning guidelines
• Bound to national policies
• Varying degree of power for development functions
• Example
• District Development Councils in Tanzania

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Federalism

• Decentralised units receive powers from national
  government constitution 
• Example
• States in USA India
•  
• Market mechanisms are introduced in the health
  care delivery  
• Purchase Providers have decision-making
  authority
•  Example National Health Service In UK

Public Sector Market
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Impact Assessment Indicators

• Increased Community Participation in planning
  management of health services
•  
• Accountability of health staff about their
  performance
•  
• Increased Inter-sectoral Co-ordination leading to
  utilisation of other resources for improving
  health services
•  
• Improved Efficiency, Effectiveness and Quality of
  the health services
•  
• Reduced Infant and Maternal Mortality rate
•  
• Decreased Morbidity and Mortality rate in the
  area

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Decentralization Problems Issues

• Weak Local Management
• Lack of Skilled Staff
•  
• Weakening of the Ministry
• Planning Implementation Problems
•  
• Equity in the delivery of services
• Unequal Resources
•  
• Political domination
• Local Elites Control

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Decentralization Conclusions

• Inherently implies expansion of choices at the
  local level
• Is predicted to improve health sector performance
  through increased efficiency, quality of
  services, accountability, equity
• Could be political, administrative, fiscal,
  market - major overlaps

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Conclusions Cont.

• Is not a single transfer of a block of authority
  responsibility, but a set of functions that
  pertain to finance, service organisation, human
  resources, access, governance
• Preliminary data indicates that results have been
  mixed at best
• Issue at hand is how to better adopt
  decentralization policies to achieve national
  health policy objectives

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Decentralization Not a Magic Bullet

• ? Benefits Improved delivery utilisation of
  services enhanced capacity for district health
  planning, increased funds etc
• ? Constraints Conflict between civil servants
  politicians, procedures not streamlined
  retrenchment of staff undermines performance
  resistance of health personnel problem of
  defining role of DoH vis-à-vis local government

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An Agenda for Effective Decentralization

• Why is decentralization being introduced?
• What form will decentralization take how will
  relations of authority be set out?
• At what level in the governmental system should
  decentralization of resources functions been
  made to?
• Has adequate attention being paid to the role of
  center in the decentralized system?
• What resources, functions authority will be
  decentralized?

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Agenda. Cont.

1. Has a program of district health management
   strengthening been agreed?
2. Does decentralization facilitate the
   democratization of health management planning?
3. Does decentralization contribute to the
   development of intersectoral coordination?
4. How does decentralization fit into the
   development of national planning?
5. What provisions have been made to ensure the
   compatibility of decentralization with the
   principle of equity?

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Conclusions Cont

• Decentralized small management units are
• Faster
• More Focused
• More Flexible
• More Friendly,
• More Fun
• (Handy 1994)