“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)

Decentralization

By

Dr Arshad UsmaniLahore, Pakistan

Historical Perspectives1950 – 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

-

1. A component of Health Sector Reforms (HSR)

programme

2. Scarce financial resources

3. Low efficiency & quality of health care

4. Political will

5. Pressure from donors

6. To improve PHC services

(Cont…)

Rationale (Cont’d)

7. 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

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

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 AmericaSpread 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

Rationale for Decentralization: “Real Agenda”

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

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 systemsWhat choices local officials make with their increased discretion; andWhat effects these choices have on the performance of the health system

Prerequisites forEffective Decentralization

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

Different forms are not mutually exclusive;any model have characteristics of different types superimposed upon one another

Deconcentration*FunctionalPrefectoral

• Integrated• Un-integrated

Delegation* to semi-independent bodies

Devolution*Decentralization to local bodiesFederalismPublic Sector MarketFragmentation

 “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)

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

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

Field Officers are Sub-ordinate to Prefect (Commissioner, Governor)  Communication through Prefect.Example: British India before IndependenceWhere:1. Collector/ District Commissioner exercised powers of

Finance & Judiciary2. 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

Semi-independent AgenciesFunctions 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 PunjabSocial Security Organisations in Latin America

“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….

Cont…. 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

Local bodies (District Development Councils) or regional bodies are decentralised units formed by locally elected members and central government representatives Semi-autonomous bodiesDependent on central government for financial resources & planning guidelinesBound to national policiesVarying degree of power for development functions

Example: District Development Councils in Tanzania

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

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

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

Decentralization: Problems & IssuesWeak 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

Decentralization: ConclusionsInherently 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

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, governancePreliminary data indicates that results have been mixed at bestIssue at hand is how to better adopt decentralization policies to achieve national health policy objectives

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

An Agenda for Effective Decentralization

1. Why is decentralization being introduced?2. What form will decentralization take &

how will relations of authority be set out?3. At what level in the governmental system

should decentralization of resources & functions been made to?

4. Has adequate attention being paid to the role of center in the decentralized system?

5. What resources, functions & authority will be decentralized?

Agenda…. Cont….

6. Has a program of district health management strengthening been agreed?

7. Does decentralization facilitate the democratization of health management & planning?

8. Does decentralization contribute to the development of intersectoral coordination?

9. How does decentralization fit into the development of national planning?

10.What provisions have been made to ensure the compatibility of decentralization with the principle of equity?

Conclusions: Cont…Decentralized small management units are:

• Faster

• More Focused

• More Flexible

• More Friendly, &

• More Fun(Handy 1994)