DECENTRALIZATION

1. 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)

2. Decentralization By Dr Arshad Usmani Lahore, Pakistan

3. Historical Perspectives 1950 – 1960General 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

4. 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…)

5. Rationale(Cont’d) • 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Forms of Decentralization Different forms are not mutually exclusive;any 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

12. 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)

13. 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

14. 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

15. 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

16. Delegation Semi-independent Agencies • 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

17. 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….

18. Devolution 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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?

27. Agenda…. Cont…. • Has a program of district health management strengthening been agreed? • Does decentralization facilitate the democratization of health management & planning? • Does decentralization contribute to the development of intersectoral coordination? • How does decentralization fit into the development of national planning? • What provisions have been made to ensure the compatibility of decentralization with the principle of equity?

28. Conclusions:Cont… Decentralized small management units are: • Faster • More Focused • More Flexible • More Friendly, & • More Fun (Handy 1994)