Decentralization of health services in Emrovia for improved performance of health systems

1. Decentralization of health services in Emrovia for improved performance of health systems GROUP 1

2. Background • Middle income country with 30m people • 10 health regions each with a regional health directorate (RHD) supervising 3-5 provinces • Provincial health directorate (PHD) supervises: PG hospital, health centres & private sector • Three-tier HS: central, provincial & peripheral • MoH took policy decision to decentralize health services to better achieve HS goals • Issue: How best to decentralize to improve efficiency, equity & sustainability • In-depth system review undertaken by MoH & a team of experts

3. Q1: Most appropriate form of decentralization & rationale • De-concentration (of power to PHDs)/delegation • Why? • 3-tier health system already exists • MoH has a clear policy on decentralization • MoH has power for deconcentration & delegation but not devolution (which would require legislative action) • PHDs have financial, personnel, planning, monitoring, & IT capacities to efficiently manage services • PHDs have operational policies & procedures

4. Q2a: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS Finance Central Provincial Peripheral Rationale Revenue generation +++ + + To ensure equity in financial allocations Allocation of resources to programmes ++ ++ _ More financial authority to PHDs Power of expenditure + ++ ++ Financial responsibility & accountability to service providers Line item flexibility - - - Only MoF has authority to change Income from fee & contracts - - -

5. Q2b: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS Information & Planning Central Provincial Peripheral Rationale Prepare annual plans ++ ++ ++ All levels need POAs Processing & analysis + + + Each level should collect, analysis & use its information

6. Q2c: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS Service organization Central Provincial Peripheral Rationale Hospital autonomy - - - MoH does not have powers for giving autonomy Insurance plans - - - Does not exist in Emrovia Payment mechanisms + + + - No change - No info on payment mechanisms Contracts with private producers ++ ++ ++ All levels to facilitate management of contracts closer to where services are provided Local programs/norms + + + Shared responsibility

7. Q2d: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS Human Resources Central Provincial Peripheral Rationale Recruit staff + + + Needed at all levels Dismiss staff + + + Empower PHD & peripheral managers Reward staff + + + Non-monetary rewards Determine salaries - - - Set nationally Relocate staff + + - Authority to PHD Performance evaluation + +++ + Best placed to evaluate them Continuing education +++ ++ + Concerns all levels

8. Q2e: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS Procurement And Logistics Central Provincial Peripheral Rationale New equipment ++ ++ + Easier to identify needs at PHD & periphery Drugs ++ ++ + Incentives for efficient prescribing practise at periphery Repair & maintenance + ++ ++ Ease of identifying needs & contract management

9. Q3: Essential steps needed in preparation for decentralization • Step 1: Health services mapping • Step 2: Binding ministerial decree establishing authority for decentralization to PHD • Step 3: Establishment of a policy and planning Committee • Review & disseminate operating policies & procedures • Develop & disseminate guidelines for roles and responsibilities (+ToRs) • Develop & disseminate an advocacy/communication plan targeting the management, HRH, and public

10. Q3: Essential steps needed in preparation for decentralization • Undertake capacities strengthening needs assessment & develop & implement a capacity building plan • Identify potential threats & mitigation strategies • Generate & disseminate pertinent research • Step 4: Establish a rigorous M & E system.

11. THANK YOU