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Decentralization and Governance in Health. Thomas Bossert, Ph.D. Harvard School of Public Health. Health Governance Workshop Washington DC June 13, 2007. Decentralization and Our Governance Model. Decentralization changes “ who ” in the state makes decisions:
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Decentralization and Governance in Health Thomas Bossert, Ph.D. Harvard School of Public Health Health Governance Workshop Washington DC June 13, 2007
Decentralization and Our Governance Model • Decentralization changes “who” in the state makes decisions: • Local elected officials (devolution) • Local district or provincial officials (deconcentration) • It also defines “who” has authority over some “providers” and other health system entities • And “who” can be held accountable and who is responsive to local patients/citizens, local participation, local NGOs
Why do countries decentralize? • Political decision to reduce opportunities for concentration of power by authoritarian rulers • Core Aquino in Philippines • Improve the accountability and responsiveness of the local officials to preferences of the local population • Better knowledge about the local conditions = better policies for addressing specific local needs. • Improve the equity of allocations to localities
Decentralization also defines: • “How Much” Choice over “What Functions”: Decision Space Approach • Rules of governance
Decision Space Challenge • What is the appropriate range of decision space that local officials should have? • Need some choice to reflect local preferences and needs but not so much as to make poor technical choices • May depend on the capacities (skills, education, staffing levels) of localities to make and implement good choices • May depend on how accountable local officials are to the local “patients”.
Decentralization and Financing • If done right, decentralization can improve equity of allocation of central government transfers to localities –appropriate policy process • Decentralization can also improve the mobilization of local funding for health – an indication of local accountability. • Responsibility for financing is a political decision
Some Best Practices • Decentralization in Chile • Equitably financed municipal primary health care systems • Local financing around 30% • Maintained highly effective control of communicable diseases and MCH • Much of the system still dominated by central decisions • Governance practices (low corruption, high transparency, respect for laws) are in evidence throughout the Chilean state
Some Best Practices (2) • Decentralization of logistics systems in Guatemala and Ghana • Better performance evident with: • More local control over budgeting and forecasting • More central control over inventory and information systems • More local control over procurement under certain conditions (central bidding for decentralized procurement)
Capacity and Accountability Improvement • PAIMAN study in Pakistan • Study of variations in decision space, capacities and accountability in districts in Pakistan • Find lack of congruence suggesting some districts need increased capacities in relation to decision space while others have sufficient capacities to take on more decision space • Use findings to tailor capacity building and accountability and for evaluating the performance of interventions to increase capacity or change decision space
Final Thoughts • Decentralization processes are evolving in most countries – adapting and changing • We need to know more about the relationships among: • Decision space • Capacities at local and central levels • Accountability – conditions under which it works • How do these relationships relate to improved governance: better performance, more responsiveness, better rule enforcement?