Public health professional and students can use this materials

1. Concept of Decentralization, Federalism and
health
Hari Krishna Bhattarai,
MPH, MPA, Mphil

2. Concept- Constitution
Constitution is a single written document establishing the
legal foundations of a political system. But, this is not
always…………
The constitution is a combination of a number of written
documents as well as uncodified practices and custom.- UK

3. Federalism
• Federalism requires a constitutional recognition of the autonomy of the
regional units
• Almost sovereign in some of the policy areas and insulated against the
encroachment by the center.
• Federalism is constitutionally entrenched and cannot be changed by ordinary
government legislation.

4. Federalism
• Federalism is a political system where the central government and regional
governments share power, and where self rule for the regions is combined
with shared rule for all.
• The autonomy of regional units is constitutionally entrenched in federalism.
• This means we have two orders of governments. We have constituted
regional states and we have the central state. The two orders of government
have different responsibilities. Within which, they are autonomous. And
citizens are simultaneously subject to both governments.

5. Federalism
• One would simultaneously be a citizen of both- Gandaki Pradesh
and Federal Democratic Republic of Nepal. And would be dealing
with different levels of government depending on the issue area.
• This is quite different from the one nation, one state, one legal
system unitary states, where a single order of government
exists throughout the country without autonomous regional states.

6. Decentralization
Decentralization, on the other hand, is federalism's somewhat less
flashy sibling. It devolves some responsibility to the lower levels of
that administration, but without the full fledged regional autonomy
we see in federalism.

7. Decentralization
Decentralization, addresses similar issues and promises similar things
but this is done through devolving the center's power. Hence, the
emphasis on the decenter and not through the constitutional
recognition of the region's autonomy as it is the case in federalism.

8. Decentralization
• In many ways these reforms are easy to implement because decentralizing
political authority to the local government is done through ordinary
legislation, without large-scale constitutional amendments.
• The autonomy of the local government is more limited in decentralization
and is initially dependent on the decisions made by the center.
• The center simply devolves some of its powers to the lower levels of
government. And in principle, not always in practice, it can perhaps recall these
powers.

9. 3 promises of Federalism and Decentralization
Better democracy
Good governance and efficiency
Management of diversity

10. Better democracy
By empowering the regional and local levels of
governments they intend to bring democracy closer to the
citizen, empower local communities, and bring more
democratic accountability to politics.
Furthermore, regional and local governments are expected
to balance off the center. Bringing in that horizontal
separation of political power which is supposed to induce a
healthy competition between layers of government.

11. Good governance and efficiency
• Public policies closer to the regions of local level are more likely to
address local diversity and the concerns of the people. Policies will be
customized to local circumstances, and this is suppose to improve public
policy formulation, and delivery.
• Furthermore, this is a way to avoid the risk of putting all eggs in one
basket. Allow regional variations in policies to flourish. Regional labs of policy
making and implementation, in other words. The trials and errors of this
variation is supposed to bring out best practices.

12. Management of diversity
Federalization and decentralization provide territoriality based communities a
degree of autonomy, to manage their own affairs.

13. Heart of Federalism
• Self-rule and shared-rule
• Distribution of power
• Multiple identities.
• Note: These ideas lie behind decentralization as well, but not as pronounced as in
federalism.

14. Self-rule and shared-rule
• Central government jurisdiction usually tends to be in policy areas such as defense,
foreign policy, natural resources and macro-economic policy. The center is
responsible for such national policies.
• Policy areas like transportation, communication, banking, research and development
emerge as federal jurisdictions.
• In some other policy areas, regional-states might enjoy exclusive jurisdiction, but
their activities could have spill over effects for the neighbors. Say in environmental
pollution of rivers or they could be need for coordinating polices.
• Common issues requires coordination among the states and the central government.

15. Distribution of power
• Everybody does something different in a federal system. That is because
power is distributed across orders of government.
• Trias politica
• Executive, legislative, and judicial powers are these powers and their
distribution across orders of government is an indispensable part
of federalism and to a lesser extent of decentralization.

16. Multiple identities
• Different issues, different political loyalties, and different priorities guide the
citizens' relationship with multiple orders of government.
• We can be different people when dealing with different governments.

17. Conclusion
• In decentralization, such a constitutionally entrenched legitimacy protecting the autonomy
does not exist.
• In federalism, the existence of the constitute regions and their autonomous powers are
constitutionally guaranteed.
• That is, they cannot be created, merged, or abolished by ordinary legislation passed by the
central government. This Insulates them against potential encroachment by the center.
• Self-rule and shared-rule, Distribution of power, Multiple identities are the heart of the
federalism. These ideas lie behind decentralization as well, but not as pronounced as in
federalism

18. Definitions of Decentralization
The transfer of responsibility for planning, management, and
resource-raising and allocation from the central government to
(a) field units of central government ministries or agencies;
(b) subordinate units or levels of government;
(c) semi-autonomous public authorities or corporations;
(d) area-wide regional or functional authorities; or
(e) NGOs/PVOs
Rondinelli, et. al.:

19. Definitions of Decentralization
Decentralization transfers authority and responsibility of major government
functions from central to sub-national governments — including local
governments, civil society, and the private sector.
Is a ‘socio-political process’ of ‘power-sharing arrangements’ between central
government and local authorities in planning, management and decision-
making

20. Definitions of Decentralization
• Decentralization has often been evaluated according to four-part classification of
delegation, de-concentration, devolution and privatization.
• Delegation transfers responsibility to a lower organizational level,
• De-concentration to a lower administrative level,
• Devolution implies transferring authority to a lower political level and
• Privatization takes place when tasks are transferred from public into private
ownership
Rondinelli (1983)

21. Why Dec
• Economic efficiency, public accountability, and empowerment:
• It gives greater voice and choice to citizens to influence decisions that affect their
lives.
• It allows local governments to respond dynamically to communities.
• It results in allocative efficiency by matching of local needs and preferences with
patterns of local public expenditure (assumes substantial fiscal autonomy).
• Decentralization also provides a powerful impetus for enhancing the scaling up
potential of community-driven development (CDD) operations

22. Types of decentralization
• Intergovernmental decentralization: which involves transfers of authority,
responsibility, power and resources downward among different levels of
government,
• Market-based decentralization: where these are transferred from governments to
the market and Non-Governmental Organizations (NGOs). Each category embraces
numerous specific strategies for transferring functions.
Bennet (1990)
• Wolman (in Bennet, 1990) - three types of decentralization: political
decentralization, administrative decentralization, and economic decentralization
(though admitting that there is no clear distinction between the first two).

23. Types of decentralization- WB
Types of decentralization include political, administrative, and fiscal
decentralization.
Political decentralization transfers policy and legislative powers from
central governments to autonomous, lower level assemblies, and local
councils that have been democratically elected by their constituencies. To
be effective, it requires regular elections, clearly defined jurisdictions and
powers, and the appropriate legal, political and functional space.

24. Types of decentralization- WB
• Administrative decentralization places planning and implementation
responsibilities in the hands of locally situated civil servants and these local
civil servants under the jurisdiction of elected local governments. To be
effective, it requires ability to make independent staffing decisions and ability
to negotiate conditions of service (though the center may retain a useful role
in training)

25. Types of decentralization- WB
• Fiscal decentralization accords substantial revenue and expenditure
autonomy to local governments, including the power to levy taxes
and user charges. To be effective, it requires linking pleasure of
spending with pain of revenue generation, increasing revenue
autonomy, building capacity to analyze data for budget decisions
and establishing proper fiduciary controls.

26. Rationale for decentralization
• Means of improving public service- for economic efficiency, public accountability, and empowerment.
• Greater voice and choice of individual constituents to influence decisions which affect their lives, and
of sub-national and local governments to respond dynamically to constituency concerns.
• Allocative efficiency — matching of local needs and preferences with patterns of local public
expenditure (assumes substantial fiscal autonomy)
• Empowerment of districts, villages, communities, and individual.
The underlying assumptions on which these potential benefits of decentralization rest include:
• Representative elected bodies: Each council member has a mandate to articulate needs of an
identifiable constituency and can be held accountable.
• Inclusive local decision-making: Decision-making that does not systematically exclude the poorest,
most vulnerable groups, specific social or ethnic groups.

27. Potential dangers and challenges of decentralization include- WB
• Elite capture
• Corruption
• Patronage politics
• Local civil servants feel compromised
• Impedes further decentralization
• Incomplete information
• Constituents not able to hold representatives accountable
• Opaque decision-making affecting accountability upwards and downwards
• Rationalizes reform delays and central claw back of power
http://www.worldbank.org/en/topic/communitydrivendevelopment/brief/Decentralization

28. Decentralization in health care
The transfer of formal responsibility and power to make decisions
regarding the management, production, distribution and/or
financing of health services, usually from a smaller to a larger
number of geographically or organizationally separate actors.
World Health Organization 2007 on behalf of the European Observatory on Health Systems and Policies.

29. Decentralization in health care
• Research has shown that decentralization has increased the potential to more
effectively address poverty, gender inequality and overall improvement in
health care systems
• One of the principal goals of any health care system is to improve health
through the provision of clinical and public health services.
• Decentralization as a reform measure aims to improve inputs, management
processes and health outcomes, and has political, administrative and financial
connotations.

30. assessing decentralization-challenges
(1) measuring decentralization
(2) measuring the outcomes of decentralization in health care;
(3) comparing decentralization between countries.

31. +ve outcomes of decentralization in health
• Capacity to innovate within county councils, improved efficiency, a more patient-oriented
system and enhanced cost-consciousness (Bergman 1998);
• Higher regional and local authority accountability (Jommi and Fattore 2003);
• Stimulation of broader change regarding work organization and working time (Arrowsmith
and Sisson 2002);
• Better implementation of health care strategies based on need (Jervis and Plowden 2003).
• Decentralization is associated with increased service access and utilization and improved
service delivery. Likely impact of decentralization both at organizational and service level
performance. decentralization creates both opportunities as well as challenges for health
service provision. (Regmi et al. 2009)

32. -ve outcomes of decentralization in health
• Equity issue- inequity being the most frequent concern (Collins and
Green 1994; Koivusalo 1999; Jommi and Fattore 2003).

33. Objectives, rationale and controversies of health decentralization
Objectives Rationale Issues and controversies
To improve technical
efficiency
• Through fewer levels of bureaucracy
and greater cost consciousness at
the local level
• Through separation of purchasers
and provider functions in market-
type Relations
• May require certain
contextual conditions to
achieve it
• Incentives are needed for
managers
• Market-type relations may
lead to some negative
Outcomes
To increase allocative
efficiency
• Through better matching of public
services to local preferences
• Through improved patient
responsiveness
• Increased inequalities
among administrative units
• Tensions between central
and local governments and
between different local
Governments

34. Objectives, rationale and controversies of health decentralization
Objectives Rationale Issues and controversies
To empower local
governments
• Through more active local
participation
• Through improved capacities of
local administration
• Concept of local
participation is not
completely clear
• The needs of local
governments may still be
perceived as local needs
To increase the
innovation of service
delivery
• Through experimentation and
adaptation to local conditions
• Through increased autonomy of
• Increased inequalities

35. Objectives, rationale and controversies of health decentralization
Objectives Rationale Issues and controversies
To increase
accountability
• Through public participation
• Transformation of the role of the
central government
• Concept of public participation is
not completely clear
• Accountability needs to be clearly
defined in terms of who is
accountable for what and to whom
To increase the
innovation of
service
delivery
• Through experimentation and
adaptation to local conditions
• Through increased autonomy of
local governments and institutions
• Increased inequalities

36. Objectives, rationale and controversies of health decentralization
Objectives Rationale Issues and controversies
To increase
equity
• Through allocating resources
according to local needs
• Through enabling local
organizations to better meet the
needs of particular groups
• Through distribution of resources
towards marginalized regions and
groups (through cross-subsidy
mechanisms)
• Reduces local autonomy
• Decentralization may improve
some equity measures but may
worsen others

37. conclusion
• Decentralization is not a “magic bullet”, capable of solving all structural and
policy dilemmas at a single stroke.
• The rapid decentralization of public service provision may lead to poorer fiscal
efficiency, fewer public services assured by the central government, or even the
disruption of public service delivery in the short term.
• Existing inter-district and intra-district disparities can be exacerbated. Corrupt,
rent-seeking interests may permeate the local level, leading to the monopolizing
of funds or continued catering to special interest groups. (UNDP,2006)

38. conclusion
• Adopting decentralization as a health system strategy is labor-intensive: it is hard to
introduce, hard to maintain, and requires continual re-adjustment if it is to be successfully
sustained over time.
• The legitimacy of local government in the eyes of the population is dependent upon its
ability to provide needed services. If decentralization impedes the delivery of those
services, the result can be to delegitimize decentralization generally.
• There is no set model, no perfect or permanent solution that all countries should seek to
adopt. Rather, there are multiple models of decentralization, each developed to fit the
particular context and circumstances of an individual country. (WHO 2007)