1. DECENTRALIZATION
IN HEALTH SYSTEM DEVELOPMENT
Shreejeet Shrestha
MPH, M.Sc. Medical Microbiology

2. WHAT IS HEALTH SYSTEM?
Health care system is the organization of
people, institutions, and resources to
deliver health care services to meet the
health needs of target populations.
A health system consists of all
organizations, people and actions whose
primary intent is to promote, restore or
maintain health.(WHO, 2007)

3. HEALTH SYSTEM DEVELOPMENT (HSD)
Necessitates For The Development Of Health Care
Systems
Continuous support to policy and managerial
practices for appropriate infrastructure and logistics
Use of technology, information collection and
dissemination, organization of health workforce
development at national and institutional levels,
Universal coverage and Sustainable financing, and
Assured quality and safety in health-care

4. MEASURES OF HSD
 Identify and remove health-system bottleneck
 Monitor the progress and programs in
coverage
 Intervention packages and health-system
strengthening (Health Care Service Delivery)
 Address the Human Resources Crisis
 Strengthen the Health Systems
(Decentralization)
 Efforts of improve harmonization

5. WHAT IS DECENTRALIZATION?
 According to WHO in 1990, Decentralization is
transfer of authority or dispersal of public
planning, management and decision making from
the national level to sub-national levels

6. Decentralization shifts decision-making powers
to lower-levels of government and entails setting
legal and regulatory provision to ensure the:
 Favorable political environment
 Good coordinating and cooperating
mechanism
 Initiatives are sustained and required
strong political permanence.
 Entities act in conformity at national
standard
 Citizens have access to local decision
making

8. NEED FOR DECENTRALIZATION
 At the past, many countries in the world, particularly the
countries in Asia and Africa strengthened the national and
regional administration by reducing the responsibility of the
local government
 But now, many of these countries realized the need to
strengthen the peripheral and local authorities and have
adopted decentralization as one of the major means for
implementing the reforms.

9. NEED FOR DECENTRALIZATION (CONT:)
There are many complex reasons why
governments in various countries are beginning
to decentralize their services. For example
Demands for more regional autonomy have
played a major role in Papua New Guinea and
Spain
Political ideologies were important in Chile
and Yugoslavia
The need to rationalize over burdened and
outmoded administration plays a large role in
New Zealand and Srilanka

10. CONCEPTS OF DECENTRALIZATION
 On philosophical and ideological level, decentralization
have been seen as an important political ideal, providing
the means of community participation, local self reliance
and ensuring the accountability of the government
officials to the population.

11. CONCEPTS OF DECENTRALIZATION (CONT: )
 Decentralization policies are usually initiated by
central governments and only subsequently are
adopted by the health sectors. This means that the
central government has initiated a national policy by
adopting constitutional changes that set the pattern
for the reforms to be adopted by the different
ministries.

12. DECENTRALIZATION IN HEALTH SERVICES
 Decentralization is one of the main concept for Health
system Development
 Decentralization of health system structure and
management is a key issue for many countries in the
achievement of ―Health For All‖ and in the
development of Primary Health Care. (Health System
Decentralization; Concepts, Issue and Country
Experience, WHO, Geneva 1990)

13.  In practice, health system decentralization takes many
different forms, depending not only in overall government
political and administrative structures and objectives, but
also on the pattern of health system organization prevailing
in the particular country.
 Decentralization demands a holistic approach, and the
decentralization of health services cannot be looked into in
isolation. As a part of reforms in the health care delivery
system, decentralization is currently being promoted in
many countries as a means to improve the performance
and outcomes of national health care systems.

14.  It is often imputed that health ministries in developing countries
have a reputation of being the most bureaucratic and least
effectively managed institutions. Such centrally managed health
care systems, by and large, are poorly structured, badly led and
inefficiently organized.
 Failure of such systems spawned the need for "people centered"
health care systems that build on bottom-up approaches in
planning, allow wider participation of people in needs
assessment, ownership over there sources and facilities and
stewardship of the local bodies.

16. OBJECTIVE AND RATIONAL FOR DECENTRALIZATION IN HEALTH SERVICES
Objective Rationale
1) To improve
technical efficiency
 Through fewer levels of bureaucracy and
greater cost consciousness at the local level
 Through separation of purchasers and
provide functions in market-type relations.
2) To increase
allocative efficiency
Through better matching of public services
to local preferences
Through improved patient responsiveness
3) To empower local
governments
Through more active local participation
Through improved capacities of local
participation
4) To increase the
innovation of service
delivery
Through experimentation and adaptation to
local conditions
Through increased autonomy of local
governments and institutions

17. Objective Rationale
5) To increase
accountability
Through public participation
Transformation of the role of the central
government
6) To increase quality
of health services
Through integration of the health services
and improved information systems
Through improved access to health care
services for vulnerable groups
7) 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)

18. DIFFERENT APPROACHES TO DECENTRALIZATION:
Public administration approach
Local fiscal choice
Social capital approach
Principal agent approach

19. PUBLIC ADMINISTRATION APPROACH
 focuses on the distribution of authority and
responsibility for health services within a national
political and administrative structure.
 different forms of decentralization:
 Deconcentration
 Delegation
 Devolution
 Privatization

20. LOCAL FISCAL CHOICE
was developed by economists to analyze
choices made by local governments using their
own resources and inter-governmental transfers
from other levels of government.
It has been applied mainly in federal systems
where local governments have had a history of
constitutionally determined authority and
significant locally generated resources.

21. SOCIAL CAPITAL APPROACH
focuses on explaining why decentralized
governments in some localities have better
institutional performance than do governments
of other localities.
Applied to health care, this approach suggests
that those localities with long and deep histories
of strongly established civic organizations will
have better performing decentralized
governments than localities which lack these
networks of associations.

22. PRINCIPAL AGENT APPROACH
proposes a principal (individual or institution)
with specific objectives and agents who are
needed to implement activities to achieve those
objectives.
Agents also have an advantage allow them to
pursue their own interests at the expense of the
principal.

23. Decentralization policies are usually initiated by
central governments and only subsequently are
they adopted by the health sector by
adopting constitutional changes that set the
pattern for the reforms to be adopted by the
different ministries
making innovative choices within the decision
spaces of local authorities
using local governments own resources and
intergovernmental transfers from other levels of
government (local fiscal choice model)

24. HOW CAN WE MAKE DECENTRALIZATION?
 equalization funds
 allocation formulae for intergovernmental transfers
 allocation rules that earmark funding for specific
purposes
 training exercises for local authorities and
communities to achieve institutional performance
(social capital approach: Putnam, 1993)

25. FLOW CHART OF DECENTRALIZATION

26. CASE STUDIES FOR DECENTRALIZATION

27. MALDIVES AND DECENTRALIZATION
 The Seventh National Development Plan states that “the
health policy of the government is targeted to ensure access
to primary health care to all citizens in an equitable manner”.
 Health Master Plan for 2006-2015, the Government of
Maldives has committed itself to provide equitable access to
health care for all its citizens.
 The government aims to achieve these goals primarily through
decentralization of health services and the primary health care
approach.
 “Act on Decentralization of the Administrative Divisions of the
Maldives”, 2010.
 This is the Act on the creation of offices, posts, island councils,
atoll councils and city councils and the determination of their
characteristics, jurisdiction and required principles or rules for
the purpose of decentralized administration of the Maldives as
stipulated in Chapter 8 of the Constitution.

28. DECENTRALIZATION IN MYANMAR
Growing the needs
 to involve all relevant sectors at all administrative levels
 to mobilize the community more effectively in health
activities health committees had been established in
various administrative levels down to the wards and village
tracts
 These committees at each level were headed by the
responsible person of the organs of power concern and
include heads of related government departments and
representatives from the social organizations as members.
 Heads of the health departments were designated as
secretaries of the committees.

29. CASE STUDIES OF NEPAL FOR DECENTRALIZATION
IN HEALTH SERVICES
 During the past few decades, many countries have embarked
on the decentralization of public services. Nepal has also
tried to adopt decentralization as a key reform process.
 During the 1990s there was significant progress in the
development of health systems under the framework of long-
term (1997–2017) health plans and policies, guided by a
vision of equitable access and the principles of community
participation, decentralization, gender equality, effective
services management, and a public–private partnership
approach.
 Under the guidance of these plans and polices, Nepal has
made visible progress in health sector reform despite the
nature of difficult topography (hills, mountains).

30.  The main drivers for decentralization in Nepal include:
socio-economic inequalities, multi-ethnicity and cultural
heterogeneity, poverty, low efficiency of centralized delivery
systems and the global phenomenon of decentralization.
 As in other countries, two important factors—technical or
managerial, and political motives—are major contributing
factors behind the decentralization process.
 In the governance system, decentralization and local self-
governance have been made operational in Nepal since the
1960s.
 In 1999, Nepal enacted a Local Self-Government Act
(LSGA) and this Act, whose monitoring committee was
chaired by the Prime Minister, laid the foundation for
establishing a local self-governance system adopting a
broad-based and cross-sectoral approach.

31.  This Act recognized the role of local self governance and
devolution of authority and responsibility to make local
authorities more responsive and accountable to people.
 The rationale for this Act was both philosophical and
practical and involved legislation, institutional provision,
resources (both financial and human) mobilization and
considerations, i.e. autonomy and equality.
 One of the major reforms in Nepal's health sector under
decentralization was the restructuring of health services.
 In 1987, the centre (MoH) underwent change and as a
result—Regional Health Directorates were established in
five development regions in Nepal.

32.  Restructuring of the district health services (preventive
and curative) was considered to be vital for meeting the
health needs of local populations.
 A unique feature of the health sector in Nepal is that
there is a strong community-based health workforce
(more than 50 000 female community health workers
in addition to 28 000 public health staff) across the
country who are mainly responsible for preventive
care.
 Since 2001/02, over 1435 primary health care facilities
(100% in the study district) devolve to the local
community management. Government is now in the
process of devolve other health care facilities i.e.
district hospitals, zonal and regional hospitals to the
management of local committees.

33. RECOMMENDATIONS AND CONCLUSION

34. Decentralization is regarded as the
most important force in improving
efficiency as well as equity and
responding to local health conditions
and demands.

35. STRENGTH OF DECENTRALIZATION
Governance
 Trained local and district managers
 Formation of DMHT for inter-sectoral collaboration
 Creation of new posts at sub district level for monitoring at
grass root level
Financing
 Retention of taxes by district
 Autonomy for need-based allocation
Resources and services
 Outsourcing leading to regularity, punctuality and service
delivery
 Procurement of drugs at district level

36. WEAKNESS OF DECENTRALIZATION
Governance
 Lack of administrative capacity and accountability
 Selection on personal and political choice
 Lack of power delegation at sub-district level
 Lack of practical planning at local level
 Lack of focus on preventive side
 Lack of evidence based policy making
 Duplication of power between provincial and district
governments
 Limited authority on vertical programs
 Bureaucratic resistance

37. WEAKNESS OF DECENTRALIZATION
Financing
 Allocation are not need-based
 Late release of funds
 Underpaid health care workers
 Extra-burden of non-development funds
Resources and services
 Lack of capable trained health care staffs and doctors
 Lack of laboratory facilities
 Transport for emergency referrals
 Failure to deliver service practically
 Tertiary service excluded
 Non-functioning HMIS

38.  Implementing decentralization in the health sector
has many advantages for the health system
development, primary health care and health for-
all strategies.
 However, decentralization is very sensitive political
issue, for it concerns the distribution of power and
allocation of resources.
 The adoption of a national policy on
decentralization is only the beginning of a lengthy
process that strong political commitment over
many years to achieve the good results.

39. REFERENCES
 http://indonesiahealth.wordpress.com/2010/10/26/o
bjectives-of-decentralization/
 http://www.hsph.harvard.edu/ihsg/publications/pdf/
No-54.PDF
 http://www.burmalibrary.org/docs14/Myanmar-
Health-Care-System.pdf