strategy

Decentralizing government health services

Synonyms:
Devolving responsibility for health provision
Implementation:
Some countries, such as Botswana and Ghana, have delegated a wide range of management responsibilities to regional and district-level offices of the ministry of health; other, including Chile and Poland, have devolved authority and resources to local government agencies. Extreme and hasty decentralization can create inefficiencies, as in Poland where the average provincial population of less than a million is proving too small to make efficient use of the tertiary care hospital being built in each province, and the available medical personnel are begin spread too thin. For these reasons, the government is now experimenting with health regions covering two to four provinces, but the provinces are reluctant to finance such regions. Moreover there are political pressures for further decentralization to the level of district governments, where there is even less capacity for managing health systems.

Decentralization of health services in Chile (dating from the 1970s) caused initial job insecurity and displacement. Because municipalities were reimbursed for each unit of service delivered they tended to provide too much high-cost curative care and too few preventive services, which caused costs to explode. The government then moved to cap allocations to local authorities, using as a basis historical budget shares that favoured the wealthier municipalities. The democratically elected government that came to power in 1989 has chosen to maintain the broad thrust of the health reforms while seeking ways to overcome their adverse effects. These include: municipal elections, training programmes for municipal health officiers, management contracts for decentralized hospitals, and central allocation of funds on a capitation basis with provision for further adjustment to favour the poorest localities.

Claim:
In the long run, decentralization can help to increase efficiency of health delivery when there is adequate capacity and accountability at lower levels of the national health system. At the same time as they decentralize, governments will have to reduce the size of publicly owned health services, freeing resources for vital public health services, including immunization, workplace and food safety, environmental regulation, health education, drug control and prevention, and quality control of privately delivered clinical care.
Counter Claim:
The global gains in immunization coverage, for example, could never have been achieved without centralized public health systems.
Subjects:
Services
Health
Government
Resource utilization
Type Classification:
C: Cross-sectoral strategies