Decentralization and equity of resource allocation: evidence from Colombia and Chile

OBJECTIVE: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. METHODS: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. FINDINGS: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization. CONCLUSION: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.     

Decentralization in Zambia: resource allocation and district performance

Zambia implemented an ambitious process of health sector decentralization in the mid 1990s. This article presents an assessment of the degree of decentralization, called 'decision space', that was allowed to districts in Zambia, and an analysis of data on districts available at the national level to assess allocation choices made by local authorities and some indicators of the performance of the health systems under decentralization. The Zambian officials in health districts had a moderate range of choice over expenditures, user fees, contracting, targeting and governance. Their choices were quite limited over salaries and allowances and they did not have control over additional major sources of revenue, like local taxes. The study found that the formula for allocation of government funding which was based on population size and hospital beds resulted in relatively equal per capita expenditures among districts. Decentralization allowed the districts to make decisions on internal allocation of resources and on user fee levels and expenditures. General guidelines for the allocation of resources established a maximum and minimum percentage to be allocated to district offices, hospitals, health centres and communities. Districts tended to exceed the maximum for district offices, but the large urban districts and those without public district hospitals were not even reaching the minimum for hospital allocations. Wealthier and urban districts were more successful in raising revenue through user fees, although the proportion of total expenditures that came from user fees was low. An analysis of available indicators of performance, such as the utilization of health services, immunization coverage and family planning activities, found little variation during the period 1995-98 except for a decline in immunization coverage, which may have also been affected by changes in donor funding. These findings suggest that decentralization may not have had either a positive or negative impact on services.     

Financial priorities under decentralization in Uganda

This paper explores changes to budget allocations for health during the decentralization process in UGANDA: When the districts were given the authority to allot their own budgets, allocations for health were reduced considerably. The rationale for this by district leaders is investigated and analyzed. Their criteria for budget allocations for health are often based on views different to those held at central level, hence there can be conflict between the two. The mechanisms instituted by central government in reaction to what was perceived as a lack of local support to the health sector are described. In conclusion, while conditional funding may be a useful short-term step, long-term development requires less conditionalities. Health professionals need to work closely with local leaders and district officials to make health a political priority in order to develop and allocate resources for health at local level.     

Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan

Health sector decentralization has been widely adopted to improve delivery of health services. While many argue that institutional capacities and mechanisms of accountability required to transform decentralized decision-making into improvements in local health systems are lacking, few empirical studies exist which measure or relate together these concepts. Based on research instruments administered to a sample of 91 health sector decision-makers in 17 districts of Pakistan, this study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as "decision space"), institutional capacities, and accountability to local officials. Composite quantitative indicators of these three dimensions were constructed within four broad health functions (strategic and operational planning, budgeting, human resources management, and service organization/delivery) and on an overall/cross-function basis. Three main findings emerged. First, district-level respondents report varying degrees of each dimension despite being under a single decentralization regime and facing similar rules across provinces. Second, within dimensions of decentralization-particularly decision space and capacities-synergies exist between levels reported by respondents in one function and those reported in other functions (statistically significant coefficients of correlation ranging from ρ=0.22 to ρ=0.43). Third, synergies exist across dimensions of decentralization, particularly in terms of an overall indicator of institutional capacities (significantly correlated with both overall decision space (ρ=0.39) and accountability (ρ=0.23)). This study demonstrates that decentralization is a varied experience-with some district-level officials making greater use of decision space than others and that those who do so also tend to have more capacity to make decisions and are held more accountable to elected local officials for such choices. These findings suggest that Pakistan's decentralization policy should focus on synergies among dimensions of decentralization to encouraging more use of de jure decision space, work toward more uniform institutional capacity, and encourage greater accountability to local elected officials.     

Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning,allocation, and use of financial resources

While decentralisation of health systems has been on the policy agenda in low‐income and middle‐income countries since the 1970s, many studies have focused on understanding who has more decision‐making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision‐making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The findings of this study indicated that the decentralisation process in Tanzania has provided authorities with a range of decision‐making space. In the areas of priority setting and planning, district health authorities had moderate decision space. However, in the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision‐making space. The districts, nevertheless, had wider decision‐making space in mobilising and using locally generated financial resources. However, the ability of the districts to allocate and use locally generated resources was constrained by bureaucratic procedures of the central government. The study concludes that decentralisation by devolution which is being promoted in the policy documents in Tanzania is yet to be realised at the district and local levels. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans.     

Protecting resources for primary health care under fiscal federalism: options for resource allocation

The introduction of fiscal federalism or decentralization of functions to lower levels of government is a reform not done primarily with health sector concerns. A major concern for the health sector is that devolution of expenditure responsibilities to sub-national levels of government can adversely affect the equitable distribution of financial resources across local jurisdictions. Since the adoption of fiscal federalism in South Africa, progress towards achieving a more equitable distribution of public sector health resources (financial) has slowed down considerably. This study attempts to identify appropriate resource allocation mechanisms under the current South African fiscal federal system that could be employed to promote equity in primary health care (PHC) allocations across provinces and districts. The study uses data from interviews with government officials involved in the budgeting and resource allocation process for PHC, literature on fiscal federalism and literature on international experience to inform analysis and recommendations. The results from the study identify historical incremental budgeting, weak managerial capacity at lower levels of government, poor accounting of PHC expenditure, and lack of protection for PHC funds as constraints to the realization of a more equitable distribution of PHC allocations. Based on interview data, no one resource allocation mechanism received unanimous support from stakeholders. However, the study highlights the particularly high level of autonomy enjoyed by provincial governments with regards to decision making for allocations to health and PHC services as the major constraint to achieving a more equitable distribution of PHC resources. The national government needs to have more involvement in decision making for resource allocation to PHC services if significant progress towards equity is to be achieved.     

Shared local health system management and community participation in Brazil

The introduction of the Unified Health System (SUS) by the Brazilian government has helped enhance community participation. A survey in 12 municipalities in different States of the country focused on the decentralization process implemented by the Federal government (Basic Operational Ruling NOB01/93). Based on the ruling's implementation, community participation has improved in the municipalities, the number of local health councils has increased, and more local people have become involved in the process. Another important aspect of the new health policy has been the direct influence of the local health councils in managing the system. Local health councils have thus been an efficient channel for community involvement. This paper discusses how the population has been represented in such councils in the wake of the decentralization process. The authors ask, what is the relationship between social democracy and political democracy, and what kind of state reform should be carried out?     

Prevention and promotion in decentralized rural health systems: a comparative study from northeast Brazil

Policies to reform health care provision often combine the organizational restructuring of decentralization with ideological restructuring through a new model of health care that gives greater weight to prevention and promotion. Decentralization provides a discretionary space to the local health system to define and develop its own activities. The central policy aim to shift the model of health care therefore must rely on incentives rather than directives and is likely to result in variation at local levels in the extent and mode of its implementation. The local processes affecting variation in local implementation of policies for prevention and promotion have not been studied in a developing country. This study does so by comparing two rural health systems with different levels of prevention and promotion activities in one of the poorest regions of Brazil, Ceará State in the northeast. The health system with greater activities of prevention and promotion also has a more advanced stage of decentralization, but this is in combination with many other, interacting influences that differentiate the two health systems' ability to adopt and implement new approaches. While beyond the scope of this paper to detail options for regional and national managers to encourage the adoption of a greater focus on prevention and promotion, it is clear that strategies needs to target not only the vision and actions of local health system staff, but critically also the expectations of the local population and the attitudes of local government.     

The implementation of decentralized health systems: a comparative study of five cases in Bahia, Brazil

Understanding the effects of health decentralization policies in Brazil requires different methodological approaches to capture the issue's complexity from distinct angles. Five case studies were thus performed to evaluate the degree of implementation of components related to decentralization of the health system management in selected municipalities (counties) in Bahia State, Brazil. A logical model was elaborated with definitions related to policy goals. A comparative study of the five municipalities, considered "exemplary cases", showed that decentralization alone does not explain the organizational changes in the municipal health systems. Local government characteristics such as the municipal master plan, governing capacity, and governance proved important for heath care changes. The main problems and insufficiencies were found in the system's management and quality of healthcare delivered to the population. The authors discuss their findings and identify critical areas for future interventions with special emphasis on the institutionalization of planning and evaluation and the development of inter-sector projects.     

Developing an information system to support the pursuit of decentralization. The perspective of Cearà State in Brazil

Discusses the national health information system in Brazil which, until very recently, consisted of two main structures of health services with a dichotomy between curative and preventive health care acting in a vertical manner. The autonomy of health authorities and specialized structures created numerous independent health information systems with different methods of data collection. Although the issues of decentralization and a unified health system had been agreed on in 1963, they had not been implemented until the new health policy reform was lunched in 1988. The reform was based on the strengthening of primary health care at national level and accelerating decentralization of health systems. However, in spite of strong political will the new health managers at local level are lacking essential information, data and instruments that only a decentralized health management information system can provide. Based on a study conducted in the Cearà State of the north east of Brazil, explores how the present health information system can support the process of decentralization.     

Multicultural social policy and community participation in health: new opportunities and challenges for indigenous people

Community participation in local health has assumed a central role in the reforms of public healthcare, being increasingly associated with the issue of decentralization of the health system. The aim of this paper is to raise questions regarding the structural approaches to multicultural social policy in Chile and to analyze the results of its implementation. The article analyzes the case study of Makewe Hospital, one of the pioneering experiences of intercultural health initiative in Chile. The Makewe Hospital, which involves the indigenous community of the Mapuche, provides interesting insights to understand the dynamics of multicultural social policy and presents an example of a successful initiative that has succeeded in involving local communities in multicultural health policy. This case study discusses the effectiveness of grassroots participation in multicultural healthcare provision and presents the main strengths and challenges for the replicability of this experience in other settings.     

Decentralization of leprosy control actions in the micro-region of Almenara, State of Minas Gerais

This study analyzes the decentralization process of Leprosy control actions for Family Health Strategy units in the cities of the Almenara micro-region, in the state of Minas Gerais, Brazil. This qualitative research, based on the concept "Technological Organization of Work", was carried out in nine municipalities. Semi-structured interviews and document research were used for data collection. Forty-five interviews with care providers and health managers were conducted. The data collection took place between November 2007 and February 2008. Content Analysis was utilized to study the data and results indicate that the cities present different levels of decentralization and that the process was determined based on local specifications and on the engagement of care providers and health managers. Several cities kept a reference team to provide support to primary health care. The conclusion is that the decentralization process is a strategy that proves to be useful in facing Leprosy in the micro-region.     

Sanitary surveillance: descentralization strategies in Mato Grosso (Brazil), 1996-2005

The decentralization process of sanitary surveillance services to states and municipalities was improved after NOB/96, when funding transferences were defined. In Mato Grosso, this responsibility was incorporated by the Sanitary Surveillance Coordination (Visa/SES) which developed strategies to decentralize at first, the basic actions to all municipalities of the state. The objective of this research is to describe and analyze the strategies adopted by Visa/SES in decentralization of Visa actions to municipalities and the main difficulties found. This research is a qualitative study with documental and interview analysis. The results show as main adopted strategies: several training to professionals from regional, central and local levels; development of technical material to municipals services; assessment with join inspections between three levels of management; creation of law documents. It was observed an active performance in the decentralization, the Visa/SES keeps performing the high and middle complexity actions in almost all municipalities and even those of low complexity, in some, which impede other important tasks as supervision and evaluation of this process, besides continuous support and organization of municipalities services.     

Health services and decentralized government: the case of primary health services in Norway

Decentralized forms of government are becoming more common in Western European countries. The effects of decentralization of public health services are explored in this article. In 1984 the Norwegian Municipal Health Act allocated the responsibility for primary health care to the municipalities. Based on data from a sample of 70 municipalities, the author shows that the number of primary health service personnel has expanded considerably during 1984-88, but the distribution of services has not become more equitable. Though the formal role of local politicians in the decision-making process has increased, the health sector officers and the Municipal Executives have in practice controlled the evolution of the municipal health services. The author concludes that decentralization does not necessarily lead to more democracy, and that an equitable distribution of public health services becomes more difficult to attain.     

Changes in public health: the role of the state and the autonomous governments. SESPAS Report 2010

The first responsibilities in health passed on to the autonomous governments were those referring to public health. However, the decentralization process has not been accompanied by an updated management of the collective efforts to promote and protect health, or by a greater weight of public health within the system. To carry out such a reform, public health authorities and the central and autonomic administrations must assume their corresponding roles. The leading role should correspond to the central administration and includes the coordination and evaluation of the entire process, while the regional public health authorities should be in charge of providing public health services to the population, promoting innovations, and collaborating among themselves as well as with the central administration. Recent legal initiatives show some political sensitivity and may provide an opportunity, in addition to those provided by the economic crisis, to emphasize the role of guarantor rather than that of supplier for the state. Paradoxically, the marginality of public health could facilitate the necessary political agreements, even though party interests may be an obstacle. The influence of professional associations could be important.     

Governing the health sector: power and policy making in the English and Swedish health services

Although both are publicly owned and financed, the health care systems of England and Sweden are widely different in levels of funding, patterns of resource allocation, and types of planning and management. In England, control is more closely tied to national government; in Sweden, it is shared between national and local governments. A comparative analysis of decision making in the two systems reveals critical differences in determinations of how resources are allocated among competing interests, and how resources are used. Interestingly, as the English move toward more decentralization, the Swedes are considering greater central controls, but, in any event, convergence is unlikely.     

Health sector decentralisation in Tanzania: Analysis of decision space in human resources for health management

While decentralisation of health systems has dominated the political arena in the low‐ and middle‐income countries since the 1970s, many studies on decentralisation have focused on understanding who is given more decision‐making authority, but less attention is paid to understanding what that authority involves. This paper assesses the range of decision‐making authority transferred from the central government to subnational levels in the area of human resources for health management in Tanzania. This analysis was guided by the decision space framework and relied on interviews, focused group discussions, and analysis of documents. Data were analysed using thematic approach. While districts had narrow decision space on recruitment and promotion of health service providers, they had wide decision space on distributing health providers within districts and providing incentives. Centrally managed recruitments resulted in frequent delays, thereby intensifying shortages of skilled health service providers. This analysis concludes that decentralisation of human resources for health planning and deployment role to lower levels of the administrative hierarchy in Tanzania is limited. This suggests the need for the central government to increase decision space to districts in the area of recruitment. In order for the Ministry of Health to perform its functions better in the area of human resources for health management, there is a need to strengthen the capacity of the department dealing with recruitment of skilled health staff at the Ministry of Health.     

Complications of unsafe abortion in sub-Saharan Africa: a review

The Commonwealth Regional Health Community Secretariat undertook a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The results of the literature review component of that study, and research gaps identified as a result of the review, are presented in this article. The literature review findings indicate a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynaecology admissions. The most common complications of unsafe abortion seen at health facilities were haemorrhage and sepsis. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay (and thus, lower resource costs) and a reduced need for a repeat evacuation. Very few articles focused exclusively on the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behaviour and abortion reported that almost all patients suffering from abortion complications had not used an effective, or any, method of contraception prior to becoming pregnant, especially among the adolescent population; studies on post-abortion contraception are virtually nonexistent. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs that were identified include: community-based epidemiological studies; operations research on decentralization of post-abortion care and integration of treatment with post-abortion family planning services; studies on system-wide resource use for treatment of incomplete abortion; qualitative research on the role of males in the decision to terminate pregnancy and use contraception; clinical studies on pain control medications and procedures; and case studies on the provision of safe abortion services where legally allowed.     

Are market-oriented health insurance reforms possible in Latin America? The cases of Argentina, Chile and Colombia.

The process of health care reform benefits tremendously from comparing characteristics and performance across nations. This paper studies market-oriented health insurance reforms in three Latin American countries: Argentina, Chile and Colombia. Chile allowed private health insurers to compete for workers payroll contributions in the 1980s, permitting the modernization of the private health sector but relatively impoverishing the public health sector as a consequence of selection practices by private carriers. In the 1990s, Argentina and Colombia started liberalizing the health insurance sector but using policies to avoid the adverse effects encountered in the Chilean experience. These policies are scrutinized while challenges for these and future health insurance reform processes are discussed.     

Sur model with spatial effects: an application to mental health expenditure

This study analyses, through the adoption of a seemingly unrelated regression approach, the temporal evolution of policy interactions among local authorities in England when allocating mental health resources. This new approach in health economics may shed light on the degree of interdependence between adjacent municipalities at a specific point in time (e.g. before, during, or after a change in policy), exploiting the information carried by the panel, rather than that of a single cross-section.