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DECENTRALIZATION AND HEALTH

DECENTRALIZATION AND HEALTH. HOW TO PROTECT PRIORITY SERVICES Patricio Murgueytio, MD, Ph.D. Abt Associates, Inc. Educational Objectives. Understand implications of decentralization on provision of priority health services

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DECENTRALIZATION AND HEALTH

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  1. DECENTRALIZATION AND HEALTH HOW TO PROTECT PRIORITY SERVICES Patricio Murgueytio, MD, Ph.D. Abt Associates, Inc.

  2. Educational Objectives • Understand implications of decentralization on provision of priority health services • Consider options to manage potential adverse effects of decentralization USAID SOTA 2001

  3. Behavioral Objective • Review potential adverse effects of decentralization on priority services and develop some strategic thinking to manage such effects. USAID SOTA 2001

  4. Priority Health Services • Basic care services provided to address population-based health problems, such as vaccine-related illnesses, maternal deaths, HIV/AIDS, endemic infectious diseases, etc. • Scope and content of priority services may depend on country’s epidemiological profile. • In LAC Region, many priority services have traditionally been offered through vertical, centralized government structures and programs. USAID SOTA 2001

  5. Potential Adverse Effects of Decentralization • May alter program/service effectiveness • May disrupt efficiency • May affect equity • May alter sustainability USAID SOTA 2001

  6. Altering program/service effectiveness • Examples: • In Honduras, efforts to decentralize MOH programs towards regions brought about decline in HIV/AIDS surveillance. Underreporting increased significantly. • In Colombia, overall vaccination rates declined after decentralization, leading to higher incidence of vaccine-preventable illnesses. Poor capacity for EPI management and resource competition at local levels were key factors. USAID SOTA 2001

  7. Potential Effects on Efficiency • Decentralization does not necessarily lead to reduced costs. Costs may increase due to increased hiring, training, infrastructure, and equipment. • Examples: • In the Dominican Republic, “provincialization” and now “regionalization” have increased already inflated MOH payroll. Regional MOH layer may represent bureaucratic bottleneck. Roles and responsibilities are not clear. Politics is a key factor when appointing local managers. • Corruption may affect decentralization. USAID SOTA 2001

  8. Potential Effects on Equity • During the 1980s, decentralization in Mexico led to some inequitable resource distribution among states. Least developed states had a hard time raising cash to support insurance program for the poor. • In Colombia, localities with greater political influence got greater share of public resources. • Before 1994, most public health resources in the DR were allocated to regional home sites, shortchanging provinces. This led to within-region inequities and thus creation of “provincial health directorates.” USAID SOTA 2001

  9. Potential Effects on Sustainability • Decentralized districts may have lower capacity to compete for resources (consider “compensatory financing”; earmarked government transfers). • Local authorities in smaller communities may exhibit less capacity to manage and maintain programs, e.g. water and sanitation. • Some programs require central government support for long-term sustainability, e.g. Immunizations, malaria control. USAID SOTA 2001

  10. Strategic Options • Facilitate clear, concerted decentralization strategy • Promote user/client and impact orientation of decentralization strategy (“means to an end”). • Seek functional coordination between center and periphery. • Develop effective monitoring and evaluation. • Build central and local level capacity. • Consider uniqueness of decentralization process. USAID SOTA 2001

  11. What Next? • Decentralization does and should work, although there is no cookie cutter approach. • Be aware and alert. • Be ready to exercise (informal) leadership. • Be sensitive to host country conditions. USAID SOTA 2001

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