What is Decentralization in Health?

Table of Contents

What is Decentralization?

In simple words, Decentralization is the distribution or transfer of power, control or authority from central government to local and regional authority.
Decentralization is the restructuring of authority so that there is system of co-responsibility between institutions of governance at the central, regional and local levels according to the principle of solidarity, thus increasing the overall quality and effectiveness of the systems of governance, while increasing the authority and capabilities of sub-national levels. (UNDP)

Why Decentralization?

Better coordination and corporation at action level.
Improved implementation of health program.
Better transparency and accountability.
Ensures sustainability.
Improves equity and quality of care.
Reduction in duplication of health services.
Improves delivery and utilization of health service.
More community participation in health sector development activities
Capacity for district health planning is improved.

Forms/Types of Decentralization:

Deconcentration:- (transfer of responsibility/ authority to lower administrative level)
Devolution:- (transfer of responsibility/ authority to lower political level)
Delegation:- (transfer of managerial responsibility)
Privatization:- (transfer of governmental function to private ownership)

Conceptual framework of decentralization (Example from Nepal):

Objectives, Rationale and some Controversies of Health decentralization

Objectives	How?	Issues and controversies
To improve technical efficiency	Having less bureaucratic levels and greater cost consciousness at the local level. It also includes different function of purchaser and provider in the market.	Necessity of contextual conditions to achieve it. Moreover, motivation/incentives are needed
To increase allocative efficiency	By better matching between public services and local preferences, through enhanced patient responsiveness	Decreased consensus and increased coldness central and local governments or among different local governments
To empower local governments	Through more active local participation, and capacity building of local administration	Concept of local participation is not crystal clear
To increase the innovation of service delivery	Experimentation and adaptation to local conditions, increasing autonomy of local governments and institutions	Increased inequalities
To increase accountability	Through public participation Transformation of the role of the central government	Who is accountable for what and to whom must be clarified
To increase quality of health services	By integrating health services, improving health information systems and access to health care.
To increase equity	Need based resource allocation and distribution (through cross subsidy mechanism) and capacity building of local organizations	Decrease in local autonomy

Advantages of Decentralization:

Community/local needs are better identified and fulfilled
Decision making is quick
Less bureaucracy
Lower level managers also gain experience in decision making
Local units develop necessary skills to solve the problem
Development of ownership in local units and functions improve
More accountable.
Load for top management is reduced.
Effective control and supervision.
Increased job satisfaction
Quick response and action in matters of urgency

Limitations of Decentralization

It may lead to coordination problem
It increases administrative cost
Maintaining global standards is difficult.
Extra infrastructure cost is encountered.
Complexity in coordination of decentralized unit.
It may lead to absence of uniformity at organizational level.

Challenges to Health Sector Decentralization

A report titled, “Addressing the challenges to health sector decentralization in Nepal: an inquiry into the policy and implementation processes.” found following challenges in health sector decentralization: