Abstract
Designers and implementers of decentralization and other reform measures have focused much attention on financial and structural reform measures, but ignored their human resource implications. Concern is mounting about the impact that the reallocation of roles and responsibilities has had on the health workforce and its management, but the experiences and lessons of different countries have not been widely shared. This paper examines evidence from published literature on decentralization's impact on the demand side of the human resource equation, as well as the factors that have contributed to the impact. The elements that make such an impact analysis exceptionally complex are identified. They include the mode of decentralization that a country is implementing, the level of responsibility for the salary budget and pay determination, and the civil service status of transferred health workers.The main body of the paper is devoted to examining decentralization's impact on human resource issues from three different perspectives: that of local health managers, health workers themselves, and national health leaders. These three groups have different concerns in the human resource realm, and consequently, have been differently affected by decentralization processes. The paper concludes with recommendations regarding three key concerns that national authorities and international agencies should give prompt attention to. They are (1) defining the essential human resource policy, planning and management skills for national human resource managers who work in decentralized countries, and developing training programs to equip them with such skills; (2) supporting research that focuses on improving the knowledge base of how different modes of decentralization impact on staffing equity; and (3) identifying factors that most critically influence health worker motivation and performance under decentralization, and documenting the most cost-effective best practices to improve them. Notable experiences from South Africa, Ghana, Indonesia and Mexico are shared in an annex.
Highlights
Decentralization, in its various forms, is a common feature of reform in both developed and developing countries
Concern has been mounting among health managers and workers about the impact that decentralization has had on human resources for health (HRH) and the way they are managed
Dussault and Dubois echo the concerns of many observers, when they comment, "In many reforms, there is discordance between the elevated attention given to issues of financing and structural transformation and the low attention given to HRH issues..."[1]
Summary
Decentralization, in its various forms, is a common feature of reform in both developed and developing countries. A tightly centrally-controlled civil service may not allow local managers to create new posts, or their budget http://www.human-resources-health.com/content/2/1/5 may be insufficient to increase staffing levels, even if they have this power. Health workers respond positively to the human resource demands of a decentralized unit if they seek employment in it, accept a post if it is offered, and remain in service Their ability and willingness to act in response to local demands depend on a number of factors. These include a worker's personal family and economic situation, attractiveness of salary levels and other terms and conditions of service, opportunities for professional growth and career development, alternative employment opportunities in the labor market, the level of morale and motivation in the workforce, etc. What protection do they have against unfair hiring practices or unjust dismissal? What legal resources do they have, if they are sued for malpractice? Does the national malpractice insurance that covered them as national civil servants still apply when they are seconded or transferred to the employ of local governments? Addressing such important legal concerns is an important central government responsibility that requires the establishment or maintenance of appropriate mechanisms for legal protection of all staff on the public payroll
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