Abstract
Devolution, as other types of decentralization (e.g. deconcentration, delegation, privatization), profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. The key question of this article is: what does devolution mean for human resources for health in Mali?This article assesses the key advantages and dilemmas associated with devolution such as responsiveness to local needs, downward accountability and health worker retention. Challenges of politics and capacities are also addressed in relation to human resources for health at the local level. Examples are derived from experiences in Mali with a capacity development programme and from case studies of other countries. It is not research findings that are presented, but highlights of key issues at stake aimed at inspiring the debate in Mali and elsewhere.A first lesson from the discussion suggests that in the context of human resources for health, decentralization of authority and resources is not the main issue. The challenge is to develop or strengthen accountability of those who decide and act, whether they are local politicians, bureaucrats or community representatives. If decentralization policies do not address public accountability, they will not fundamentally change human resource management, quality and equity of staffing. A second lesson is that successful devolution requires innovations in capacity development of all actors involved and in designing effective incentive measures. A final key conclusion is that the topic of devolution policy and its effects on human resources for health, and vice versa, merit more attention. A better understanding may lead to more appropriate policy designs and better preparation for the actors involved in countries that are embarking on decentralization, as is the case in Mali.
Highlights
Key constraints to health service provision in rural Mali are often linked to resource management, and in particular to the allocation and performance of available human resources
The clinics have a designated catchment area defined by the number of people living within a 5 to 15 km radius from the clinic
“Local governments” in Mali are autonomous entities that consist of locally elected councillors, a mayor and basic administrative staff
Summary
Key constraints to health service provision in rural Mali are often linked to resource management, and in particular to the allocation and performance of available human resources. One of the strategies of the Government of Mali is to decentralize responsibilities for the management of local health centres to local institutions This is done through two complementary approaches that both aim at increased community involvement, strengthened autonomy and the division of labour (subsidiarity) for increased efficiency. This has been done through (1) delegation of management of health centres to community health associations since 1990 and (2) the devolution of decision-making power to locally elected governments since 2002. “Local governments” (communes) in Mali are autonomous entities that consist of locally elected councillors, a mayor and basic administrative staff They are different from the “local administration” represented by the prefect. The community health association and the local government function as separate structures but representatives from both organizations form the commune health commission that discusses health programmes
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