Decentralization Of Services Research Articles

Addressing severe chronic NCDs across Africa: measuring demand for the Package of Essential Non-communicable Disease Interventions-Plus (PEN-Plus).

Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent diabetes, heart failure, sickle cell disease, and chronic pain. Ministry of Health NCD Programme Managers from across Africa (N = 47) were invited to participate in an online survey. Respondents were asked to report the status of clinical care across the health system. A care package including diagnostics and treatment was described for each condition. Respondents were asked whether the described services are currently available at primary, secondary and tertiary levels, and whether making the service generally available at that level is expected to be a priority in the coming 5 years. Thirty-seven (79%) countries responded. Countries reported widespread gaps in service availability at all levels. We found that just under half (49%) of respondents report that services for insulin-dependent diabetes are generally available at the secondary level (district hospital); 32% report the same for heart failure, 27% for chronic pain and 14% for sickle cell disease. Reported gaps are smaller at tertiary level (referral hospital) and larger at primary care level (health centres). Respondents report ambitious plans to introduce and decentralize these services in the coming 5 years. Respondents from 32 countries (86%) hope to make all services available at tertiary hospitals, and 21 countries (57%) expect to make all services available at secondary facilities. These priorities align with the Package of Essential NCD Interventions-Plus. Efforts will require strengthened infrastructure and supply chains, capacity building for staff and new monitoring and evaluation systems for efficient implementation. Many countries will need targeted financial assistance in order to realize these goals. Nearly all (36/37) respondents request technical assistance to organize services for severe chronic NCDs.

Health Care System Decentralization, the Case of Venezuela Historic Evolution, Results, and Consequences of its Institutional Reversal

The author exposes the political, social, and technical foundations that motivate and justify the decentralization of health care services, as a means, not as an end. He highlights the Venezuelan constitutional and legal framework that establishes the foundations of transference and sets competencies. Throughout the article, the author highlights the fundamental role of the decentralization of modern Health Systems, for the equitable and efficient achievement and quality health services and products, with the participation of the communities, as well as the conditions and requirements for its application; the purposes, objectives, benefits, and new challenges derived from its implementation. A historical recount is made on the experience garnered by the decentralization of the health care sector in Venezuela. The process for the construction of the Decentralization and Transfer of Competencies Agreements is briefly described, as well as the scope, limitations, and implementation results in the Venezuelan health care system. Briefly I explain the process of nonapplication of the Constitutional norm, and later reversal of the decentralization in health care which occurred from 2007, and its consequences. Finally, I pose strategic proposals for the defense of decentralization.

A situational analysis of primary health care centers in Brazil: challenges and opportunities for addressing mental illness and substance use-related stigma.

The detrimental impact of stigma toward people with mental illness and substance use problems (MISUP) is well documented. However, studies focusing on stigma reduction in Latin American primary health care (PHC) contexts are limited. This situational analysis incorporating a socioecological framework aims to provide a comprehensive understanding of MISUP-related stigma in PHC centers in Brazil. The objectives of this analysis are twofold: (1) to understand the current mental health and substance use service delivery context and (2) identify challenges and opportunities for addressing MISUP-related stigma in PHC centers in Ribeirão Preto, Brazil. Environmental scans of four Family Health Units were conducted in early 2018 to explore population needs and service delivery for individuals with MISUP. In addition, a symposium was organized in October 2018 to consult with diverse stakeholders and gather local perspectives about MISUP-related stigma conveyed in PHC settings. NVivo 12 software was used to conduct a thematic analysis of the qualitative data collected from the environmental scans and the symposium consultation. Themes identified at the national level in the socioecological framework indicate that political support for national policies related to reducing stigma is limited, particularly regarding social inclusion and the decentralization of mental health services. Themes at the regional, organizational, and interpersonal levels include insufficient mental health expertise and the limited involvement of those with lived experience in decision-making. Suggestions for stigma interventions were provided, including increased contact with individuals with lived experience outside of client-patient interactions, capacity building for professionals, and public education campaigns. Increased government support, capacity building, and promoting social inclusion will provide opportunities to reduce stigma and reach marginalized populations. These findings will assist with addressing current gaps in PHC mental health service provision and may inform anti-stigma strategies for Brazil and other Latin American low- and middle-income countries.

Risk factors predicting early in-hospital mortality among underfive children and need for decentralization of pediatric emergency care services.

Lack of pediatric triage and emergency care system in peripheral healthcare centers leads to unnecessary referral of low- and medium-risk patients. This study was conducted to study the risk factors predicting mortality within 48 h of admission in neonates and under-five children referred to the pediatric emergency of a tertiary care hospital in India. This prospective study was conducted on children (0-5 years) referred to the pediatric emergency who were enrolled and followed up. The outcome was defined as "survival" or "death" at 48 hours. Logistic regression analysis was conducted to assess the predictors of early in-hospital mortality. A total of 246 consecutive pediatric (62 neonates, 52 young infants, and 132 children aged 1-5 years) referral cases were enrolled; mortality within 48 hours was 20%. Lack of pediatric intensive care (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.0, 8.32, P = 0.02), lack of neonatal intensive care (OR 2.10, 95% CI 1.01,4.28, P ≤ 0.001), distance from referral center >20 km (OR 4.61, 95% CI 2.01, 10.58, P = 0.0003), >1 h taken during transport (OR 7.75, 95% CI 2.93, 20.46, P < 0.001), lack of ambulance facility (OR 0.04, 95% CI 0.009, 0.143, P < 0.0001), very sick condition on arrival (OR 210.1, 95% CI 12.1, 3643.41, P = 0.0002), and unstable temperature-oxygenation-perfusion-sugar on arrival were the independent risk factors predicting in early in-hospital mortality. Developing a pediatric triage and monitoring system, tele-pediatric intensive care unit, regionalizing referral-back-referral services with robust interhospital communication, and strengthening pediatric emergency services are the need of the hour to reduce early in-hospital mortality.

Interface between primary and specialized care in a context of decentralization of services for HIV/AIDS

RESUMO A interação entre Atenção Primária à Saúde (APS) e especializada é tão relevante quanto crítica. O cuidado às Pessoas Vivendo com HIV/Aids (PVHA), que era realizado em ambulatórios especializados, recentemente, passou a se dar também pela APS, considerando seu potencial de ampliar o acesso. A partir de estudo de caso realizado em uma região municipal do Rio de Janeiro entre 2018 e 2019, discutiu-se tal problemática, destacando como resultados: desconhecimento/hesitação dos profissionais da atenção especializada sobre a atenção básica quanto à sua capacidade de cuidar das PVHA; priorização de investimento material, simbólico e político na atenção básica; quase inexistência de canais de diálogo entre serviços; entre outros. Na experiência estudada, a interface entre APS e atenção especializada tem se dado mais em uma lógica binária e de isolamento que em uma perspectiva de interação e gestão (compartilhada) do cuidado, que seria esperada em uma conformação de rede de atenção. Apesar dos potenciais ganhos de acesso e ‘racionalização’ do uso do especialista (infectologista), tais resultados indicam a necessidade de fortalecer processos e mecanismos de comunicação e interação entre profissionais de diferentes tipos de serviços, além de dispositivos de coordenação dos cuidados, como apoio matricial e prontuário eletrônico integrado em rede.

Upward and downward accountability in local government: the decentralisation of agricultural extension services in Tanzania

A key assumption behind decentralisation in developing countries is that it enhances the accountability of local government and results in policies that reflect the preferences of the local community. However, previous research shows that local politicians and administrators in many developing countries to a large extent behave as if they were primarily accountable to central government, not local communities. The literature suggests various explanatory factors but does not provide insight into their relative weight and into how different factors interact. This paper combines comparative case-study research with in-depth interviews and focus group discussions with local government politicians and officials involved in the delivery of agricultural extension services in Tanzania. It shows that limited administrative and political decentralisation and centralistic human resources management restrict downward accountability to the community. Downward accountability is also constrained by the social rules that local politicians and administrators observe. For downward accountability to materialise, formal systems of public administration need to introduce incentives to that effect.

Fiscal Decentralisation of Services: The Case of the Local Public Sector in European Countries

Services are a dynamically developing economic sector in all countries. The paper focuses on public services, evaluated from the perspective of fiscal decentralization. It aims to evaluate the level of fiscal decentralization of expenditures in selected categories of public services in European countries. For this purpose, government expenditures by the local government sector are analyzed in the set of the selected 28 European countries in the period 2010-2018. Cluster analysis has been carried out in order to determine four clusters of countries based on their level of decentralization of expenditures on services. The results show differences in the extent of decentralization between the European countries in the provision of specific public services and reflect the form of financing of local public needs. A low level of fiscal decentralization of expenditures on services (public order and safety; housing and community amenities; recreation, culture, and religion) was observed in the majority of the countries. However, the majority of the countries failed to prove a high level of fiscal decentralization of expenditures on services (social protection, health, education) and a medium level of decentralization of expenditures in terms of general public services and services of economic affairs. These findings demonstrate that the degree of decentralization of public services is determined, to a certain degree, determined by country history and its geographical location, as well as by the different roles of sector-specific public policies. The findings can be helpful for creators of local public policies, strategic plans, and financial concepts.

Provision of Decentralized TB Care Services: A Detect-Treat-Prevent Strategy for Children and Adolescents Affected by TB.

In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.

The social control and rainwater management in Brazil / O controle social e a gestão das águas pluviais no Brasil

The aim of this article is to discuss the conflicts of jurisdiction between the different entities of the Brazilian Federation about water management, particularly since these were not determined by the resolutions of the 1988 Federal Constitution. Although the role of the different players involved was outlined in the Water Resources Law, it was only through the enactment of the Law on Basic Sanitation, updated in 2020, that the municipalities were given responsibility for the management of rainwater in Brazil. Rainwater management currently forms, or should form, a part of the municipal planning of basic sanitation and community involvement, together with transparency, is becoming a key principle underlying the new model of local governance. The adoption of sustainable techniques and non-conventional methods of water management, based on the concept of Low Impact Urban Design and Development (LIUDD), is serving as a model for the kind of rainwater management that can allow social control together with democratic participation and the decentralization of sanitation services.

Antihypertensive Medication Adherence and Associated Factors: A Cross-Sectional Analysis of Patients Attending a National Referral Hospital in Asmara, Eritrea.

BackgroundRecent research suggests that poor adherence to antihypertensive medication (AHM) is a major problem in the management of hypertension. This study was therefore designed to evaluate the frequency of AHM and associated risk factors in patients attending a national referral hospital in Asmara, Eritrea.MethodsA total of 335 respondents (females: 222 (66.3%) participated in this cross-sectional study. Adherence to Medication was evaluated using a modified version of the Medication Adherence Report Scale (MARS). Additional data were abstracted from patients’ medical records and a WHO STEPwise questionnaire.ResultsThe mean (±SD) age of the study participants was 59.65 (±12.20) years (females: 56.82 (±9.95) vs males: 57.17 (±9.60) years, p-value=0.001). Similarly, the median (IQR) for diastolic blood pressure (DBP) and systolic blood pressure (SBP) were 85.00 mmHg (IQR: 80.00–90.00 mmHg) and 145.00 mmHg (IQR: 130.00–160.00 mmHg), respectively. Overall, 246 (73.4%) and 244 (72.8%) participants had poor knowledge and poor adherence to AHM, respectively. In the multivariate analysis, factors associated with increased odds of poor adherence to AHM included sex (females: adjusted odds ratio (aOR): 4.95; 95% CI: 1.52–16.11, p value=0.008); employment status (Ref: employed/NGO) (self-employed: aOR: 1.95; 95% CI: 0.45–8.48, p-value=0.373) (housewife: aOR: 0.13; 95% CI: 0.04–0.413, p-value=0.001) (unemployed: aOR: 1.38; 95% CI:0.32–5.98; p-value=0.670); lack of attendance of health talk at the clinic (aOR: 2.33; 95% CI: 1.17–4.63; p-value=0.016); high cost of transportation (yes: aOR: 6.87; 95% CI: 3.25–14.52; p-value<0.001); knowledge (poor: aOR: 6.23; 95% CI: 2.36–18.05, p-value<0.001) and hypertension stage (Stage 3: aOR: 5.55; 95% CI, 1.44–21.37, p-value=0.013). Low level of knowledge regarding hypertension-related complications or associated risk factors was also noted.ConclusionThe high level of poor adherence to anti-hypertension medications and low level of knowledge on hypertension should raise concern. Overall, decentralization of health care services and educational support are vital intervention pathways in this population.

The Impact of Decentralization of Fire Protection on Fire Deaths in the US: A Cross-State Analysis

In this paper, we offer an estimate of the effect of decentralization of fire protection service on fire deaths in the US, while using individual US states as points of observation. We assess the degree of decentralization in each state by the average size of its fire departments, which is the basic unit of fire protection service in the US. A number of other factors that are relevant to the causes of fires are included in our regression model. Our results show that the size of fire departments measured both in population and in the area served by one fire department positively correlates with fire death rate. We interpret these results as an evidence that there is room for improving efficiency in fire protection service around the US through decentralization.

Institutionalizing Quality Declared Seed in Uganda

Farmer-led seed enterprises can produce good quality seed and market it. However, for them to thrive, they need a conducive policy and regulatory framework that is inclusive and less stringent than existing regulatory frameworks. One way to provide a more enabling environment for farmer-led enterprises is through the Quality Declared Seed (QDS) production and marketing system. In Uganda, this seed class is specifically introduced for farmer-led enterprises to produce and market quality assured seed of crops and varieties not served by the private sector. The class is anchored in the Ugandan National Seed Policy and its seed regulations and its operationalization plan. We identified a combination of three strategies that enabled the QDS class to be incorporated into the National Seed Policy. These were: (i) to generate evidence to demonstrate that local seed businesses (farmer groups) can produce and market quality seed; (ii) to engage stakeholders towards an inclusive seed policy; and (iii) to develop a separate QDS regulatory framework. By 2021, institutionalization has reached a critical mass. Areas of attention for full institutionalization are the decentralization of inspection services, awareness and demand creation for quality seed, increasing the number of seed producers, and solving shortages of basic seed (starting material for producing seed).

Implementation of an Effective Decentralised Programme for Detection, Treatment and Prevention of Tuberculosis in Children.

Childhood tuberculosis (TB) is consistently under-detected in most high-burden countries, including Uganda, especially in young children at high risk for severe disease and mortality. TB preventive treatment (TPT) for high-risk child contacts is also poorly implemented. The centralised concentration of services for child TB at the referral level is a major challenge in the prevention, detection and treatment of TB in children. In 2015, the DETECT Child TB Project was implemented in two districts of Uganda and involved decentralisation of healthcare services for child TB from tertiary to primary healthcare facilities, along with establishing linkages to support community-based household contact screening and management. The intervention resulted in improved case finding of child and adult TB cases, improved treatment outcomes for child TB and high uptake and completion of TPT for eligible child contacts. A detailed description of the development and implementation of this project is provided, along with findings from an external evaluation. The ongoing mentorship and practical support for health workers to deliver optimal services in this context were critical to complement the use of training and training tools. A summary of the project’s outcomes is provided along with the key challenges identified and the lessons learnt.

Perceived consequences of healthcare service decentralization on access, affordability and quality of care in Khartoum locality, Sudan

BackgroundDecentralization of healthcare services has been widely utilized, especially in developing countries, to improve the performance of healthcare systems by increasing the access and efficiency of service delivery. Experiences have been variable secondary to disparities in financial and human resources, system capacity and community engagement. Sudan is no exception and understanding the perceived effect of decentralization on access, affordability, and quality of care among stakeholders is crucial.MethodsThis was a mixed method, cross-sectional, explorative study that involved 418 household members among catchment areas and 40 healthcare providers of Ibrahim Malik Hospital (IBMH) and Khartoum Teaching Hospital (KTH). Data was collected through a structured survey and in-depth interviews from July–December 2015.ResultsAccess, affordability and quality of healthcare services were all perceived as worse, compared to before decentralization was implemented. Reported affordability was found to be 53 and 55% before decentralization compared to 24 to 16% after decentralization, within KTH and IBMH catchment areas respectively, (p = 0.01). The quality of healthcare services was reported to have declined from 47 and 38% before decentralization to 38 and 28% after, in KTH and IBMH respectively (p = 0.02). Accessibility was found to be more limited, with services being accessible before decentralization approximately 59 and 52% of the time, compared to 41 and 30% after, in KTH and IBMH catchment areas respectively, (p = 0.01).Accessibility to healthcare was reported to have decreased secondary to facility closures, reverse transference of services, and low capacity of devolved facilities. Lastly, privatized services were reported as strengthened in response to this decentralization of healthcare.ConclusionsThe deterioration of access, affordability and quality of health services was experienced as the predominant perception among stakeholders after decentralization implementation. Our study results suggest there is an urgent need for a review of the current healthcare policies, structure and management within Sudan in order to provide evidence and insights regarding the impact of decentralization.

PECULIARITIES OF RESOURCE PROVISION OF SOCIAL PROTECTION OF THE POPULATION OF UKRAINE

On the way to decentralization in order to achieve the goals of territorial development and local needs, local authorities can not do without having complete and comprehensive information on the full range of local resources and their effective management. Considering the resource potential of the region as a set of the whole range of resources that are formed in a given area and can be used in the process of socio-economic development and characterized by saturation of factors of production (natural resources, labor, fixed assets, infrastructure, etc.) and intangible factors, it is clear that it is a prerequisite for the implementation of development programs in the region. For the most part, the resource provision of the process of implementation of socio-economic development programs of the region is reduced to financial support, but in order to achieve the goals of such development, the use of non-monetary resources is no less important.The article identifies the components of resource provision of social protection at the local level, including: economic resources (financial and logistical); regulatory resources (regulatory framework, methodology); administrative resource; innovation resource; information resource. Problematic aspects of resource provision are outlined, among which: insufficient financing and low efficiency of budget funds use; lack of interest in finding additional sources of income; too extensive system of social benefits and privileges; disunity of institutions providing social services; insufficient integration and decentralization of services; low innovation of the sphere; insufficient use of information resources. Tools for improving the management of social protection resources are proposed.

Does better job accessibility help people gain employment? The role of public transport in Great Britain

The combined decentralisation of many firms and services and the increasing concentration of traditional public transport services in the main corridors of urban centres have made it more difficult for people to access jobs, in particular when residing outside these prime accessibility areas. This is the first national study within the context of Great Britain to examine whether better public transport job accessibility, modelled at the micro level of individuals, improves employment probabilities for people living in Great Britain. While previous studies have typically concentrated on US metropolitan areas, our study uses British national employment micro datasets to assess which urban and rural areas and population groups would benefit from better public transport services. In an important departure from most standard accessibility methodologies, we computed a public transport job accessibility measure applied nationwide and combined this with individual-level employment probability models for Great Britain. The models were corrected for endogeneity by applying an instrumental variable approach. The study finds that better public transport job accessibility improves individual employment probabilities, in particular in metropolitan areas and smaller cities and towns with lower car ownership rates and in low-income neighbourhoods. It further shows that mainly lower educated groups and young people would benefit from better public transport job accessibility. The findings in this study are important for policymakers in that they imply that, in particular, job seekers who rely on public transport services may benefit from more targeted public policies to improve their accessibility to employment and thereby their social mobility.

Institutionalizing a Regional Model for Improving Quality of Newborn Care at Birth Across Hospitals in Eastern Uganda: A 4-Year Story.

Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region. This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions. In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs. The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.

BLOCKCHAIN AND THE DECENTRALISATION OF THE CYBERSECURITY INDUSTRY

This paper aims to analyse the potential impact that blockchain technology will have on the cybersecurity industry. We will look at different applications of blockchain technology in the field of cybersecurity, as well as a new trend of decentralisation of cybersecurity services. Blockchain is precisely a cybersecurity architecture that enables the decentralisation of processes and business models, which could have a direct consequence on cybersecurity services, as well as on the industry itself. Cybersecurity companies will have to adapt to a new ecosystem in which the blockchain technology will enable crowdsourcing of cybersecurity services. Keywords: Blockchain, Cybersecurity, Disruptive Technology, Technology Innovation, Technology Strategy

Central‐local tensions in the decentralization of social policies: Street‐level bureaucrats and social practices in the Netherlands

AbstractEuropean welfare reforms often involve the decentralization of social care services. This potentially creates central‐local tensions for professionals implementing and delivering policies on the ground. Using the capability approach (CA) as a conceptual frame, this article compares local professionals' experiences in the decentralization of social work and care services in an urban and a rural mid‐sized municipality in the Netherlands. It offers a missing insiders' perspective on central‐local tensions, focusing on front‐line workers' capabilities to effectively implement policy on the ground. It finds that perfect policy implementation is hardly achievable locally and that policies are translated through implementation and on‐the‐ground delivery. This leads to central‐local tensions and the absence of reflective space for professionals to deal with normative dilemmas. We conclude that the CA is both useful for identifying these tensions as well as providing a normative framework to guide professionals in reflecting on and negotiating street‐level issues.

Containing costs in the Italian local healthcare market.

We aim to investigate the cost containment effects of the creation in 2005 of agencies specifically responsible for all technical and administrative services within the regional healthcare system of the Tuscany region of Italy. We seek to contribute to the existing literature on the centralization and decentralization of purchases and technical services by assessing the amount of savings produced by these agencies at the intermediate level between local authorities and hospitals and the regional administration. We use the balances of all Italian local health authorities and hospital trusts combined with the synthetic control procedure to create from a donor pool of untreated units a weighted average of observations resembling the exposed units before and after the policy change in 2005. The magnitude of the effect is significant as the creation of these agencies is estimated to have reduced expenditures on auxiliary goods and contracted services by 6% in the period from 2006-2014. Moreover, we find that the cost reduction is not associated with a decrease in the provision of healthcare services and procedures to the general population or in the quality or efficiency of the regional healthcare system itself.