Health Decentralization Research Articles

Political and Programmatic Health Decentralisation in Karnataka State: An Evidence-based Rural Participatory Decision-making

Health decentralisation is a dynamic tool for providing quality and inclusive healthcare. The effectiveness of the administration of an institutional-quality healthcare delivery system focusing on health decentralisation has been under question for the last three decades. Also, examining the successes of decentralisation and the correlation between autonomy, decision space (degree of decentralisation) and health outcomes is gaining momentum today. The major aim of this research study is to assess the effectiveness of Panchayati Raj Institutions (PRIs) in managing the rural healthcare system in the state of Karnataka (South India). The study has used mixed methods, drawing samples from PRIs and Public Health Institutions. The study has found some notable issues in rescheduling decentralised health administrative structures, reducing benefaction and political meddling and implementing performance-based resource distribution. It is concluded that structural, dynamic and geographically specific reforms in age-old administrative procedures are very essential in the administrative and financial management systems of PRIs for effective health decentralisation in India.

Rural local government and healthcare delivery in an Eastern Indian state

Based on field research in the remote and tribal-dominated Kandhamal district in the eastern Indian state of Odisha during 2019-20, the study examines the extent to which Constitutionally-created rural self-governance institutions (village Panchayats) fulfilled their mandated healthcare functions. Primary data was collected from villagers, front-line public health officials, elected local government (Panchayat) members and party cadres through focus group discussions and interviews. Employing the Foucauldian governmentality framework, the analysis moves away from a depoliticized understanding of decentralized delivery of rural health. The study concludes that Panchayats’ contributions to rural health are influenced by politically motivated factors, which may not be compatible with considerations of democracy and efficiency. Panchayat performance in the study villages remained poor as the state allowed them only regulated freedom and did not create space for their autonomy to flourish. Rural health decentralization led to new forms of governmentality as Panchayats were instrumentally used to consolidate state power at the rural grassroots. Top-down management of political process in these areas makes local government mechanical outpost of the ruling party.

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China.

Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective. This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes. Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents. The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

N-of-1 health optimization: Digital monitoring of biomarker dynamics to gamify adherence to metabolic switching.

The digital health field is experiencing substantial growth due to its potential for sustained and longitudinal deployment. In turn, this may drive improved monitoring and intervention as catalysts for behavioral change compared to traditional point-of-care practices. In particular, the increase in incidence of population health challenges such as diabetes, heart disease, fatty liver disease, and other disorders coupled with rising healthcare costs have emphasized the importance of exploring technical, economics, and implementation considerations, among others in the decentralization of health and healthcare innovations. Both healthy individuals and patients stand to benefit from continued technical advances and studies in these domains. To address these points, this study reports a N-of-1 study comprised of sustained regimens of intermittent fasting, fitness (strength and cardiovascular training), and high protein, low carbohydrate diet and parallel monitoring. These regimens were paired with serial blood ketone, blood glucose (wearable and finger stick) and blood pressure readings, as well as body weight measurements using a collection of devices. Collectively this suite of platforms and approaches were used to monitor metabolic switching from glucose to ketones as energy sources-a process associated with potential cardio- and neuroprotective functions. In addition to longitudinal biomarker dynamics, this work discusses user perspectives on the potential role of harnessing digital devices to these dynamics as potential gamification factors, as well as considerations for the role of biomarker monitoring in health regimen development, user stratification, and potentially informing downstream population-scale studies to address metabolic disease, healthy aging and longevity, among other indications.

Concurrent Authority in Regional Government Relating to the Health Sector Based on Indonesian Regulations

This study supports analyzing health decentralization from three factors: authority, regional resources, and access. The research method used is by normative legal research examines law that is conceptualized as an applicable norm. The results of the study show how the implementation of concurrent affairs health decentralization in North Sulawesi and East Bolaang Mongondow regency is as follows: Low regional capacity characterized. Research indicates that concurrent authority in Indonesia’s decentralized health sector is governed by Law Number 23 of 2014. This law delineates responsibilities among the central government, provincial government, and city district governments in managing four specific health-related matters. The legal foundation aligns with constitutional recognition of health as a fundamental human right, as outlined in Law Number 39 of 1999 and the International Covenant on Economic, Social and Cultural Rights (Law Number 11 of 2005). To optimize health services, stakeholders are urged to collaboratively implement concurrent authority efficiently. This synergy, grounded in legal frameworks and human rights principles, promises to advance the realization of an adequate standard of living and the highest attainable health standards for all Indonesians.

The Impacts of Health Decentralization on Equity, Efficiency, and Effectiveness: A Scoping Review

Decentralization is considered an important component of participatory democracy. However, despite its widespread implementation in the healthcare sector, its impact on health systems’ performance remains unclear. Using a theoretical framework based on the World Health Organization’s five decentralization variables—geography and sociodemographics, organization of political processes, functions and economic weight, steering, and control—we conducted a scoping review to unveil causal mechanisms linking each feature to equity, efficiency, and effectiveness. Following the PRISMA protocol, 1627 articles were screened, and 63 were selected for data analysis, with a focus on middle- and high-income countries. The findings show that the most frequently discussed forms of decentralization are fiscal and administrative, with a primary focus on how governance mechanisms affect equity and efficiency. The effects of decentralized healthcare governance on equity, efficiency, and effectiveness are diverse and contingent on contextual factors and the implementation processes. The spatial context (geography) of decentralization negatively impacts equity, and steering strongly affects effectiveness. Functions and economic weight significantly influence efficiency, albeit with variability. Overall, decentralization falls short of delivering substantial healthcare system benefits, although this depends on contextual factors.

Reconstructing Legal Frameworks: Central-Local Government Collaboration during the Pandemic in Indonesia

This research discusses the issue of centralization and decentralization in handling the COVID-19 pandemic, focusing on the Indonesian context. Criticism of decentralization in COVID-19 was conveyed by Smith (2012), who considered it a form of centralization that strengthens narrow interests and threatens the public interest. This research also looks at the implementation of health decentralization in Natuna, which is experiencing severe challenges such as a shortage of medical personnel, lack of timely available funds, and inadequate availability of vaccines and medical materials. In addition, the COVID-19 pandemic has raised challenges in coordinating and managing responses in various countries, with some adopting a centralized approach and others favoring decentralization. This research tries to explore the legal links between the central and regional governments in handling COVID-19 in Indonesia, with a focus on the impact of existing regulations such as Law No. 24 of 2007 concerning Disaster Management, Law No. 23 of 2014 concerning Regional Government, and Law no. 6 of 2018 concerning Health Quarantine regarding cooperation and coordination between the central and regional governments in handling the pandemic. This research is vital because COVID-19 is a global health crisis affecting various social, economic, and political aspects. With a better understanding of the legal relationship between central and regional governments in handling the pandemic, it is hoped that response coordination and effectiveness can be improved, thereby saving lives and reducing adverse social and economic impacts. This research has the advantage of focusing on the legal relationship between the central and regional governments in handling the COVID-19 pandemic in Indonesia and recommendations for reconstructing this legal relationship by referring to the 1945 Constitution. Good collaboration between the central and regional governments is considered vital in handling the COVID-19 pandemic -19 in the future.

Health and quality of life development plan: from theory to practice

Abstract In 2019, a decentralization process in Portugal transferred health governance competencies and autonomy from central to municipal level. Despite empowering local authorities to shape health policies and strategic partnerships, municipalities turned to academia for public health planning expertise. This work depicts how the National School of Public Health devised a Health and Quality of Life Development Plan for one such municipality. A two-stage approach was used. Firstly, a comprehensive overview of population health status and determinants was produced. It involved analysing local and national legal frameworks and worldwide strategic literature; assessing sociodemographic, economic, environmental and health indicators; questioning residents and key stakeholders; and city council and local health authorities working sessions. Secondly, detailed strategies were laid out to address specific health needs and determinants. It involved analysing similar municipal plans; selecting priority health actions; and designing evidence-based interventions with target, timeline, estimated resources and outcomes measures. The authors built and applied a public health planning methodology, resulting in a profound health diagnosis. Public and stakeholder scrutiny ensured prioritization of key action areas and effective working pathways in strategic planning were introduced. Furthermore, evidence-based actions adapted to local capacity, budget and resources were presented. Outputs range from health literacy sessions in schools to contingency plans for public health emergencies. Health governance responsibilities’ redefinition evidenced a knowledge gap and drove the need to consult academia to develop evidence-based health policies. By creating this methodology, the authors defined strategic pillars and tailored operational recommendations for municipalities, which rely on ongoing indicator monitoring and, ultimately aim to improve population health through concerted efforts. Key messages • The decentralization of health competencies granted local autonomy in shaping health policies. To support decision and policy-making, a comprehensive tool for health diagnosis assessment was designed. • The need for a concerted local action with definition of territorialized development strategies, highlights the value of a deep connection between decision-makers and academia as a consulting entity.

Decentralization of Health Service at Darussalam Public Health Center Medan

The problem with health decentralization in Indonesia is that health decentralization is still half-hearted. The policy direction in the health sector initially rested on efforts to treat disease and restore health. And next, policy direction has also shifted towards implementing comprehensive health efforts with an emphasis on disease prevention and health promotion. The shift also occurred in the focus of policy direction in the health sector, which initially focused on individual health, which then shifted to public health. This study aims to determine how the decentralization of health service delivery at the Darussalam Public Health Center, Medan City. type of research in this study is a qualitative research with a descriptive approach in the form of written or spoken words from people and observable behavior. data collected is in the form of words, pictures, and not numbers. All the data collected may be the key to what has been researched. The results showed that the planning, budgeting, and management processes were still relatively slow because they had to get approval from the Medan City Health Office. The Darussalam Health Center can only submit this deficiency to the Medan City Health Office. because the one who has the authority to make repairs is the Medan City Health Office.There are still obstacles in the referral process,because there are several administrations that must be completed and the procedures must also comply with the specified standards.

Call for Asymmetric Health Decentralisation in Indonesia

Disparities, Inequalities and inequities are still significant problems after decades of experiencing health decentralisation. This study arranges massive issues on health decentralisation to endorse improvement. The analysis offers insight into decentralisation practices in Indonesia to perform health affairs. A systematic review approach was practised to identify the Scopus database and PubMed MEDLINE from 1999 to 2020, using the terms "health" and "decentralisation." Inclusion criteria were final manuscript, full-text access, and elaborate health administration in the decentralised era. Non-journal articles and non-Indonesia research sites were applied as exclusion criteria. The study analysed 32 reports through Vosviewer tools to confirm health decentralisation trends based on word frequency mentioned in the abstract. Using Atlas.ti qualitative apps tools, the full text of the identified manuscript was analysed into the categorisation of main decentralisation issues; 1) intergovernmental relations, 2) fiscal capacity, 3) regional capacity and capability to elaborate on implementation gap, obstacles, and pros and cons of Indonesia's experience in health decentralisation. The study found that changing decentralisation patterns that mismanaged unequal distribution of health resources raises inequality issues. Second, there is conflictual relation between national and regional health administration-sandwich function caused by the unclear division of government authority. Third, the health policy necessity of a symmetrical approach to coping with regional disparities in fiscal capacity, local government capacity, and capability to provide health services, and inequity problems follow. Moreover, various specific local needs and contexts do not fit in with national health policy. In this context, an asymmetrical approach to managing health answers diverse context responses in implementing decentralisation and inequality and inequity issues.

Will Health Grants to Local Governments by the Fifteenth Finance Commission Eventually Become a Victim of Mission Creep Syndrome?


 While the health grants to local governments recommended by Fifteenth Union Finance Commission in the wake of Covid 19 pandemic lays emphasis on the trust-based approach to local governments and decentralization of health, the danger of Mission Creep can undo the potential and effectiveness of the grants to strengthen the primary health care sector. Lack of sensitization towards local governments; the misconception that local governments and its stakeholders are illiterate, weak and corrupt entities; absence of an institutional monitoring mechanism to conduct a follow-up of the recommendations made by the respective Finance Commissions; lack of co-ordination between various Ministries of union and state governments; and the erosion of cooperative federalism can all contribute to health grants falling prey to the vicious cycle of Mission Creep Syndrome.

MELHOR EM CASA: A NÃO ADESÃO PELOS MUNICÍPIOS AO PROGRAMA: UM PROBLEMA DA ADMINISTRAÇÃO PÚBLICA?

This article aims to identify the causes of non-adhesion by Brazilian municipalities to the Better at Home Program (BHP). Therefore, it takes into account (a) the characteristics of Home Care (HC) in Brazil and in the world; (b) the historical trajectory of HC; (c) the Better at Home Program; (c) the causes for the non-adhesion of most Municipalities to the BHP. This is a bibliographic research carried out on scientific articles, dissertations and theses, which deal with the theme and a documentary research, to point out the relevant legislation about the BHP. The results showed that, among the causes of non-adherence, are the decentralization of health; the historic difficulty of the Northern region in implementing public health policies; the fact of not being sure that small municipalities would have the technical-scientific capacity to adhere to the BHP; the prioritization of municipalities with population > 40 thousand inhabitants by the Federal Government until May 2013; municipal elections with changes of government. The literature visited presents some possibilities among which the following can be highlighted: the need for the government to turn to the Brazilian reality when implementing health policies and analyzing the technical-scientific capacity of municipalities to adhere to these policies , including the BHP, on pain of observing a significant increase in the number of municipalities in the more developed regions to continue to be privileged to the detriment of those less favored who, unfortunately, constitute the majority.

The Influence of Job Satisfaction and Psychological Well-Being On Turnover On Hospital Employees

Health decentralization allows the Bandar Lampung City Health Office to design programs and service activities that are appropriate to local conditions. Based on data obtained from the HR department of private hospitals in Bandar Lampung City, the number of employees in private hospitals is 326 people and therate turnover reaches more than 10% per year. The purpose of this study was to determine the relationship between psychological well-being and job satisfaction with therate turnover at the Bandar Lampung City Private Hospital. The results of the study found that Job Satisfaction and Psychological Wellbeing had a simultaneous effect on employee turnover. This is evidenced by the statistical results of F count 18,539 > F table value of 3.07, with a significance of 0.00; Job satisfaction has a significant effect on employee turnover with a t-table value of 1.657 and a t-count value of 3.437; Psychological Wellbeing has a significant effect on employee turnover, with t count of 6.051 which means t count > t table (6.051> 1.657) and sig 0.00 < 0.05.

Conceptul de sănătate publică. Tipuri de sisteme de sănătate. Paralelă între sistemul de sănătate românesc şi cel australian

Medical management is a field that combines, both in theory and in practice, two somewhat different domains, administration and the medical domain, creating a third area of activity, namely that of medical management. This review is part of a study of health services management, which seeks to find solutions to improve the efficiency of the the management and administration of the medical system, both locally and nationally. In order to be able to study and evaluate, from a scientific point of view, the concepts of centralization and decentralization of the public health system in Romania, it is absolutely pertinent, but also mandatory, to focus on defining the notion of health system. Only later can we approach and research the process of decentralization of health, the political and economic context in which it can be initiated, as well as how to activate and carry it out. Decentralization, as a phenomenon of the transfer of rights and obligations, from the level of the central authority to the level of the local authority, can take various forms. From a theoretical and practical point of view, the forms of decentralization can be studied, evaluated and concluded by emphasizing the strengths and weaknesses. Also important to study are the ways of putting health systems into practice, which from the point of view of the source of funding are divided into state-funded health systems (Semashko, Beveridge and Bismarck) and privately funded health systems.

Intercâmbio internacional na era COVID-19

Problema: O intercâmbio internacional é um excelente instrumento de formação para estudantes e Portugal apresenta diversas vantagens para os alunos brasileiros. No entanto, a literatura brasileira carece de relatos de experiência sobre tais atividades e os estudantes frequentemente encontram- se preocupados sobre quais atividades serão desenvolvidas, sobre que tipo de sistema de saúde encontrarão e, recentemente, sobre como a pandemia se desenrolou no país de destino. Métodos: Trata-se de um estudo descritivo, do tipo relato de experiência, referente a um estágio internacional na área da saúde, realizado por um acadêmico brasileiro em Portugal. O trabalho foi elaborado a partir de pesquisas bibliográficas e resgate mnemônico da experiência. Resultados: O sistema de saúde português funciona de forma semelhante ao brasileiro, baseado na atenção primária à saúde e na descentralização, e apresentou bom desempenho em relação à pandemia da COVID-19. O intercâmbio foi realizado na área de medicina geral e familiar e de medicina de emergência pela Universidade de Lisboa, no início de 2020, e foi composto por uma vasta gama de atividades desenvolvidas, principalmente o acompanhamento de consultas. Os aprendizados do estágio incluem os conteúdos técnicos das consultas acompanhadas, os conhecimentos não científicos ensinados durante a rotina e as experiências sociais vivenciadas na viagem. Conclusão: Os estudantes brasileiros encontrarão familiaridades e diferenças positivas no sistema de saúde português e observarão excelentes números em relação ao controle da pandemia da COVID-19. O intercâmbio em Portugal possibilitou o crescimento profissional e pessoal do estudante e é recomendado para os estudantes brasileiros da área da saúde interessados em uma experiência transcultural.

A Knowledge, Attitudes and Practices (KAP) survey on canine rabies prevention and control in four rural areas of Sri Lanka.

Rabies is a fatal viral disease that affects all mammals. It causes an estimated 59,000 human deaths worldwide annually. Dogs are the main reservoir and transmitter of rabies to human in Sri Lanka. Prevention and control measures include the mass vaccination of dogs and human post-exposure treatment. While these measures appear to be homogeneous across the country, there is a need to identify community-level gaps due to the decentralization of regional health and veterinary services in conducting such activities. A community-based questionnaire survey was conducted to identify potential risk factors and gaps related to knowledge, attitudes and practices on rabies prevention and control in the rural regions of Sri Lanka. Lower knowledge scores were associated with respondents between 18 and 38years old, had no experience of being bitten, and own semi-independent dogs. Despite associated fear of stray dogs with health issues, some communities provide shelter and/or food for the stray dogs. Uptake of population control and vaccination of dogs across the grama niladhari divisions (GNDs), which are the smallest administrative units, differed. More than 80% of dogs were not desexed and community knowledge on vaccination delivery, booster and vaccination schedules were also variable. Even though 69% of respondents identified stray/community dogs as potential carriers' owners allow their dogs to roam the neighbourhood. Most of the respondents were able to identify the need for post-exposure treatment after a dog bite. However, post-exposure prophylaxis uptake by the local victims ranged between 83.00% and 87.50%. Low participation was reported in health education in the communities. Lack of knowledge on other potential carriers was similar to previous survey studies in the last decade. Collaborations between local communities, veterinary and medical services are necessary to scale up the control programme in order to achieve the global target of zero rabies deaths by 2030. Further community-level studies are recommended.

Expenditure Decentralization: Does It Make Us Happier? An Empirical Analysis Using a Panel of Countries

This paper analyzes whether fiscal decentralization of education, health, housing, social protection, recreation, culture and religion, public order and safety, and transportation have a significant effect on individual well-being. The empirical analysis is based on a non-linear hierarchical model that combines individual data (level 1) with country-level data (level 2). We match 89,584 observations from the World Value Service and the European Value Service (various years) with the average value of data recorded for 30 countries by the Government Financial Statistics (IMF). While fiscal decentralization in education and housing appears to have a negative effect on well-being, this effect is positive in the cases of health and culture and recreation. We interpret this as evidence in favor of a “selective” decentralization approach.

Relationship between air temperature and mortality in two Portuguese cities

Abstract Background Current global climate changes are significant and the concern with temperature-related mortality have been investigated, especially related to extreme heat. In the current Portuguese scenario of health decentralization to municipalities, knowing the local climate profile associated to other risks allows public policies to be implemented to protect population. Methods The present study is observational and cross-sectional in two Portuguese cities, Odivelas and Torres Vedras. The daily data on average temperature and the number of deaths were analyzed between 2015 to 2018. The data were provided by statistics Portugal and Portuguese Institute of Sea and Atmosphere. For data organization and preliminary analysis, Microsoft Power BI and Phyton software were used. Results A scatter plot of the average day-temperature versus the number of deaths showed that the variables did not present a clear functional form, but there is symmetry on the graph. Preliminary analyzes were performed between these variables which resulted in a Pearsońs coefficient of -0.17 (p-value = 0.000, confidential interval = 95%) for Torres Vedras and -0.21 (p-value = 0.000, confidential interval = 95%) for Odivelas. The negative coefficient means the lower the temperature, greater the number of deaths. However, these results show that the coefficient is weak and there is no correlation with each other. Conclusions The result shows that the average day-temperature and the number of deaths is not correlated and it will be necessary to include other variables in the study. Other data will be assessed, including period and related factors (season and seasonality, for example). The statistical evaluation for the maximum and minimum temperature data for the day will be applied. Gender and age will be available too. In addition, mortality, morbidity, medication consumption and other environmental variables will also be analyzed. Key messages We believe that the results of this study will provide data for the development of public health policies. The decentralization of health to cities is a challenge that needs data support.

The challenges of the outbreak: the Italian COVID-19 integrated surveillance system

BackgroundIn Italy, the National surveillance of all SARS-CoV-2 laboratory-confirmed cases was established on 27 February 2020, building on a previously existing laboratory network focused on suspected and confirmed COVID-19 severe respiratory infections.MethodsThe integrated epidemiological and microbiological surveillance systematically collects and analyzes information on all SARS-CoV-2 confirmed cases. Regional reference laboratories analyze samples, inform Local Health Authorities of the results and coordinate data flow between cases, hospitals and GPs. Regions provide data through a web interface connected to a dedicated IT platform or by sending a dataset. The Infectious Diseases Department at Istituto Superiore di Sanità processes and analyzes data, producing reports on a daily and weekly basis, as well as indicator analyses based on the monitoring of “phase 2” (post-lockdown). Moreover, mathematical models are constructed daily on these data.ResultsSince the beginning of the epidemic, the surveillance system recorded 238.901 COVID-19 cases and 33.369 deaths on 19-6. Main challenges were the coordination of different actors, hampered by the decentralization of health to the Regions, and data interpretation due to the delay in the detection of cases and deaths. Besides the COVID-19 surveillance, we planned ad hoc studies and periodic surveys: health care workers, long term care facilities, clusters and red zones, health system resilience monitoring.ConclusionsCOVID-19 surveillance is an essential tool to inform the public about the epidemic trend and provide support to public health response. We urge upon all relevant stakeholders a reflection on important issues such as defining ethical boundaries for data scavenging during emergencies, how existing laws on data protection could affect record linkage among different existing datasets to assess diseases and other variables for correlation, or which ethical approaches on open data would apply to our setting.Key messages A strong and adequately funded public health system in place allows an efficient response in times of epidemics both in terms of data collection and public health response, policy and decisions.COVID-19 epidemic showed us all the limits of a regionalized health system which was not entirely coordinated between periphery and central institutions.

Territorial Inequality in Health Service Delivery: Lessons from Latin America’s Federations

ABSTRACTAccess to quality healthcare varies across the national territory inside Latin American countries, with some subnational units enjoying higher-quality care than others. Such territorial inequality is consequential, as residents of particular regions face shorter life spans and an increased risk of preventable disease. This article analyzes trajectories of territorial healthcare inequality across time in Argentina, Brazil, and Mexico. The data reveal a large decline in Brazil, a moderate decline in Mexico, and low levels of change followed by a moderate decline in Argentina. The article argues that two factors account for these distinct trajectories: the nature of the coalition that pushed health decentralization forward and the existence of mechanisms for central government oversight and management.