Health Sector Decentralization Research Articles

Organizations matter in local governance: evidence from health sector decentralization in Honduras.

Health systems strengthening is at the forefront of the global health agenda. Many health systems in low-resource settings face profound challenges, and robust causal evidence on the effects of health systems reforms is lacking. Decentralization has been one of the most prominent reforms, and after more than 50 years of implementation and hundreds of studies, we still know little about whether these policies improve, harm or are inconsequential for the performance of health systems in less-developed countries. A persistent problem in existing studies is the inability to isolate the effect of decentralization on health outcomes, struggling with heterogeneous meanings of decentralization and missing counterfactuals. We address these shortcomings with a quasi-experimental, longitudinal research design that takes advantage of a unique staggered reform process in Honduras. Using three waves of household survey data over 10 years for a matched sample of 65 municipalities in Honduras, we estimated difference-in-difference models comparing changes in outcomes over time between local health systems that were decentralized using one of three types of organizations [municipal governments, associations of mayors or non-governmental organization (NGOs)] and those that remained centrally administered. We find evidence of overall improvements between 2005 and 2016 in several service delivery-related outcomes, and additional improvements in decentralized municipalities governed by NGOs. NGO-led municipalities saw a 15% decrease in home delivery relative to centralized municipalities in 2016, a 12.5% increase in MCH facility delivery and a 7% increase in the use of a skilled birth attendant. There were no detectable positive treatment effects for vaccination, and a slight decline in the weight-for-length z-scores in NGO municipalities, but we find no systematic evidence of decentralization negatively impacting any maternal and child health outcomes. These findings highlight the importance of considering implementation context, namely organization type, when assessing the effects of decentralization reform.

Tracking health sector priority setting processes and outcomes for human resources for health, five-years after political devolution: a county-level case study in Kenya

BackgroundHealth sector priority setting in Low and Middle-Income Countries (LMICs) entails balancing between a high demand and low supply of scarce resources. Human Resources for Health (HRH) consume the largest allocation of health sector resources in LMICs. Health sector decentralization continues to be promoted for its perceived ability to improve efficiency, relevance and participation in health sector priority setting. Following the 2013 devolution in Kenya, both health service delivery and human resource management were decentralized to county level. Little is known about priority setting practices and outcomes of HRH within decentralized health systems in LMICs. Our study sought to examine if and how the Kenyan devolution has improved health sector priority setting practices and outcomes for HRH.MethodsWe used a mixed methods case study design to examine health sector priority setting practices and outcomes at county level in Kenya. We used three sources of data. First, we reviewed all relevant national and county level policy and guidelines documents relating to HRH management. We then accessed and reviewed county records of HRH recruitment and distribution between 2013 and 2018. We finally conducted eight key informant interviews with various stakeholder involved in HRH priority setting within our study county.ResultsWe found that HRH numbers in the county increased by almost two-fold since devolution. The county had two forms of HRH recruitment: one led by the County Public Services Board as outlined by policy and guidelines and a parallel, politically-driven recruitment done directly by the County Department of Health. Though there were clear guidelines on HRH recruitment, there were no similar guidelines on allocation and distribution of HRH. Since devolution, the county has preferentially staffed higher level hospitals over primary care facilities. Additionally, there has been local county level innovations to address some HRH management challenges, including recruiting doctors and other highly specialized staff on fixed term contract as opposed to permanent basis; and implementation of local incentives to attract and retain HRH to remote areas within the county.ConclusionDevolution has significantly increased county level decision-space for HRH priority setting in Kenya. However, HRH management and accountability challenges still exist at the county level. There is need for interventions to strengthen county level HRH management capacity and accountability mechanisms beyond additional resources allocation. This will boost the realization of the country’s efforts for promoting service delivery equity as a key goal – both for the devolution and the country’s quest towards Universal Health Coverage (UHC).

Making social services work better for the poor: Evidence from a natural experiment with health sector decentralization in Honduras

Abstract Governments in many less developed countries have decentralized their social support systems over the last several decades. However, despite enthusiasm for these reforms, evidence remains limited and mixed as to whether they improve the delivery of basic social services. I take advantage of an unexpected pause in reform implementation in Honduras due to the country’s 2009 coup to investigate the effects of decentralization on local health services. Drawing on administrative data, an original survey of health workers, and qualitative interviews, my analysis shows that decentralization is credibly associated with increases in preventive care for women and that improved accountability and greater resilience to shocks are important mechanisms for this change. Moreover, my analysis highlights how regional organizations use decentralization to assert their own influence and deflect negative political consequences while pressuring for improvements in service delivery. These findings shed light both on the possibilities for improving local social services through governance reform and how national-level reforms can be leveraged by powerful actors at lower rungs of the governmental hierarchy.

Decentralization in India's health sector: insights from a capacity building intervention in Karnataka.

The Government of India has adopted decentralization/devolution as a vehicle for promoting greater equity and supporting people-centred, responsive health systems. This article reports on our year-long intervention project in Karnataka, South India, and articulates insights of both practical and theoretical significance. It explores the intersection of the political goal of enhanced local level autonomy and the programmatic goal of more responsive health service delivery. Focusing on the Village Health, Sanitation and Nutrition Committees (VHSNCs) set up under the National (Rural) Health Mission (NHM), the project set out to explore the extent to which political and programmatic decentralization are functional at the village level; the consonance between the design and objectives of decentralization under NHM; and whether sustained supportive capacity building can create the necessary conditions for more genuine decentralization and effective collaboration between village-level functionaries. Our methodology uses exploratory research with Panchayati Raj Institution (PRI) members and functionaries of the Health Department, followed by a year-long capacity building programme aimed at strengthening co-ordination and synergy between functionaries responsible for political and programmatic decentralization. We find that health sector decentralization at the village level in Karnataka is at risk due to lack of convergence between political and programmatic arms of government. This is compounded by problems inherent in the design of the decentralization mechanism at the district level and below. Sustained capacity building of the VHSNC can contribute to more effective decentralization, as part of a larger package of interventions that (1) provides for financial and other resources from the district (or higher) level to political and programme functionaries at the periphery; (2) helps the functionaries to develop a shared understanding of the salience of the VHSNC in addressing the health needs of their community; and (3) supports them to collaborate effectively to achieve clearly articulated outcomes.

Assessing the impacts of governance reforms on health services delivery: a quasi-experimental, multi-method, and participatory approach

Despite considerable advances in developing new and more sophisticated impact evaluation methodologies and toolkits, policy research continues to suffer from persistent challenges in achieving the evaluation trifecta: identifying effects, isolating mechanisms, and influencing policy. For example, evaluation studies are routinely hampered by problems of establishing valid counterfactuals due to endogeneity and selection effects with respect to policy reform. Additionally, robust evaluation studies often must contend with heterogeneity in treatment, staggered timing, and variation in uptake. And finally, on practical grounds, researchers frequently struggle to involve policymakers and practitioners throughout the research process in order to engender the type of trust needed for policy influence. While it can be difficult to generalize about appropriate evaluation methodologies across contexts, prominent policy interventions like governance reforms for improving health services delivery nonetheless demand rigorous and comprehensive evaluation strategies that can produce valid results and engage policymakers. Drawing on illustrations from our research on health sector decentralization in Honduras, in this paper we present a quasi-experimental, multi-method, and participatory approach that addresses these persistent challenges to policy evaluation.

The evolution of income-related inequalities in healthcare utilisation in Indonesia, 1993-2014.

ObjectiveWhile the major policy changes in the Indonesian healthcare system over the last 25 years have been well documented, less is known about the accompanying changes in inequalities in healthcare utilisation during this period. Our study aimed to describe the trends in income-related inequalities in healthcare utilisation in Indonesia during the period 1993–2014.MethodsA repeated cross-sectional study was conducted using data from the Indonesian Family Life Surveys from 1993, 2000, 2007, and 2014. We measured outpatient and inpatient healthcare utilisation in public and private provider as well as the overall utilisation. Standardised prevalence rate and relative index of inequality (RII) were used to measure the extent of inequalities in healthcare utilisation by income level (income-related inequalities).ResultsRelatively large income-related inequalities were observed in the utilisation of private outpatient care and public and private inpatient care in 1993. Income-related inequalities in public and private outpatient care utilisation decreased between 1993 and 2007 but increased in 2014. Income-related inequalities in public and private inpatient care utilisation continued to decrease between 1993 and 2014. The largest decrease was observed in private inpatient care utilisation.ConclusionIncome-related inequalities in all types of healthcare utilisation decreased until 2007. This trend continued until 2014 only for public and private inpatient care utilisation. This phenomenon may be explained by the changes to the healthcare system (e.g. expansion of the government health insurance programme and health sector decentralisation), which coincided with the changes in inequalities in healthcare utilisation in Indonesia.

Public hospitals’ finance management systems, and accountability mechanisms in the context of decentralized health systems in low- and middle-income countries – A thematic review

Background: Health sector decentralization, defined as the transfer of decision making over health sector resources from a central to a peripheral entity; has been and continues to be a widely adopted health system reforms in many low and middle-income countries (LMICs). However, its reported effects have been varied. Nevertheless, decentralization reforms aimed at providing public hospital management autonomy are increasing in prevalence in many LMICs. The range and form of this autonomy because of these reforms has often produced mixed effects. We set out to understand the range of financial management autonomy that has been granted to public hospitals in decentralized health systems in LMICs, and what forms of accountability arrangements have been used to facilitate this autonomy. Methods: We systematically searched PubMed, Google Scholar, Web of Science and CINAHL databases for published articles on this subject. We only included articles that reported empirical findings on hospital level financing and financial management in the context of decentralization in LMICs and/or those that included findings on hospital level finance management accountability arrangements. After a systematic search we found four articles that met our inclusion criteria. We undertook a thematic synthesis of the data and narrative reporting of our findings. Results: From the review – we find that decentralization reforms did not result in improved funding flows, finance management autonomy or accountability mechanisms and for public hospitals. These outcomes were irrespective of the mode and form of decentralization reform adopted. Conclusion: From our review, it is evident that though health sector decentralization reforms have been widely promoted and adopted in the past few decades across LMICs, there is minimal evidence that these reforms have improved funding flows to public hospitals, improved financial management autonomy or accountability mechanisms; so as to enhance the performance of these hospitals at sub-national level.

Health sector decentralisation in Tanzania: Analysis of decision space in human resources for health management.

While decentralisation of health systems has dominated the political arena in the low- and middle-income countries since the 1970s, many studies on decentralisation have focused on understanding who is given more decision-making authority, but less attention is paid to understanding what that authority involves. This paper assesses the range of decision-making authority transferred from the central government to subnational levels in the area of human resources for health management in Tanzania. This analysis was guided by the decision space framework and relied on interviews, focused group discussions, and analysis of documents. Data were analysed using thematic approach. While districts had narrow decision space on recruitment and promotion of health service providers, they had wide decision space on distributing health providers within districts and providing incentives. Centrally managed recruitments resulted in frequent delays, thereby intensifying shortages of skilled health service providers. This analysis concludes that decentralisation of human resources for health planning and deployment role to lower levels of the administrative hierarchy in Tanzania is limited. This suggests the need for the central government to increase decision space to districts in the area of recruitment. In order for the Ministry of Health to perform its functions better in the area of human resources for health management, there is a need to strengthen the capacity of the department dealing with recruitment of skilled health staff at the Ministry of Health.

HEALTH SECTOR DECENTRALIZATION AND ITS IMPLICATION TO HEALTH SERVICES IN INDONESIA

Background: After more than a decade, in what way decentralization has affected health service and population health status in Indonesia, is still partly known. This paper aims to review about to what extent the health sector decentralization has affected health services in Indonesia, especially in access and health systems management. 
 Methods: We conducted systematic search studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We search for relevant studies using keywords ‘decentralization’ OR ‘decentralisation’ AND ‘(public health)’ AND ‘effect’ OR ‘impact’ AND ‘reform’ AND ‘(health inequalities)’ AND ‘Indonesia’ on electronic sources Proquest, Science Direct, and EBSCOHost. The articles then filtered using pre determined criterias and duplication removal.
 Results: Database search resulting on 628 articles in Proquest, 0 articles in Science Direct, and 13 articles in EBSCOHost. The screening result were 5 eligible articles. We found equality of access in health services were jeopardized by fragmented health services and worsen health disparities among districts that occured after decentralization. This worsen gap between the most developed provinces of Java-Bali and those of other island groupings affected the community’s health status. Low local government’s capacity in planning, managing and utilizing health resources were the most reported evidence in decentralized health system.
 Conclusion: This study concludes that good capacity of local government, coordination and monitoring system between central and local government, partnership with private sectors and community empowerment are essential to achieve better health outcome result in decentralized Indonesia.
 Keywords: Decentralization, Health Services, Health Policy, Indonesia

The Impact of Political Reforms in Improving Quality Health Services: The Case Study of Shamva District

Zimbabweans continue to experience challenges in combating communicable diseases such as tuberculosis, diarrheal diseases, and HIV/AIDS. The country’s health sector decentralisation implementation is moving at a snail’s speed, triggering complaints of unsatisfactory service delivery at rural health centres. The study examined the impact of political reforms in improving quality health services in Shamva District. The identified political reforms were decentralisation and the second republic that emerged in November 2018 that embraced the 100-day plans approach, civil service reform agenda, development of transitional stabilisation plan and vision 2030 agenda. The study was guided by interpretive and critical post-modernist paradigms. Qualitative methodology was utilised; key informant interviews, focus group discussion and desk reviews were data generation tools that were utilised. The data generated were analysed using grounded theory. The key findings are that decentralisation enabled district health officials to interact with communities through social accountability strategies such as community scorecard, results-based financing and village health worker model that is implemented in Shamva District by Civil Society Organisations. The second republic political reforms enforced the user fee policy in the health sector and focused on improving primary health care. The political reforms led to improved health rights knowledge of communities and quality health services in Shamva District. The study concluded that lack of continuous funding and sustainable plans led to the reversal of positive results that were brought in by the political reforms. The major recommendation is that government should understand that service delivery is not poor by accident; rather it is a symptom of the underlying institutional environment and political economy analysis should be done to address the real blockages in health sector.

Health sector decentralisation in Tanzania: How do institutional capacities influence use of decision space?

While decentralisation of health systems has dominated political arena in the low-income and middle-income countries since the 1970s, there is scarcity of studies on how organisational capacities influence the ability of the decentralised local-level officials to use the available decision space. Using qualitative approach through in-depth interviews and focus group discussions in 4 districts in Tanzania, this study explored how organisational capacities influence the use of decision space available in the 5 broad categories namely planning, finance, human resources, service organisation, and governance. The findings of the study indicated that while the district health managers had authority in many health system functional areas, limited capacity of the local government in financial resources highly affected their capacity to make use of the available decision space. In addition, while the district health managers had skills, knowledge, and experiences in preparing district health plans, health facilities and community representatives had limited capacity. Most of the health facilities had critical shortage of skilled health providers. Similarly, health committees had limited capacity in knowledge and skills. This study concludes that decentralisation will only improve delivery of health services when an appropriate degree of discretion is combined with adequate institutional capacities to enable exercise of those authorities. The district councils and the Ministry of Health should strengthen the capacities of health service providers and members of health committees and boards.

Strengthening Public Health Management Capacity in Vietnam: Preparing Local Public Health Workers for New Roles in a Decentralized Health System.

Health sector decentralization has created an urgent need to strengthen public health management capacity in many countries throughout the developing world. This article describes the establishment of a national management training network in Vietnam that used Project-Based Learning to strengthen management competencies of HIV program workers and linked training to measurable improvement in HIV/AIDS public health program outcomes. Skills were taught using a combination of classroom learning and mentored fieldwork. From 2005 to 2015, 827 HIV/AIDS program managers were trained with this method throughout Vietnam by trainers in 3 regional training centers. A total of 218 applied learning projects were carried out by trainees during this period; 132 resulted in measurable improvements in HIV/AIDS program outputs, and 86 produced well-organized plans for implementing, monitoring, and evaluating HIV/AIDS intervention strategies. Vietnam's management training network represents an important advancement in public health workforce development that helps prepare workers for new roles and responsibilities in a decentralized health system.

Devolution and its effects on health workforce and commodities management \u2013 early implementation experiences in Kilifi County, Kenya

BackgroundDecentralisation is argued to promote community participation, accountability, technical efficiency, and equity in the management of resources, and has been a recurring theme in health system reforms for several decades. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments, with substantial transfer of responsibility for health service delivery from the central government to these counties. Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, we analysed the early implementation experiences of this major governance reform at county level.MethodsWe employed a qualitative case study design, focusing on Kilifi County, and adapted the decision space framework developed by Bossert et al., to guide our inquiry and analysis. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014.ResultsAs with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. For HRH, this led to major disruptions in staff salary payments, political interference with HRH management functions and confusion over HRH management roles. There was also lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level. Subsequently health worker strikes and mass resignations were witnessed. With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution.ConclusionThe devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies.

How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya

BackgroundA common challenge for health sector planning and budgeting has been the misalignment between policies, technical planning and budgetary allocation; and inadequate community involvement in priority setting. Health system decentralisation has often been promoted to address health sector planning and budgeting challenges through promoting community participation, accountability, and technical efficiency in resource management. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, and a substantial transfer of responsibility for healthcare from the central government to these counties.MethodsThis study analysed the effects of this major political decentralization on health sector planning, budgeting and overall financial management at county level. We used a qualitative, case study design focusing on Kilifi County, and were guided by a conceptual framework which drew on decentralisation and policy analysis theories. Qualitative data were collected through document reviews, key informant interviews, and participant and non-participant observations conducted over an eighteen months’ period.ResultsWe found that the implementation of devolution created an opportunity for local level prioritisation and community involvement in health sector planning and budgeting hence increasing opportunities for equity in local level resource allocation. However, this opportunity was not harnessed due to accelerated transfer of functions to counties before county level capacity had been established to undertake the decentralised functions. We also observed some indication of re-centralisation of financial management from health facility to county level.ConclusionWe conclude by arguing that, to enhance the benefits of decentralised health systems, resource allocation, priority setting and financial management functions between central and decentralised units are guided by considerations around decision space, organisational structure and capacity, and accountability. In acknowledging the political nature of decentralisation polices, we recommend that health sector policy actors develop a broad understanding of the countries’ political context when designing and implementing technical strategies for health sector decentralisation.

The path dependence of district manager decision-space in Ghana.

The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970–85); (2) Strengthening District Health Systems Initiative (1986–93); (3) health sector reform planning and creation of the Ghana Health Service (1994–96) and (4) health sector reform implementation (1997–2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.

Improving Health System Performance in a Decentralized Health System: Capacity Building in Pakistan

—Key policy questions on decentralization in health relate to whether and in which ways health sector decentralization can improve health outcomes. Focusing on a maternal, neonatal, and child health program in Pakistan, this study examines relationships between three dimensions of decentralization: the degree of local decision-making choice (“decision space”), individual and institutional capacities, and local accountability. Additionally, these relationships are examined at two points in time to assess whether “capacity building” interventions, as well as any changes in decision space, are related to improvements in health sector performance as measured by improved administrative processes and indicators of health coverage in important primary care services. The study is based on surveys administered in 2006 and 2009 to local health sector decision-makers in 15 districts in Pakistan—ten of which received capacity-building assistance from the US government–funded maternal and child health project (PAIMAN), and five control districts not receiving capacity-building interventions. Findings indicate that while local authorities in both districts reported using wider decision space by 2009, institutional capacities in PAIMAN districts improved to a higher degree than in comparison districts. Officials in neither set of districts reported significant changes in their accountability to local elected officials, although those districts with more decision space and institutional capacities mobilized greater local support for health programs. Extending findings from an earlier study focused on similar questions, there were strong synergies among the dimensions of decentralization for different health sector functions, as well as some evidence of associations between stronger institutional capacities/wider decision-space and improvements in health coverage and in better administration of the health system. Findings suggest that targeted capacity-building activities at the district level may contribute to improved decision-making abilities and, in turn, improved health system performance.

Decentralization in Indonesia: lessons from cost recovery rate of district hospitals.

In 1991, Indonesia began a process of decentralization in the health sector which had implications for the country's public hospitals. The public hospitals were given greater authority to manage their own personnel, finance and procurement, with which they were allowed to operate commercial sections in addition to offering public services. These public services are subsidized by the government, although patients still pay certain proportion of fees. The main objectives of health sector decentralization are to increase the ability of public hospitals to cover their costs and to reduce government subsidies. This study investigates the consequences of decentralization on cost recovery rate of public hospitals at district level. We examine five service units (inpatient, outpatient, operating room, laboratory and radiology) in three public hospitals. We find that after 20 years of decentralization, district hospitals still depend on government subsidies, demonstrated by the fact that the cost recovery rate of most service units is less than one. The commercial sections fail to play their role as revenue generator as they are still subsidized by the government. We also find that the bulk of costs are made up of staff salaries and incentives in all units except radiology. As this study constitutes exploratory research, further investigation is needed to find out the reasons behind these results.

Challenges to the implementation of health sector decentralization in Tanzania: experiences from Kongwa district council

BackgroundDuring the 1990s, the government of Tanzania introduced the decentralization by devolution (D by D) approach involving the transfer of functions, power and authority from the centre to the local government authorities (LGAs) to improve the delivery of public goods and services, including health services.ObjectiveThis article examines and documents the experiences facing the implementation of decentralization of health services from the perspective of national and district officials.DesignThe study adopted a qualitative approach, and data were collected using semi-structured interviews and were analysed for themes and patterns.ResultsThe results showed several benefits of decentralization, including increased autonomy in local resource mobilization and utilization, an enhanced bottom-up planning approach, increased health workers’ accountability and reduction of bureaucratic procedures in decision making. The findings also revealed several challenges which hinder the effective functioning of decentralization. These include inadequate funding, untimely disbursement of funds from the central government, insufficient and unqualified personnel, lack of community participation in planning and political interference.ConclusionThe article concludes that the central government needs to adhere to the principles that established the local authorities and grant more autonomy to them, offer special incentives to staff working in the rural areas and create the capacity for local key actors to participate effectively in the planning process.

Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan

Health sector decentralization has been widely adopted to improve delivery of health services. While many argue that institutional capacities and mechanisms of accountability required to transform decentralized decision-making into improvements in local health systems are lacking, few empirical studies exist which measure or relate together these concepts. Based on research instruments administered to a sample of 91 health sector decision-makers in 17 districts of Pakistan, this study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as "decision space"), institutional capacities, and accountability to local officials. Composite quantitative indicators of these three dimensions were constructed within four broad health functions (strategic and operational planning, budgeting, human resources management, and service organization/delivery) and on an overall/cross-function basis. Three main findings emerged. First, district-level respondents report varying degrees of each dimension despite being under a single decentralization regime and facing similar rules across provinces. Second, within dimensions of decentralization-particularly decision space and capacities-synergies exist between levels reported by respondents in one function and those reported in other functions (statistically significant coefficients of correlation ranging from ρ=0.22 to ρ=0.43). Third, synergies exist across dimensions of decentralization, particularly in terms of an overall indicator of institutional capacities (significantly correlated with both overall decision space (ρ=0.39) and accountability (ρ=0.23)). This study demonstrates that decentralization is a varied experience-with some district-level officials making greater use of decision space than others and that those who do so also tend to have more capacity to make decisions and are held more accountable to elected local officials for such choices. These findings suggest that Pakistan's decentralization policy should focus on synergies among dimensions of decentralization to encouraging more use of de jure decision space, work toward more uniform institutional capacity, and encourage greater accountability to local elected officials.

Primary Heealth Care Development: Where is Nepal after 30 years of Alma Ata Declaration??

The year 2008 has witnessed the global conversation to return to tenets of Alma-Ata and to review its 30 years of journey. We reviewed Nepal's journey on Primary Health Care development: policy formulation, structure development, progress and constraints. Though Nepal has institutionalised the PHC approach in health policy, strategy and health care delivery system, this has not been effectively translated into actions, and the results are mixed. Nepal has gained impressive achievements in selective primary health care markers: 45.43% maternal mortality and 62.34% child mortality reduction during 1990-2005. But gain in comprehensive health care markers is not impressive: 18.7% Skilled Birth Attendant (4% in poorest quintile and 45% in richest quintile), 39% having access to improved sanitation and 55.7% of females are literate as compared to males. Socio-political environment until recently was not favourable for comprehensive primary health care, allowing limited health sector decentralisation and community empowerment. Health activities were focussed more on selective health care strategy in the form of disease control, immunisation, vitamin A supplementation, oral rehydration solution use and contraceptive use. Nepal's rural hilly geography posed great challenge on logistic supply, communication and retention of health workers rendering public health centres of low quality with negative perceptions of consumers. Nepal is on the pathway to build equitable comprehensive primary health care.