Decentralization to improve health delivery not merely a byproduct of political changes

Decentralizing the health service delivery provides a unique opportunity to improve health performance at the district level. Decentralization approach includes transferring financial, administrative, ownership, and political authorities for alternate institutions in the peripheral. The rationale for transferring such power is; local decision makers have access to better information on local circumstances than central authorities, thus they have all the legitimacy to modify services, operation, spending pattern as it suits to the local needs and preferences.

In the past, various forms of decentralization have been instituted in many developing nations and the results have not always resulted in an improvement of the health of the national population for many reasons. For instant, in Chile and Mexico, when decentralization of the health sector was implemented, municipal authorities were given decision making power with respect to health including employing health professionals. However, the central government retained economic power over the national health budget, thus the local authorities were unable to address health needs of the their people because they were not able to pay salaries of their workers.[1] On the other hand, when China implemented decentralization in the 1980s, the local public health authorities
 were given full control of health services delivery, however the central government decreased the national provided health budget and imposed user fees and taxes on families for health services.[2] In contrast to the above examples, Cameroon and Brazil’s implementation of decentralization proved to be the best models not only in controlling specific disease, but also in improving health services delivery nationally.[3] One of the noticeable benefits of the decentralization approach was enabling of efficient distribution of antiretroviral treatments to control HIV/AIDS. For example, Cameroon provided medical access to 58% of all eligible HIV/AIDS patients; this is one of the highest treatment rates in Africa.[4]  Brazil once had very high prevalence of HIV/ADIS similar to South Africa, however through the decentralization approach, it was able to stabilize the HIV epidemic to levels resembling those of the United States and Western Europe[5]. The secret to their successful implementation of decentralization was attributed the central government that fully decentralized its national health planning, health financing and community participation programs.

The above examples demonstrate how difficult the implementation of decentralization can get and how easily the system can be manipulated to pursue other political aims. When implementing decentralization, additional reforms such as allocation of financial and qualified personnel must be followed. The focus for decentralization is to make the operation of health facilities efficient, thus routine regional supervision of the health facilities and standardization of drugs and treatment plans should continue until the peripheral administrative are fully capable of handling all the tasks. The national government should continue investing on peripheral health systems and not to pursue other political aims with name of decentralization. If decentralization is implemented correctly, the positive outcomes will include equitable resource allocation between urban and rural areas, improved health service delivery in rural areas, and increase in access to essential medicines.

[1] Khan, S.& Willis, K. (2009) Health Reform in Latin America and Africa: decentralization, participation and inequalities. Third World Quarterly, 30 (5), 991-1005.

[2] Blumenthal, D. & Hsiao, W. (2005). Privatization and its Discontents – The Evolving Chinese Health Care system. New England Journal of Medicine, 353(11), 1165- 1170.

[3] Berman, P.A. & Bossert, T.J. (2000). A Decade of Health Sector Reform in Developing Countries: What Have We Learned? DDM Symposium. DPE-5991-1-A-00-1052-00

[4] Loubiere, S., Boyer, S., Protopopescua, C., Bononod, C.R., Abegad, S., Spirea, B. & Moattia, J.(2009). Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers. Health Policy, 92(2/3), 165-173.

[5]  Case in global health delivery (2011) “HIV/AIDS in Brazil delivering Prevention in Decentralization Health System” Harvard Medical School.


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