Structural framework for health

Structural framework for health

Structural framework for health

Decentralization, in its various forms, is now a common feature of reform in both developed and developing countries. It is, however, rarely the only reform measure that a particular country is engaged in. Decentralization is often accompanied by profound changes in the way publicly-funded services are resourced, and human, (Bohle, 2000) financial and material resources managed. The extent to which health leaders participate in designing and planning how and to whom responsibility and authority will be transferred varies, but experience at country level shows that technical health expertise has not been adequately utilized in these reforms. This is particularly true of the many countries where the impetus to transfer power away from the center stems from political, as opposed to health sector, concerns.

Reallocation of roles and responsibilities always affects the health workforce and the way it is managed. This is true irrespective of the extent to which health leaders are allowed to shape the decentralized structures and management systems. Concern has been mounting among health managers and workers about the impact that decentralization has had on human resources for health (HRH) and the way they are managed. Attention to this issue has, however, been lacking outside the health sector itself. Dussault and Dubois echo the concerns of many observers, when they comment, "In many reforms, there is discordance between the elevated attention given to issues of financing and structural transformation and the low attention given to HRH issues..."[1]. One consequence of this lack of attention is that experiences and lessons of different countries have not been widely shared. (Bohle, 2000)

This paper aims to examine evidence from published literature on decentralization's impact on the demand side of the human resource equation, and the factors that have contributed to this impact. The main focus is on the experience of developing countries, but evidence from other countries is also considered, as appropriate. The paper starts by cataloging the various elements that make an impact analysis of this type exceptionally complex. The main body of the paper is devoted to examining decentralization's impact from three perspectives: that of local health managers, health workers themselves, and national health leaders. This analysis aims to focus on the big picture view, highlighting the most important areas. While the emphasis is on the demand side, the analysis does not totally ignore supply side issues, acknowledging that demand and supply are intricately interlinked. The paper concludes with recommendations regarding three key concerns that require prompt attention and collaboration between national authorities and international agencies. Notable experiences from South Africa, Ghana, Indonesia and Mexico are described in an annex, as these countries grapple with human resource implications of decentralization.

Local health managers have a range of new responsibilities, depending on the powers that have been decentralized to them. Under devolution, they are accountable to the local political head, such as a municipal mayor or a provincial governor. Under delegation, the local health manager may be accountable to a district health board or ...