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Healthcare system and leadership

Health care system and Leadership

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Healthcare system and leadership

  1. 1. DECENTRALIZATION IN HEALTH SYSTEM DEVELOPMENT Shreejeet Shrestha MPH, M.Sc. Medical Microbiology
  2. 2. WHAT IS HEALTH SYSTEM? Health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations. A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.(WHO, 2007)
  3. 3. HEALTH SYSTEM DEVELOPMENT (HSD) Necessitates For The Development Of Health Care Systems Continuous support to policy and managerial practices for appropriate infrastructure and logistics Use of technology, information collection and dissemination, organization of health workforce development at national and institutional levels, Universal coverage and Sustainable financing, and Assured quality and safety in health-care
  4. 4. MEASURES OF HSD  Identify and remove health-system bottleneck  Monitor the progress and programs in coverage  Intervention packages and health-system strengthening (Health Care Service Delivery)  Address the Human Resources Crisis  Strengthen the Health Systems (Decentralization)  Efforts of improve harmonization
  5. 5. WHAT IS DECENTRALIZATION?  According to WHO in 1990, Decentralization is transfer of authority or dispersal of public planning, management and decision making from the national level to sub-national levels
  6. 6. Decentralization shifts decision-making powers to lower-levels of government and entails setting legal and regulatory provision to ensure the:  Favorable political environment  Good coordinating and cooperating mechanism  Initiatives are sustained and required strong political permanence.  Entities act in conformity at national standard  Citizens have access to local decision making
  7. 7. NEED FOR DECENTRALIZATION  At the past, many countries in the world, particularly the countries in Asia and Africa strengthened the national and regional administration by reducing the responsibility of the local government  But now, many of these countries realized the need to strengthen the peripheral and local authorities and have adopted decentralization as one of the major means for implementing the reforms.
  8. 8. NEED FOR DECENTRALIZATION (CONT:) There are many complex reasons why governments in various countries are beginning to decentralize their services. For example Demands for more regional autonomy have played a major role in Papua New Guinea and Spain Political ideologies were important in Chile and Yugoslavia The need to rationalize over burdened and outmoded administration plays a large role in New Zealand and Srilanka
  9. 9. CONCEPTS OF DECENTRALIZATION  On philosophical and ideological level, decentralization have been seen as an important political ideal, providing the means of community participation, local self reliance and ensuring the accountability of the government officials to the population.
  10. 10. CONCEPTS OF DECENTRALIZATION (CONT: )  Decentralization policies are usually initiated by central governments and only subsequently are adopted by the health sectors. This means that the central government has initiated a national policy by adopting constitutional changes that set the pattern for the reforms to be adopted by the different ministries.
  11. 11. DECENTRALIZATION IN HEALTH SERVICES  Decentralization is one of the main concept for Health system Development  Decentralization of health system structure and management is a key issue for many countries in the achievement of ―Health For All‖ and in the development of Primary Health Care. (Health System Decentralization; Concepts, Issue and Country Experience, WHO, Geneva 1990)
  12. 12.  In practice, health system decentralization takes many different forms, depending not only in overall government political and administrative structures and objectives, but also on the pattern of health system organization prevailing in the particular country.  Decentralization demands a holistic approach, and the decentralization of health services cannot be looked into in isolation. As a part of reforms in the health care delivery system, decentralization is currently being promoted in many countries as a means to improve the performance and outcomes of national health care systems.
  13. 13.  It is often imputed that health ministries in developing countries have a reputation of being the most bureaucratic and least effectively managed institutions. Such centrally managed health care systems, by and large, are poorly structured, badly led and inefficiently organized.  Failure of such systems spawned the need for "people centered" health care systems that build on bottom-up approaches in planning, allow wider participation of people in needs assessment, ownership over there sources and facilities and stewardship of the local bodies.
  14. 14. OBJECTIVE AND RATIONAL FOR DECENTRALIZATION IN HEALTH SERVICES Objective Rationale 1) To improve technical efficiency  Through fewer levels of bureaucracy and greater cost consciousness at the local level  Through separation of purchasers and provide functions in market-type relations. 2) To increase allocative efficiency Through better matching of public services to local preferences Through improved patient responsiveness 3) To empower local governments Through more active local participation Through improved capacities of local participation 4) To increase the innovation of service delivery Through experimentation and adaptation to local conditions Through increased autonomy of local governments and institutions
  15. 15. Objective Rationale 5) To increase accountability Through public participation Transformation of the role of the central government 6) To increase quality of health services Through integration of the health services and improved information systems Through improved access to health care services for vulnerable groups 7) To increase equity Through allocating resources according to local needs Through enabling local organizations to better meet the needs of particular groups Through distribution of resources towards marginalized regions and groups (through cross –subsidy mechanisms)
  16. 16. DIFFERENT APPROACHES TO DECENTRALIZATION: Public administration approach Local fiscal choice Social capital approach Principal agent approach
  17. 17. PUBLIC ADMINISTRATION APPROACH  focuses on the distribution of authority and responsibility for health services within a national political and administrative structure.  different forms of decentralization:  Deconcentration  Delegation  Devolution  Privatization
  18. 18. LOCAL FISCAL CHOICE was developed by economists to analyze choices made by local governments using their own resources and inter-governmental transfers from other levels of government. It has been applied mainly in federal systems where local governments have had a history of constitutionally determined authority and significant locally generated resources.
  19. 19. SOCIAL CAPITAL APPROACH focuses on explaining why decentralized governments in some localities have better institutional performance than do governments of other localities. Applied to health care, this approach suggests that those localities with long and deep histories of strongly established civic organizations will have better performing decentralized governments than localities which lack these networks of associations.
  20. 20. PRINCIPAL AGENT APPROACH proposes a principal (individual or institution) with specific objectives and agents who are needed to implement activities to achieve those objectives. Agents also have an advantage allow them to pursue their own interests at the expense of the principal.
  21. 21. Decentralization policies are usually initiated by central governments and only subsequently are they adopted by the health sector by adopting constitutional changes that set the pattern for the reforms to be adopted by the different ministries making innovative choices within the decision spaces of local authorities using local governments own resources and intergovernmental transfers from other levels of government (local fiscal choice model)
  22. 22. HOW CAN WE MAKE DECENTRALIZATION?  equalization funds  allocation formulae for intergovernmental transfers  allocation rules that earmark funding for specific purposes  training exercises for local authorities and communities to achieve institutional performance (social capital approach: Putnam, 1993)
  25. 25. MALDIVES AND DECENTRALIZATION  The Seventh National Development Plan states that “the health policy of the government is targeted to ensure access to primary health care to all citizens in an equitable manner”.  Health Master Plan for 2006-2015, the Government of Maldives has committed itself to provide equitable access to health care for all its citizens.  The government aims to achieve these goals primarily through decentralization of health services and the primary health care approach.  “Act on Decentralization of the Administrative Divisions of the Maldives”, 2010.  This is the Act on the creation of offices, posts, island councils, atoll councils and city councils and the determination of their characteristics, jurisdiction and required principles or rules for the purpose of decentralized administration of the Maldives as stipulated in Chapter 8 of the Constitution.
  26. 26. DECENTRALIZATION IN MYANMAR Growing the needs  to involve all relevant sectors at all administrative levels  to mobilize the community more effectively in health activities health committees had been established in various administrative levels down to the wards and village tracts  These committees at each level were headed by the responsible person of the organs of power concern and include heads of related government departments and representatives from the social organizations as members.  Heads of the health departments were designated as secretaries of the committees.
  27. 27. CASE STUDIES OF NEPAL FOR DECENTRALIZATION IN HEALTH SERVICES  During the past few decades, many countries have embarked on the decentralization of public services. Nepal has also tried to adopt decentralization as a key reform process.  During the 1990s there was significant progress in the development of health systems under the framework of long- term (1997–2017) health plans and policies, guided by a vision of equitable access and the principles of community participation, decentralization, gender equality, effective services management, and a public–private partnership approach.  Under the guidance of these plans and polices, Nepal has made visible progress in health sector reform despite the nature of difficult topography (hills, mountains).
  28. 28.  The main drivers for decentralization in Nepal include: socio-economic inequalities, multi-ethnicity and cultural heterogeneity, poverty, low efficiency of centralized delivery systems and the global phenomenon of decentralization.  As in other countries, two important factors—technical or managerial, and political motives—are major contributing factors behind the decentralization process.  In the governance system, decentralization and local self- governance have been made operational in Nepal since the 1960s.  In 1999, Nepal enacted a Local Self-Government Act (LSGA) and this Act, whose monitoring committee was chaired by the Prime Minister, laid the foundation for establishing a local self-governance system adopting a broad-based and cross-sectoral approach.
  29. 29.  This Act recognized the role of local self governance and devolution of authority and responsibility to make local authorities more responsive and accountable to people.  The rationale for this Act was both philosophical and practical and involved legislation, institutional provision, resources (both financial and human) mobilization and considerations, i.e. autonomy and equality.  One of the major reforms in Nepal's health sector under decentralization was the restructuring of health services.  In 1987, the centre (MoH) underwent change and as a result—Regional Health Directorates were established in five development regions in Nepal.
  30. 30.  Restructuring of the district health services (preventive and curative) was considered to be vital for meeting the health needs of local populations.  A unique feature of the health sector in Nepal is that there is a strong community-based health workforce (more than 50 000 female community health workers in addition to 28 000 public health staff) across the country who are mainly responsible for preventive care.  Since 2001/02, over 1435 primary health care facilities (100% in the study district) devolve to the local community management. Government is now in the process of devolve other health care facilities i.e. district hospitals, zonal and regional hospitals to the management of local committees.
  32. 32. Decentralization is regarded as the most important force in improving efficiency as well as equity and responding to local health conditions and demands.
  33. 33. STRENGTH OF DECENTRALIZATION Governance  Trained local and district managers  Formation of DMHT for inter-sectoral collaboration  Creation of new posts at sub district level for monitoring at grass root level Financing  Retention of taxes by district  Autonomy for need-based allocation Resources and services  Outsourcing leading to regularity, punctuality and service delivery  Procurement of drugs at district level
  34. 34. WEAKNESS OF DECENTRALIZATION Governance  Lack of administrative capacity and accountability  Selection on personal and political choice  Lack of power delegation at sub-district level  Lack of practical planning at local level  Lack of focus on preventive side  Lack of evidence based policy making  Duplication of power between provincial and district governments  Limited authority on vertical programs  Bureaucratic resistance
  35. 35. WEAKNESS OF DECENTRALIZATION Financing  Allocation are not need-based  Late release of funds  Underpaid health care workers  Extra-burden of non-development funds Resources and services  Lack of capable trained health care staffs and doctors  Lack of laboratory facilities  Transport for emergency referrals  Failure to deliver service practically  Tertiary service excluded  Non-functioning HMIS
  36. 36.  Implementing decentralization in the health sector has many advantages for the health system development, primary health care and health for- all strategies.  However, decentralization is very sensitive political issue, for it concerns the distribution of power and allocation of resources.  The adoption of a national policy on decentralization is only the beginning of a lengthy process that strong political commitment over many years to achieve the good results.
  37. 37. REFERENCES  http://indonesiahealth.wordpress.com/2010/10/26/o bjectives-of-decentralization/  http://www.hsph.harvard.edu/ihsg/publications/pdf/ No-54.PDF  http://www.burmalibrary.org/docs14/Myanmar- Health-Care-System.pdf