Decentralisation of Health Systems

KAWONGA, MARY; MACEIRA, DANIEL; NUNN, AMY

The Right Reforms? Health Sector Reforms and Sexual and Reproductive Health

Women’s Health Project, School of Public Health, University of the Witwatersrand

Lugar: Sudáfrica; Año: 2005; p. 172 - 214

Emerging in the wake of the 1978 Primary Health Care (PHC) conference at Alma Ata, decentralisation of the health sector is by no means a new concept. Alma Ata endorsed PHC as the mechanism for achieving better health, underpinned by principles of equity, community participation and intersectoral collaboration. Decentralisation and the PHC approach thus became closely associated as they shared these principles. Decentralisation was viewed as a means for achieving PHC goals. Interest in health sector decentralisation was renewed in the 1990s when it was identified as a key health reform strategy in the World Bank’s World Development Report 1993: Investing in Health. Decentralisation has been a key strategy within health sector reform (HSR) policies of many countries, and has been seen as a means to improve efficiency, effectiveness and equity in the health sector. As of 2004, there were decentralisation projects in the health sector supported by the World Bank in at least 47 developing countries. The Programme of Action of the International Conference on Population and Development (ICPD POA) in 1994 also highlighted the role of decentralisation. The POA recommended that governments promote community participation in reproductive health services by decentralising the management of health programmes. Sexual and reproductive health advocates viewed decentralisation as a vehicle for enhancing access, community participation and empowerment of communities. In recent years sexual and reproductive health advocates have increasingly asserted that HSR initiatives, including decentralisation, undermine the ability of health systems in developing countries to deliver on ICPD goals. However, there is a paucity of data on the effect of decentralisation on sexual and reproductive health. The relative lack of literature on this matter is largely due to the dearth of specific tools for analysis, poor documentation of most HSR initiatives, and the absence of mechanisms to monitor impacts on health systems and outcomes. Better frameworks for analyses of interactions between HSR and ICPD initiatives are required, as are improved documentation and monitoring of processes and outcomes. Fundamentally, decentralisation reform changes the way health services are delivered, including sexual and reproductive health care. The critical challenge in a decentralised health system lies in achieving a careful balance of power between central and local levels in decision-making, priority setting and resource allocation, to ensure that decisions favour, or at the very least do not negatively impact on, availability and equitable access to health services, including sexual and reproductive health services. Based on a review of published and unpublished literature, this chapter appraises the experiences with health sector reform, as they pertain to decentralisation in Africa, Asia and Latin America. It attempts to establish the effects of decentralisation on health systems and specifically on sexual and reproductive health services, and to identify gaps and opportunities for decentralisation reform to advance sexual and reproductive health goals and services in a context of HSR.