Health Sector Reform

The objective was to examine whether decentralization has improved health system performance in the State of Ceara, north-east Brazil. Decentralization was associated with improved performance, but only for 5 of our 22 performance indicators. Moreover, in the multiple regression, decentralization explained the variance in only one performance indicator; indicators for informal management and political culture appeared to be more important influences. However, some indicators for informal management were themselves associated with decentralization but not any of the political culture indicators.

This presentation was given at the First Forum on Human Resources for Health in Kampala. It reviews a study of how Rwanda, faced with constrained fiscal conditions, has implemented innovative reforms to create fiscal space for human resources and to make these resources more responsive to needs through an analysis of budget documents and policy and regulation changes and key informant interviews. [adapted from author]

Community-based Health Planning and Services (CHPS) initiative as a strategy to deliver community level service is a key health system reform for the Health Sector in general and the Ghana Health Service in particular. If the health sector is to achieve the Health Millennium Development Goals’ in Ghana, then there is the need for a drastic shift in the paradigm of service provision. CHPS provides us with a vehicle for making this paradigm shift so as to deliver community level service by engaging communities in taking decisions concerning their own health and recognizing that the primary producers of health are the individuals within households – especially mothers.

This study provides initial information about current nursing issues that have arisen as a result of health care reform initiatives. Regardless of differences in service models or phases of health sector reform implementation, in all the countries the participating nurses identified many common themes, trends, and changes in nursing practice. The driving forces for change and their intensity have been different in the five countries. Nurses maintain their core values despite increased work stress and greater patient care needs in all the countries as well as economic crises in the Latin American countries.

Decentralising health workforce management may help local services to coordinate and plan their human resources more effectively to meet health care needs. Health sector decentralisation in China and South Africa is complex, with different forms being implemented within varying timescales and for different purposes. In China decentralisation has taken place alongside the transition to a market economy, whilst post-apartheid South Africa is attempting to establish a new district health system. [author’s description]

The general argument for decentralizing health care is the potential for improved service quality and coverage. This note raises the issues to consider if decentralization is to bring about beneficial results. A table summarizes a general framework for assigning responsibilities to central and local levels, while the rest of the note outlines a series of issues to consider. [From author]

Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization — the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization.

This paper presents some of the basic governance issues related to decentralization and some examples of how projects and donor policies have contributed to more effective decentralization processes. [from author]

This document offers some help in addressing decentralization for health sector actors interested in designing decentralization policies and strategies, implementing them, and/or operating within decentralized health systems. [author’s description]

Decentralization of political and administrative power, combined with a civil service reform, are increasingly prevalent components of health sector reform. The wider implications of decentralization for human resources development are, however, poorly researched and inadequately understood. This paper analyzes these implications from the experience of the author, her colleagues and published literature. [from abstract]

Dissatisfied with centralized approaches to delivering local public services, a large number of countries are decentralizing responsibility for these services to lower- level, locally elected governments. The results have been mixed. This chapter provides a framework for evaluating the benefits and costs, in terms of service delivery, of different approaches to decentralization, based on relationships of accountability between different actors in the delivery chain. Moving from a model of central provision to that of decentralization to local governments introduces a new relationship of accountability—between national and local policymakers—while altering existing relationships, such as that between citizens and elected politicians.

This study reviews the experience of decentralization in four developing countries: Ghana, Uganda, Zambia and the Philippines. It uses two analytical frameworks to describe and compare the types and degrees of decentralization in each country. The first framework specifies three types of decentralziation: deconcentration, delegation and devolution. The second framework uses a principle agent approach and innovative maps of decision space to define the range of choice for different functions that is transferred from the centre to the periphery of the system. [from abstract]

This comparative study evaluates the implementation of decentralization of health systems in three Latin American countries: Chile, Bolivia, and Colombia. In terms of the relationship between decentralization and system performance in general, the findings support the conclusion that both the die-hard detractors and the fervent advocates for decentralization are wrong. Decentralization appears to be improving some indicators of equity, such as a tendency toward similar per capita expenditures for wealthier and poorer municipalities, and to be associated with increased and more equitable per capita spending on promotion and prevention.

The viewpoint presented throughout this document tries to analyze political aspects which are normally not considered in order to understand the execution and results of health policies. In this case, we are interested in understanding the link between the decentralization process and three aspects of the human resource policy: distribution, regulation and management. Our focus, however, attempts to document the processes, more than the results, since these will have to manifest themselves during the coming years. The scientific value of documenting the process allows us to identify explicit and hidden links between the actors in this process, which are strong determinants of the final results.

In developing countries, postabortion care (PAC) programs are frequently available only in urban or regional health facilities, placing rural women at greater risk for mortality and morbidity from complications because they lack access to services. This technical brief evaluates efforts to decentralize PAC activities in Senegal and Tanzania that show PAC can be safely and successfully decentralized with services capably provided by mid-level personnel in health centers, dispensaries, and some health posts when providers are trained and supervised and equipment and supplies are available. [adap

This paper examines evidence from published literature on decentralization’s impact on the demand side of the human resource equation, as well as the factors that have contributed to the impact. The elements that make such an impact analysis exceptionally complex are identified. They include the mode of decentralization that a country is implementing, the level of responsibility for the salary budget and pay determination, and the civil service status of transferred health workers. The main body of the paper is devoted to examining decentralization’s impact on human resource issues from three different perspectives: that of local health managers, health workers themselves, and national health leaders.

This report presents findings from a survey of 252 primary health facilities and 30 local governments carried out in the states of Kogi and Lagos in Nigeria in the latter part of 2002. Nigeria is one of the few countries in the developing world to systematically decentralize the delivery of basic health and education services to locally elected governments. Its health policy has also been guided by the Bamako Initiative to encourage and sustain community participation in primary health care services. The survey data provide systematic evidence on how these institutions of decentralization are functioning at the level local—governments and community based organizations—to deliver primary health service.

This issue of The Family Planning Manager will help you to asses both the opportunities and the risks inherent in decentralizing your program. It will help you identify the new relationships that must exist between the central and local level managers, and the types of skills that local level managers must have in order for decentralization to have a positive impact. [author’s description]

This document summarizes the human resources management situation in the region, its determinants, and the projects for its development. To promote improvements in the human resources management function as part of the sectoral changes under way at the national and regional level, the Pan American Health Organization is proposing a series of strategies, actions, and operational tools through the Observatory of Human Resources in Health Sector Reform initiative. [adapted from author]

This publication is an effort to respond to the different needs for capacity building in management and implementation of health programmes and delivery of essential services. It reflects the thinking acquired from experience working with health sector reforms being implemented in the African Region. The District Health Management Training modules cover the principles that are applicable across the Region and are meant to guide and strengthen the management capacity of district health management teams. [author’s description]


Module 1: Health Sector Reform and District Health Systems; Module 2: Management, Leadership and Partnership for District Health; Module 3: Management of Health Resources; Module 4: Planning and Implementation of District Health Services.

The health care system in Pakistan has been confronted with problems of inequity, scarcity of resources, inefficient and untrained human resources, gender insensitivity and structural mismanagement. With the precarious health status of the people and poor indicators of health in the region, health care reforms were finally launched by the government in 2001. There are, however, numerous challenges and constraints in the system. The future health of the nation depends on this decentralization initiative. All our efforts should be concerted to support and facilitate the new system, which will mature into institutionalization of the health services at the district level.

This cross-sectional study was carried out in four states that were selected according to geopolitical and administrative criteria to identify the effects of decentralization on health financing and governance policies in Mexico from the perspective of users and providers. The report discusses the effect of decentralization on health service providers and community involvement. Data collection was performed using in-depth interviews with health system key personnel and community leaders, consensus techniques and document analyses. [adapted from author]

This issue of The Manager shows how health managers, though faced with multiple challenges of decentralization, can redefine their roles and responsibilities to better support both the people they serve and the staff at management levels closest to the population. It shows how health managers can adopt leadership practices to carry out their new roles and ultimately make decentralization work. [editor’s description]

This document review the Observatory of Human Resources in Health in the Health Sector Reform Processes in Latin America and Caribbean, which is a cooperative initiative among the countries of the Americas aimed at producing information and knowledge in order to improve human resource policy decisions as well as contributing to human resoures development within the health sector on the basis of sharing experiences among countries. [adapted from author]

Few countries in Latin America have experienced in such a short period the shift from a socialist government and centrally planned economy to a liberal market economy as Nicaragua. The impact of such a change in the health field has been supported by the quest for reform of the health system and the involvement of external financial agencies aimed at leading the process. However, this change has not been reflected in the planning of human resources for health.

This paper reviews current literature and debates about health sector reform in developing countries in the context of its possible implications for women's health and for gender equity. It points out that gender is a significant marker of social and economic vulnerability which is manifest in inequalities of access to health care and in women's and men's different positioning as users and producers of health care. [from abstract]

This article takes up the relatively neglected issue of gender in human resources policy and planning (HRPP), with particular reference to the health sector in developing countries.

Both the advocates and the detractors of decentralization are probably wrong. A thoughtfully designed process of decentralization is not likely to radically improve a health system, nor is it likely to severely disrupt the system. We have evidence that a well-designed decentralization can improve equity of allocations and may have other positive effects such as increased funding of promotion and prevention. Its influence over efficiency and quality is not as clear. These guidelines suggest some mechanisms which can be effective in the design and implementation of decentralization. In addition, it is clear that the central authorities need improved monitoring systems in order to assess and evaluate how well the local authorities are achieving the goals and objectives of national policy.

Costa Rica has taken the search for improvement of quality health care seriously, and has initiated several activities in that area. The Quality Assurance Project… has provided technical assistance to introduce continuous quality improvement methodology in seven hospitals and clinics in the South Central Health Region. This intervention was expected to result in concrete improvements for specific problems in each of these health facilities, and to serve as a model to be duplicated in health facilities elsewhere in the country. [author’s description]

This is the fourth of a series of policy briefs produced by the Community Health Department of the Aga Khan Health Service in Kenya. It focuses on a number of issues related to the management of health facilities: the rational for decentralisation of health services, the role of the community in the management of health facilities, the membership of local management committees, selection criteria and, finally, the involvement of local politicians.

These briefs are primarily intended for directors and managers of community-based health care programmes — whether working within ministries of health, international donor agencies or non-government organisations.