Decentralization of health systems is a common pillar of health sector reform initiatives and is often viewed as a means to improve efficiency and quality of services as well as promoting accountability and local governance of the health system. Despite many years of health decentralization initiatives in many countries worldwide, our knowledge of the relationships between particular forms of decentralization and performance of health systems remains limited. For instance, does decentralization help, hinder or have no impact on equity in resource allocation? Or are there relationships between decentralization of logistics systems and health sector performance? Part of the difficulty in addressing such questions lies in the inherently contextual relationship between decentralization and health systems performance, as well as the difficulty in untwine decentralization from other health sector reforms. Yet as importantly, we continue to lack an adequate framework to analyze decentralization both within and across countries.
IHSP faculty developed and have applied widely the innovative “Decision Space” approach to comparatively analyze health sector decentralization, see (Bossert 1998). Based on principal-agent theory, the Decision Space framework focuses on the range of choices accorded to decentralized authorities over a number of different functions. The range of choice includes both formally-permitted actions (such as laws and regulations which govern the nature of the decentralization) and unwritten lines of authority. The range of choices may or may not differ by health functions, the latter of which include financing, service organization, human resources, and governance. This approach has been implemented through survey questionnaires at municipal and district levels in Nicaragua, Morocco, Pakistan and India to determine the actual range of choice that local officials have been able to exercise. These detailed questionnaires are tailored to specific situations in each country and include questions on decision space, capacities and accountability.
One of the first studies conducted by IHSP faculty found that the Decision Space framework was able to comparatively describe decentralization across four countries [Zambia, Ghana, Uganda and Philippines; see (Bossert and Beauvais 2002)]. The studies found considerable variation in decision space across the different financing, service delivery, human resources and governance functions of the health systems. For instance, none of the countries were found to grant wide choice over revenues, expenditures, and fees, most granted a moderate range of choice over revenues and all grant a moderate range of choice over expenditures, though Zambia had little choice over alternative revenue sources. There also is commonly variation in decision space by function within a particular country. Zambian health officials, for example, were found to have a moderate range of choice over certain functions, such as expenditures, user fees, and contracting, but relatively limited over choice over others, such as salaries and allowances, see (Bossert, Chitah et al. 2003).
More recently, two major new studies have begun in Pakistan and India using an expanded decision space approach to study the decision space, capacities and accountability of health and local officials at district levels. Preliminary findings from Pakistan suggest there is a surprisingly wide variation in decision space from district to district, with districts having greater capacities generally exercising wider decision space. In some crucial areas, districts had sufficient capacity to take on even greater decision space than currently sanctioned.
In additions to providing a means to describe decentralization, the decision space methodology has been used to analyze relationships between decentralization and health sector performance. While some believe that decentralization of authority may contribute to inequity in resource allocation (e.g., wealthier localities will allocate more to health than poorer localities can), our studies have not found this to necessarily be the case, see (Bossert, Larranaga et al. 2003). Although wealthier localities in Chile and Colombia were able to spend more per capita on health, the 1998 study found that the gap between rich and poor was declining over the period of decentralization, and there was increasing equity of per capita expenditures at the municipal level. Indeed, a possible explanation for these findings was that that national-level mechanisms such as earmarking and population-based formula funding may have encouraged local authorities to assign similar amounts from their own source revenues is a local choice that is encouraging.
In another line of research, an innovative assessment of decentralization of logistics system for vaccines, essential drugs and contraceptives in Guatemala and Ghana indicated the nuanced relationship between decentralization and health sector performance. In these countries, it was found that that allowing local officials more decision space for some functions (e.g., forecasting, procurement and planning) was associated with better performance measures for those functions, while other functions were more effective if they remained centralized [e.g., logistics information systems and warehousing practices, see (Bossert, Bowser et al. Forthcoming)].
Finally, decision space analyses have also attempted to examine relationships between decentralization and health outcomes. In Zambia, utilization of health services, immunization coverage and family planning activities appeared to bear little relationship to the degree of decision space at the district level, found little variation during the period 1995-98 except for a decline in immunization coverage, which may have also been affected by changes in donor funding.
Our research findings suggest that more work needs to be done to assess the relationship between decentralization and health sector performance. While, in terms of resource allocation, we have demonstrated at least for two health systems, forms of decentralization that include mechanisms to improve equity, such as earmarking and population-based formula funding, may improve equity of resource allocation, it is necessary to assess this finding in other country contexts and to assess the impact of different forms of decentralization on efficiency, quality as well as equity of services. Our findings for logistics systems suggest that more sophisticated assessments are needed to provide policy advice for decentralizing specific programs and systems. More research in information systems, supervision systems, and other management control systems is needed.
As our recent research in Pakistan and India suggests, it is necessary also to assess the capacities and the accountability processes at local and central levels to complete the picture of decision space and decentralization. Studies of decentralization should develop policy-relevant evidence for both the types and degrees of choice allowed to local authorities and the contexts — both existing capacities and accountability processes — that foster more effective performance and outcomes of health systems.
Bossert, Thomas. “Analyzing the Decentralization of Health Systems in Developing Countries: Decision Space, Innovation and Performance.” Soc Sci Med, vol. 47, no. 10, 1998, pp. 1513-27.
Bossert, Thomas J., et al.”Decentralization of Health Systems in Ghana, Zambia, Uganda and the Philippines: a Comparative Analysis of Decision Space.” Health Policy Plan, vol. 17, no. 1, 2002: 14-31.
Bossert, Thomas J.,et al. “Decentralization in Zambia: Resource Allocation and District Performance.”Health Policy Plan, vol. 18, no. 4, 2003, pp. 357-69.
Bossert, Thomas J., et al. “Decentralization and Equity of Resource Allocation: Evidence from Colombia and Chile.” Bull World Health Organ, vol. 81, no. 2, 2003, pp. 95-100.
Bossert, Thomas J., et al. (Forthcoming). “Is Decentralization Good for Logistics Systems? Evidence on essential medicine logistics in Ghana and Guatemala.” Health Policy and Planning.
There is increasing recognition that health sector performance depends critically on the quality of human resources for health (HRH). With over 60% of recurrent health expenditures worldwide devoted to HRH, a country’s ability to effectively train and deploy those resources is an important component to health systems performance. Determining the appropriate numbers and skills mix of HRH is only one part of the equation, while ensuring that capacities to train, finance and manage those resources present an entirely different set of challenges. IHSP is contributing to building the knowledge base of how health systems issues interact with HRH policy through a combination of research activities and training in human resources strategic planning. In particular, IHSP members conducted an assessment of the human resource situation and provided policy recommendations to the government of Ethiopia in collaboration with the WHO.
In collaboration with the World Health Organization (WHO), IHSP developed and pilot-tested a strategic planning guide to diagnose country capacity in HRH planning and sequence recommendations for future policies. [this guide will be available from the WHO in early 2007] The guide is designed to identify obstacles to HRH performance commonly faced by countries (e.g., migration of health workers, poor working environment) and how three capacities of the health system — financing, education, and management — affect HRH performance through those obstacles. The guide is based on a careful review of the literature to provide evidenced-based justifications for the assessment indicators where possible. The financing module offers a framework for assessing the allocative and operational efficiency of the health workforce wage bill (i.e., recurrent expenditures on HRH). Education capacities are by analyzing six determinants of the numbers of HRH, from the initial pool of applicants to the eventual entry rate into the health workforce. The management module provides a methodology to relate factors at the macro level (e.g., decentralization policies), meso level (e.g., job classification system), and micro level (e.g., facility-level organizational culture) to HRH performance. Each module provides a menu of indicators by which the user can link each capacities in financing, education and management to the country’s obstacles to HRH performance. Based on the data collected, the tool also provides a methodology to sequence policy recommendations to improve the country’s HRH situation. This sequencing methodology includes an approach to analyzing the policy environment that is based on the IHSP’s PolicyMaker approach, see (Reich 1996).
The assessment tool is informed by a comprehensive review of literature on HRH and combines quantitative and qualitative data collection. An extensive literature review was conducted to identify the obstacles to HRH performance most commonly faced by developing countries, as well as the evidence base linking financing, education and management capacities to quality of services. Quantitative and qualitative indicators were based on the review of the evidence base, with newly developed indicators proposed when necessary. The literature review included peer-reviewed articles, “grey” literature, and previously developed assessment tools. The assessment tool was then pilot-tested in Ethiopia in collaboration with the WHO which informed subsequent revisions and refinements.
The Ethiopia field test of the strategic planning guide produced a clear current assessment according to most of the guide’s indicators, a set of recommendations for training and financing a specific cadre of health workers, processes for upgrading the management context for HRH and a sequence for investment in HRH in Ethiopia. It also reviewed the favorable political context for the recommended reforms. The report on this field test is currently under review by the government of Ethiopia and WHO.
While there has been a resurgence in interest in the role that HRH play in health systems performance, development of this HRH assessment tool indicated that much remains unknown on links between HRH and health systems performance. On the one hand, most existing tools related to assessing a country’s HRH situation and/or assisting in HRH strategic planning focus on the technical side, that is getting the numbers and skills mix right. There are many fewer instances or indicators of how HRH capacities and needs fit into the health system more generally, On the other hand, the evidence base linking system-wide capacities (i.e., capacities in financing, education and management) to obstacles to HRH performance is still lacking on many fronts. This tool is a first step towards addressing gaps in our knowledge, but much remains to be done.
Analysis and understanding of the political context in which health policies are envisioned and/or made are crucial to understanding the chances of success or failure of health reform initiatives. Several IHSP faculty are continually engaged in research on the political processes of health policy reform across a wide number of countries and settings.
While research methodologies are tailored to the specific analysis at hand, a systematic stakeholder analysis usually is a key component to the research. In particular, many of our analyses have made use of the PolicyMaker approach, a methodology and software program developed by IHSP researcher Michael Reich, see (Reich 1996; Glassman, Reich et al. 1999). The PolicyMaker approach systematically analyzes stakeholder positions and likely outcomes resulting from policy reform initiatives. Its five components of analysis include: 1) defining the policy content in question; 2) identifying political players, their interests and positions; 3) identifying opportunities and obstacles to change which exist in the political environment; 4) designing political strategies that will heighten a policy’s feasibility; and 5) assessing potential gains/impacts of those strategies.
In the 1990’s a comparative study was conducted on the policy process of health reform in Chile, Colombia and Mexico (where Chile and Colombia had successfully undertaken health while Mexico had not), evaluating the success and failure of political strategies for adoption of a significant reform, see (González-Rossetti and Bossert 2000). Conventional wisdom suggests that it is often easier to implementing broad reforms in authoritarian regimes is easier than in democratic systems because the former regimes can make decisions without having to respond to different interest groups that can often block reforms. Contrary to this expectation, however, our stakeholder and institutional analyses indicated that the formation of relatively stable and coherent “change teams” in Chile and Colombia were major factor in the success of reforms there. Made up of technical experts with a shared ideological commitment and who did not see themselves as politicians, the health sector change teams garnered critical support by the president and other major political actors. As importantly, these teams had links to a macro-economic “change team” which had successfully developed policies of economic reform and that sent key members to work in the Ministry of Health. By contrast, efforts to create a coherent health sector change team in Mexico were frustrated by intense internal competition among key macro-economic change team members over the anticipated selection of the next president. Finally, the health sector change teams in Chile and Colombia were insulated from the broader political process until it had developed a significant technically defined package of reforms. The reform package was then presented as a complete reform and as the president’s own proposal for legislative attention, with the change team able to overwhelm opposition with well-developed technical arguments.
In 2000, IHSP faculty conducted a study of the policy process surrounding national health insurance reform in Poland. The analysis centered around the National Health Insurance Law, legislations designed to separate health service financing from provision, but also the culmination of a long and contentious reform process of competing proposals. The research addressed reasons why it took much longer for health reform to be decided and implemented in Poland compared to neighboring (and also newly democratic) countries, why Poland eschewed greater involvement of market mechanisms that have been tried in other Central and Eastern European countries, and which political strategies could be used to continue the process toward a greater consensus on innovative health reform proposals. In addition to a traditional stakeholder analysis, they analysis reviewed the respective roles that “coalition politics”, incumbency, lobbying, bureaucratic politics and technical information played in the policy process. The research found that the lack of a sufficiently strong coalition of actors committed to any one health reform proposal accounted in part for the protracted reform process. In terms of market mechanisms, it appeared that pro-market forces were less adept at building consensus than their post-Communist counterparts. Finally, the analysis concluded that successful implementation of the reform would require a strengthened coalition of insurance law supporters to overcome institutional inertia, a stronger regulatory role by the Ministry of Health, and building of bargaining skills by political actors to maintain strong coalitions.
Studies on the policy process provide a number of lessons for major reform efforts in developing countries. In contexts where change teams are crucial to the reform effort (as in Colombia and Chile), developing support for reform at executive level, as well as in the Planning and Finance Ministries, can be critical to success. Additionally, strong vertical links to high-level officials and horizontal links to officials in other sectors, as well as command of technical arguments, lend a necessary degree of legitimacy and effectiveness. Finally, isolation of the change team in the formulation of policy resulted in a single and coherent reform package that could be supported by the major political actors. In other contexts where the more fluid and unstable coalition politics dominate (as in Poland), strengthening basic democratic policy process skills (e.g., bargaining and consensus-building) at all levels may be as important as garnering higher-level support or developing links to officials.
Reich, Michael R.,”Applied Political Analysis for Health Policy Reform.” Current Issues in Public Health, vol. 2, 1996, pp. 186-191.
Glassman, Amanda., et al. “Political analysis of health reform in the Dominican Republic.” Health Policy Plan, vol. 14, no. 2, 1999, pp. 115-26.
González-Rossetti, Alejandra., et al. “Enhancing the Political Feasibility of Health Reform: A Comparative Analysis of Chile, Colombia, and Mexico.” Data for Decision Making project, 2000.