dr. shahram yazdani decentralization. dr. shahram yazdani organizational reform in health system...

Dr. Shahram Yazdani

Decentralization

Dr. S

hahra

m

Yazd

ani

Organizational Reform in Health System

Marketizing Reform Non-marketizing Reform

Dr. S

hahra

m

Yazd

ani

SensorsActors

Policy MakerGovernorStrategic Manager

Administrative Manager

Dr. S

hahra

m

Yazd

ani

SensorsActors


Administrative Manager

ProblemsNeedsRequirements

Interventions

Dr. S

hahra

m

Yazd

ani

Administrative Decisions






Dr. S

hahra

m

Yazd

ani

Realisti

c

Holisti

c

Characteristics ofAdministrative

Decisions

Dr. S

hahra

m

Yazd

ani

SensorsActors




Dr. S

hahra

m

Yazd

ani

SensorsActors




Interventions

Internal Sclerosis

Administrative Work Overload in HML Sacrifice of Strategic Functions at HML

Irrelevance of Decisions

Dr. S

hahra

m

Yazd

ani

SensorsActors




Dr. S

hahra

m

Yazd

ani

SensorsActors



Interventions


Incoherence in Operations Disintegration of Policies from Functions

Dr. S

hahra

m

Yazd

ani

SensorsActors




Dr. S

hahra

m

Yazd

ani

SensorsActors



Interventions


Policy-Framed Problem-Relevant Decisions

Dr. S

hahra

m

Yazd

ani

SensorsActors



Critical Level of Inflectionor

Critical Inflectional Level

The level at which main administrative decisions are made

System Wide Scope Policy Informed

Extra Authorities Hinge of Organization

Dr. S

hahra

m

Yazd

ani

What is Decentralization?

Decentralization is the transfer of authority and responsibility for public functions from a country’s central government to sub-national levels of government or autonomous institutions (Rondinelli et al. 1983).

Dr. S

hahra

m

Yazd

ani

Key Areas of Change under Decentralization

Decentralization seeks to improve health system performance by Changing the authority and responsibility among key

actors Improving information flows for decision making and

performance evaluation Establishing accountability mechanisms and

incentives to hold all actors in the health sector accountable for fulfilling their responsibilities.

Developing the organizational and technical capacity to carry out new functions associated with reduced or increased authority.

Dr. S

hahra

m

Yazd

ani

Authority

The role of the central government in ensuring and monitoring effective and efficient decentralization is especially critical when the main concern is to enhance service delivery such as health and education that are important not only for national development but for poverty alleviation and welfare in general.

Decentralization does not mean that the central government no longer has any responsibility in these areas. What it means is that the nature of this responsibility has changed from direct service delivery to one of regulating and monitoring the efficiency and equity of services delivered by others – usually local governments”

Dr. S

hahra

m

Yazd

ani

Accountability

A key component to the success of decentralization efforts is the putting in place of mechanisms to hold all actors in the health sector – from the health minister down to outreach workers in the village – accountable for their decisions and actions. Brinkerhoff (2003) identifies three primary purposes of accountability:1. To control the misuse and abuse of public resources and/or

authority;2. To provide assurance that resources are used and authority is

exercised according to appropriate and legal procedures, professional standards, and societal values;

3. To support improved service delivery and management through feedback and learning (performance accountability).

Dr. S

hahra

m

Yazd

ani

Information

A key objective of decentralization is the generation of information– information for decision making and for holding officials, decision makers, planners, and health workers accountable for performance.

Decentralization can create new flows of information so that decisions can be informed and performance can be evaluated.

Proximity of stakeholders – e.g., health officials, clinic managers, patients – may increase the potential for information to be correct and to be used by decision makers (authority) and system monitors (accountability).

Dr. S

hahra

m

Yazd

ani

Capacity

According to Goodman et al. (1998) capacity is the ability to carry out stated objectives. It is integral to performance and particularly to sustained performance in the health sector.

Decentralization places high demands on local and national organizations to improve their capacity to handle new functions such as planning and budgeting, stakeholder consultation and consensus building, and managing information.

It is not enough to devolve responsibilities or develop systems of accountancy without providing the necessary resources, skills, and guidance to perform that function effectively.

Dr. S

hahra

m

Yazd

ani

Types of Decentralization

A common taxonomy classifies decentralization by three categories of devolved responsibilities: Political Administrative Fiscal

Dr. S

hahra

m

Yazd

ani

Political Decentralization

Political decentralization involves providing citizens or their representatives with additional public decision-making power, in particular through democratic processes (World Bank 2000).

Decisions made with greater participation will be better informed and more relevant to diverse interests in society than those made only by national political authorities.

Successful political decentralization generally depends upon several key components, including constitutional or statutory reforms, pluralistic political parties, strengthening of legislatures, and local political units.

Dr. S

hahra

m

Yazd

ani

Administrative Decentralization

Administrative decentralization “is the transfer of responsibility for planning, financing, and managing certain public functions from the central government and its agencies, subordinate units or levels of government, semi-autonomous public authorities or corporations, or are-awide, regional, or functional authorities” (Rondinelli 1999).

Dr. S

hahra

m

Yazd

ani

Administrative Decentralization

Different levels of administrative decentralization are: Deconcentration is defined as shifting power from the central

offices to peripheral offices of the same administrative structure (e.g. Ministry of Health and its district offices).

Delegation shifts responsibility and authority to semi-autonomous agencies, (e.g. a Board of Health, a separate regulatory commission or an accreditation commission).

Devolution shifts responsibility and authority from the central offices of the Ministry of Health to separate administrative structures still within the public administration (e.g. local governments of provinces, states, municipalities).

Privatization transfers operational responsibilities and, in some cases ownership, to private providers, usually with a contract to define what is expected in exchange for public funding. (e.g. the conversion of public hospitals to private ownership, contracting out specific services)

MOH

ProvincialOffices of MOH

National Level

Provincial Level

Transfer of authority to peripheral offices of the same administrative structure

Deconcentration

MOHME

UMSHS

National Level

Provincial Level

Transfer of authority to peripheral semi-autonomous organizations

Delegation

Ministry ofHealth

Provincial Government

National Level

Provincial Level

Transfer of authority to separate administrative structures still within the public administration

Devolution

Ministry ofInterior

Government

Provincial Health Board

Ministry ofHealth

Private HealthOrganizations

National Level

Provincial Level

Transfers of authority and in some cases ownership, to private providers

Devolution

Government

Dr. S

hahra

m

Yazd

ani

Fiscal Decentralization

Fiscal decentralization refers to developing local government control over financial resources, either in terms of expenditure assignments or revenue generation.

Much of the literature on fiscal decentralization focuses on the nature of intergovernmental transfers, and on addressing differences in revenue-generating capacity across jurisdictions of different income levels.

Within the health sector, however, local governments are likely to have limited revenue-generating powers and are generally restricted to local cost-sharing mechanisms or local health insurance schemes.

Decentralized health systems therefore generally remain dependent upon transfers from the central government

Dr. S

hahra

m

Yazd

ani

Objectives of Decentralization

Efficacy

Equity

Efficiency

Quality

FinancialSoundness

Local Choice& Priorities

Rationale Pros

Local leaders can better target resources to vulnerable groups

Local leaders can make more efficientdecisions because they have betterinformation about local conditions

Greater accountability may lead localleaders to improve quality

Local leaders may be more aware oftradeoffs and fiscal constraints.

In democratic localities, decentralizationcan allow more local choice and prioritysetting

Local leaders are better informed aboutlocal problems and can make betterdecisions

Cons

On a national level, decentralization may limit the ability to redistribute resources from richer to poorer localities

Local leaders may be subject to pressures, such as patronage or keeping inefficient facilities open.

Consumers may not necessarily express quality concerns to local leaders

Local leaders may be subject to pressures increasing inefficiency and may pass deficits on to higher levels

A local elite may dominate local decision Making and make choices that are not in the public's interest.

Little empirical support and reason to believe that central authorities have better technical information on efficacy

Dr. S

hahra

m

Yazd

ani

Policy Impressions

Field Requirements

Manageria

l C

apacitie

s

Level

Ince

ntiv

esDecisions

Dr. S

hahra

m

Yazd

ani

Policy Impressions

Field Requirements

Manageria

l C

apacitie

s

Level

Ince

ntiv

esDecisions

Govern

anc

eIn

f. Sys.

Capacity Building Inc. Mismatch

Dr. S

hahra

m

Yazd

ani

Policy Impressions

Field Requirements

Manageria

l C

apacitie

s

Level

Ince

ntiv

esDecisions

Govern

an

ce

Inf. S

ys.


Dr. S

hahra

m

Yazd

ani

Policy Impressions

Field Requirements

Manageria

l C

apacitie

s

Level

Ince

ntiv

es

Decisions

Govern

anc

eInf. S

ys.


Dr. S

hahra

m

Yazd

ani

Policy Impressions

Field Requirements

Manageria

l C

apacitie

s

Level

Ince

ntiv

esDecisions

Govern

anc

eInf. S

ys.


Rewards, Motivations, and Externalities at each Level Leads to Default Intentions and Behaviors at that Level

If these are the same you can Decentralize power even with a weak Governance

If there is a wide mismatch between these Externalities you need strong Governance for Decentralization

Dr. S

hahra

m

Yazd

ani

Policy Impressions

Field Requirements

Manageria

l C

apacitie

s

Level

Ince

ntiv

esDecisions

Govern

anc

eInf. S

ys.


Decentralization Impose New Managerial Competencies in Both Levels

A General Recommendation is that don’t Defer Decentralization for Capacity Building

Legal/Political•Laws•Regulations•Standards•PoliciesFiscal•Financial resources and rules governing useOrganizational•Leadership•Human Resources•Drugs, supplies & equipment•Infrastructure•Organizational structure

Legal/Political•Laws•Regulations•Standards•PoliciesFiscal•Financial resources and rules governing useOrganizational•Leadership•Human Resources•Drugs, supplies & equipment•Infrastructure•Organizational structure

InputInput Legal/Political•Stewardship•Policy-making•Enforcing regulations & laws•Strategic planningFiscal•Budgeting•Revenue generation•TransfersOrganizational•Consensus building•Communicating•Stakeholder involving•Operations/maintenance•Learning•Implementing•Supervising•Evaluating/Reporting

Legal/Political•Stewardship•Policy-making•Enforcing regulations & laws•Strategic planningFiscal•Budgeting•Revenue generation•TransfersOrganizational•Consensus building•Communicating•Stakeholder involving•Operations/maintenance•Learning•Implementing•Supervising•Evaluating/Reporting

ProcessesProcesses

Organizationalperformance•Strategies/policies that meet local needs•Formal & informal coalitions•Accountable to stakeholders•Equitable distribution of resources•Regulations enforced•Standards met•Use of information for planning and learning•Timely analysis /dissemination of national health information

Organizationalperformance•Strategies/policies that meet local needs•Formal & informal coalitions•Accountable to stakeholders•Equitable distribution of resources•Regulations enforced•Standards met•Use of information for planning and learning•Timely analysis /dissemination of national health information

OutputsOutputs

Health systemperformance•Access•Quality•Efficiency•Utilization•Responsiveness•Equity

Health systemperformance•Access•Quality•Efficiency•Utilization•Responsiveness•Equity

OutcomesOutcomes

•Incidence•Survival•Quality of Life•Equity

•Incidence•Survival•Quality of Life•Equity

ImpactImpact

Conceptual Framework for Evaluating Decentralization

Thank You!

Any Question?

dr. shahram yazdani decentralization. dr. shahram yazdani organizational reform in health system...

Documents