Felix AwantangMatar CAMARAVincent Joret

Improving Health Services Improving Health Services in a Devolved Government in a Devolved Government SystemSystem

DISC Décentralisation et Initiative de Santé

Communautaire « Decentralization and Community Health

Initiatives »

Three key questions

What were the key elements of decentralization in Senegal?

What were the major issues for the central and local governments and how were they resolved?

How has the USAID program supported the decentralization process?

Elements of Decentralization

Administrative/technical

Political: democratically elected leaders

Budgetary/fiscal: transfer of budget authority

Senegal Profile - 1999 data

Population: 9,529,029 (estimated) GNP per capita: $550 GNP Per Capita Growth Rate: 1.6% per

year Urbanization Rate: 45% Adult Female Illiteracy Rate: 70% Infant Mortality Rate: 68/1000 Total Fertility Rate: 5.7 Maternal Mortality: 510/100,000

Decentralization before 1996: A favorable environment for

health development (1)

Strengthened local health services: the PHC agenda Sine-Saloum rural health project supported by

USAID Pikine periurban experience supported by the

Belgian Cooperation Reorientation of public interventions in health

towards preventive and outreach services Strengthening the rural health infrastructure

and human resources

The 1996 Decentralization Reforms: Strengthening local

decision-making A new political local government unit (LGU)

is created, the region - 10 regions in Senegal The region, the commune and the rural

community ‘freely administer’ their local affairs

There is no hierarchical relationship between LGUs

Central Gov’t monitors budget compliance for various govt units. Corrective guidance for future.

The 1996 Decentralization Reforms:

Devolution of 9 sectors to LGUs including health and population Primary financial mechanism was to transfer

affected Ministry funds directly to LGUs through the “Fonds de Dotation”

The design of the devolution reforms did not take into account the organization and financing of the health system

These changes were occurring in an environment where health improvements were slowing down or reversing

Pre-project situation assessment (2)

The local government units did not take responsibility for health services. No new ideas, no local health planning

The MOH did little to adapt to the new order. District and Regional Medical Officers were

poor politicians District Medical Officers demonstrated no real

management skills (process over substance) Local representatives of the central government

(Preféts, Governors, etc.) did not play their roles.

Technical linkage

Urban LGU

Rural LGU

Rural LGU Rural LGU

Health post

Health post Health post

Health hutUrban LGU

The money allocatedto all health structures of the district is transferred to the mayor of the LGU where the referral

hospital is located

Health district Organization in Senegal

Project Strategies

Budgeting as a political tool Increasing Communication Implementing the new vision Putting District Associations (G.I.C) in

place Re-inforcing the « Comités de Gestion » Financing scheme (Matching)

Budgeting as a Political Tool

DISC works with DMOs to develop global budgets in 15 districts. Opportunity to train DMOs, locally elected

officials and representatives of central Gov in devolution of health

These 15 DMOs become much stronger in their political debates with local officials.

DMOs become more able to defend budgets in the new political environment.

Increasing Communication

Initially done person by person. Regional, District and Communal level meetings

to discuss the place of health in the devolved system of governance.

As understanding between the various parties grows, conflicts are reduced.

Goal is to find middle ground with a mutual respect for the responsibilities and needs of all sides.

Implementing the New Vision

Going to the level of the Health District is not sufficient.

The community, through its existing systems of governance, is now contributing in real ways: Mobilizing new local key players( women,youth ) Assessing and planing local health needs and

affordable solutions Promoting ownership through $ contributions

Putting District Associations in place

Composed of elected representatives from all local government units in the geographical area of one health district.

MOH has a consultative role.

Should evolve to a “Groupement d’Intêret Communautaire (GIC) of the health District”, which will have legal standing

Re-inforcing the ”Comités de Gestion”

Defined by decentralization texts. Mayor or Rural Community President Another representative of LGU DMO or ICP President of Health Committee Health Committee Treasurer

Sous-Prefêts working to help establish the committees.

Financing Scheme (Matching)

Co-payments are based on locally generated tax revenues, sliding scale of USAID match ranges from 400% to 25%.

Central “fonds de dotation à la décentralisation” are also matched at 20% if the health part is entirely used for local health needs

Community plans financed through both above mentioned sources require signed agreement among multiple actors at local, district and regional.

Community plans become the building stone of Health District Plans.

Overall System is Performance-based.

annual local Budgetin CFA

contributionrate of the

LGU to health

Matchingrate ofUSAID

Moins de ou égal à 10 000 000 1 4

De 10 000 001 à 25 000 000 1 3

De 25 000 001 à 50 000 000 1 2

De 50 000 001 à 100 000 000 1 1

De 100 000 001 à 250 000 000 2 1

De 250 000 001 à 500 000 000 3 1

Plus de 500 000 000 4 1

Successes to Date

By providing “real” data, the project contributes greatly to shaping the discussion on the impact of devolution on the periphery.

By discussing these real data in public meetings, the project contributes greatly to foster good governance and transparency.

MOH now involved after early disinterest. High participation by LGUs in the financing

scheme. Other donors (notably the KFW) are following

USAID’s lead.

Linkage between DISC’s and USAID/Dakar’s Strategic Objectives

DISC’s activities directly address the third Health and Pop I.R. - health financing, increased local revenue generation for health, etc.

The financing scheme also meets quantitative targets for improved services through the “performance” aspect of the grants system

The DISC activities directly address all 4 of the I.R.s in the Mission S.O., which addresses improved governance in a decentralized system.

Challenges:

Increase the understanding by all actors involved in decentralization process.

Increase communication among the various actors.

Explain and advocate Decentralization laws and regulations.

Unify competing “visions”. Have the actors (MDOs ,LGUs and Central

Gov. Representatives) play their roles. Development of budget allocation

formula