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November 19, 2019

Decentralization of Healthcare in Health System Development Perspective

Decentralization Initiations
Decentralization has been accepted as one of the fundamental mechanisms in improving governance. However, not all functions of governance can be decentralized in reality. In 2009, decentralization of health care was chosen and discussed at the World Health Organization (WHO) – South East Asia regional meeting on Healthcare Reform for the 21st Century. The regional seminar on decentralization of health-care services in the South-East Asia Region intended to discuss experiences among Member countries of the South East Asia Region including Myanmar, which have varying degrees of decentralization in health care services. The editorial perspectives in the daily newspaper Global New Light of Myanmar published on 11 September, 2019 indicated that the Ministry of Health and Sports (MOHS) would decentralize its authority by giving more power to the heads of regional and state health departments and medical superintendents to make healthcare services more effective. Under the reforms, the health leaders in regions and states would no longer need to wait for orders or permissions from superiors and they would be able to make their own decisions on their operations. At the same time, they would require more support to effectively carry out their tasks, with the delegation of more authority concerning their administration, management, staff affairs, and finance but they would have to take responsibility and be accountable for their actions.
What is Decentralization?—The term “decentralization” embraces a variety of concepts which must be carefully analyzed in any particular country before determining if projects or programs should support the reorganization of financial, administrative, or service delivery systems. Decentralization—the transfer of authority and responsibility for public functions from the central government to subordinate or quasi-independent government organizations and/or the private sector—is a complex multifaceted concept. Different types of decentralization should be distinguished because they have different characteristics, policy implications, and conditions for success.
Types of Decentralization — include political, administrative, fiscal, and market decentralization.
Political Decentralization — aims to give citizens or their elected representatives more power in public decision-making.
Administrative Decentralization— seeks to redistribute authority, responsibility and financial resources for providing public services among different levels of government. It is the transfer of responsibility for the planning, financing and management of certain public functions from the central government and its agencies to field units of government agencies, subordinate units or levels of government, semi-autonomous public authorities or corporations, or area-wide, regional or functional authorities. The three major forms of administrative decentralization — deconcentration, delegation, and devolution — each have different characteristics.
Deconcentration— which is often considered to be the weakest form of decentralization and is used most frequently in unitary states— redistributes decision making authority and financial and management responsibilities among different levels of the central government.
Delegation— is a more wide-ranging form of decentralization. Through delegation central governments transfer responsibility for decision-making and administration of public functions to semi-autonomous organizations not wholly controlled by the central government, but ultimately accountable to it. Governments delegate responsibilities when they create public enterprises or corporations, housing authorities, transportation authorities, special service districts, semi-autonomous school districts, regional development corporations, or special project implementation units.
Devolution— A third type of administrative decentralization is devolution. When governments devolve functions, they transfer authority for decision-making, finance, and management to quasi-autonomous units of local government with corporate status. Devolution usually transfers responsibilities for services to municipalities that elect their own mayors and councils, raise their own revenues, and have independent authority to make investment decisions. In a devolved system, local governments have clear and legally recognized geographical boundaries over which they exercise authority and within which they perform public functions.

Fiscal Decentralization
Financial responsibility is a core component of decentralization. If local governments and private organizations are to carry out decentralized functions effectively, they must have an adequate level of revenues –either raised locally or transferred from the central government– as well as the authority to make decisions about expenditures.
Economic or Market Decentralization— The most complete forms of decentralization from a government’s perspective are privatization and deregulation because they shift responsibility for functions from the public to the private sector.
Privatization— can range in scope from leaving the provision of goods and services entirely to the free operation of the market to “public-private partnerships” in which government and the private sector cooperate to provide services or infrastructure.
Deregulation— reduces the legal constraints on private participation in service provision or allows competition among private suppliers for services that in the past had been provided by the government or by regulated monopolies. In recent years privatization and deregulation have become more attractive alternatives to governments in developing countries. Local governments are also privatizing by contracting out service provision or administration.

Opportunities and Challenges in Decentralization
For effective decentralization of healthcare services in Myanmar, improvement of management capacity and clear understanding of the decentralization concept at all administrative levels is essential. Civil society inclusion in policy formulation, implementation and monitoring is necessary to ensure transparency, accountability and efficiency. Decentralization is an opportunity to improve public–private partnership as well as regulation of the private health care sector. There is also an opportunity to reduce the need for referral care by improving community healthcare centers in the era of epidemiological transition and increasing double disease burden. Decentralization processes in developing countries are facing a number of challenges, among them skills and capacity constraints, particularly for remote or conflict affected areas. Facing those challenges necessitate gradualism of reform, but also use of new approaches suggested by international practices. There are challenges to keep the quality of health information including data from the private sector. Outcomes of decentralization, also in terms of service delivery, do not depend solely on the intensity of decentralization but rather on how it is done. There are no easy recipes to ensure quality service delivery. Most possible recipes are not exclusive to one particular level but apply to all levels of health service provisions.

Suggestions in Myanmar Context
Policies for decentralization should be formulated through a need-based approach with the active involvement of the community, civil society, and ethnic health organizations in planning, budgeting, implementation and monitoring. These policies should provide decentralization framework ensuring adequate human and financial resources from central and local levels, regulating private sector involvement, supporting health information systems (HIS) at national and sub-national levels to collect, analyze and use data for health care quality improvement. Upgrading in primary care services, the human resource development and policy on staff deployment should be taken into consideration for retention of skilled staff and ensuring continuity of quality services distributed in equitable manner.

1. World Health Organization: Report of the Regional Seminar; Decentralization of Health-Care Services in the South-East Asia Region; Bandung, Indonesia, 6-8 July 2010
2. Global New Light of Myanmar Perspectives: Decentralization of healthcare needs coordinated effort; Date: September 11, 2019
3. Decentralization in health care; European Observatory on Health Systems and Policies Series; Josep Figueras, Martin McKee, Elias Mossialos and Richard B. Saltman; 2007
4. Asian Development Bank: Decentralization and Public Service Delivery in Asia; ADB Economics Working Paper Series; Giorgio Brosio; 2014
5. World Bank Institute: Decentralization Briefing Notes Edited by Jennie Litvack and Jessica Seddon


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