Dr. Shahram Yazdani Intermediary Measures in Health System Performance Assessment.
Dr. Shahram Yazdani Decentralization. Dr. Shahram Yazdani Organizational Reform in Health System...
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Transcript of 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
Policy MakerGovernorStrategic Manager
Administrative Manager
ProblemsNeedsRequirements
Interventions
Dr. S
hahra
m
Yazd
ani
Administrative Decisions
Administrative Decisions
Administrative Decisions
Administrative Decisions
Administrative Decisions
Administrative Decisions
Dr. S
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Yazd
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Realisti
c
Holisti
c
Characteristics ofAdministrative
Decisions
Dr. S
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Yazd
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SensorsActors
Policy MakerGovernorStrategic Manager
Administrative Decisions
ProblemsNeedsRequirements
Dr. S
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m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
Administrative Decisions
ProblemsNeedsRequirements
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
Administrative Decisions
ProblemsNeedsRequirements
Interventions
Internal Sclerosis
Administrative Work Overload in HML Sacrifice of Strategic Functions at HML
Irrelevance of Decisions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
ProblemsNeedsRequirements
Administrative Decisions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
ProblemsNeedsRequirements
Administrative Decisions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
ProblemsNeedsRequirements
Interventions
Administrative Decisions
Incoherence in Operations Disintegration of Policies from Functions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
ProblemsNeedsRequirements
Administrative Decisions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
ProblemsNeedsRequirements
Administrative Decisions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
ProblemsNeedsRequirements
Interventions
Administrative Decisions
Policy-Framed Problem-Relevant Decisions
Dr. S
hahra
m
Yazd
ani
SensorsActors
Policy MakerGovernorStrategic Manager
Administrative Decisions
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
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Yazd
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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
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Yazd
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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
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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
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Yazd
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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
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Yazd
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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
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m
Yazd
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Types of Decentralization
A common taxonomy classifies decentralization by three categories of devolved responsibilities: Political Administrative Fiscal
Dr. S
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Yazd
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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
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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
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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
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Yazd
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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
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Yazd
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Policy Impressions
Field Requirements
Manageria
l C
apacitie
s
Level
Ince
ntiv
esDecisions
Govern
an
ce
Inf. S
ys.
Capacity Building Inc. Mismatch
Dr. S
hahra
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Yazd
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Policy Impressions
Field Requirements
Manageria
l C
apacitie
s
Level
Ince
ntiv
es
Decisions
Govern
anc
eInf. S
ys.
Capacity Building Inc. Mismatch
Dr. S
hahra
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Yazd
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Policy Impressions
Field Requirements
Manageria
l C
apacitie
s
Level
Ince
ntiv
esDecisions
Govern
anc
eInf. S
ys.
Capacity Building Inc. Mismatch
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.
Capacity Building Inc. Mismatch
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?