Health system decentralization : concepts, issues and country experience

Abstract

Evaluates the extent to which decentralization can serve as a policy instrument for the improvement of a nations health system. Addressed to policy-makers and administrators, the book combines a literature review with an analysis of country experiences to define what decentralization actually means when applied to the organization and management of health services. While noting the many theoretical benefits of a decentralized health system, the book concentrates on the gap between the intentions and the reality, stressing facts and arguments that show why decentralization is never easily implemented and rarely brings immediate gains. Problems identified include the resistance of civil servants to a change in the power structure, the difficulty of persuading staff and their families to accept peripheral posts, and the risk that greater local authority will mean greater opportunity for patronage and corruption. Throughout, emphasis is placed on the need to accept the fact that reform requires a long-term commitment. The main part of the book consists of case studies of decentralization as experienced in Botswana, Chile, Mexico, the Netherlands, New Zealand, Papua New Guinea, Senegal, Spain, Sri Lanka and Yugoslavia. Apart from illustrating the different legal and administrative mechanisms that support decentralization, these studies also provide a rich inventory of the many practical and human factors that ultimately determine the success of reforms. The book concludes with an analysis of lessons learned from these experiences. Policies for raising revenue and controlling expenditure are identified as the most sensitive issues, followed by a number of practical problems with personnel