REGIONAL COMMITTEE Fifty-fifth Session
Provisional Agenda item 9.1 SEA/RC55/16 11 September 2002
CONSIDERATION OF THE RECOMMENDATIONS ARISING OUT OF THE TECHNICAL DISCUSSIONS ON “MANAGEMENT OF DECENTRALIZATION O F HEALTH CARE”
SEA/RC55/16
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INTRODUCTION
TECHNICAL DISCUSSIONS on “Management of Decentralization of Health Care” was held on 6 September 2002. Dr Kyi Soe, Director-General, Department of Health Planning, Ministry of Health, Myanmar, was elected Chairperson and Dr Deddy Ruswendi, Head, Center of Health Policy Analysis, Ministry of Health, Indonesia, as Rapporteur. The Agenda and Annotated Agenda (SEA/PDM/Meet.39/TD/1.1 and 1.2 respectively) and the working paper for the Technical Discussions (SEA/PDM/Meet.39/TD/1.3) formed the basis for the discussion. 1.1 Introductory Remarks by the Chairperson
WELCOMING the participants and representatives of nongovernmental organizations, the Chairperson highlighted the further need for evidence-based information and practical experiences from the countries in order to understand the process and implementation of decentralization of health care and to provide appropriate support to countries. He stressed that the primary intention of decentralization of health care is to improve efficiency, quality and equity. Therefore, every effort should be made to ensure that the above objectives are achieved to improve the health status of people, particularly the poor and marginalized sections of the population. However, he said that the experiences so far are mixed. He urged the participants to carefully analyze the prevailing situation in the countries and provide suggestions for future improvements. 1.2 Introduction of the Working Paper on Management of Decentralization of Health Care
DR MONIR ISLAM, Director, Family and Community Health, WHO/SEARO, presented a summary of the working paper. He highlighted the rationale for countries adopting the process of decentralization of health care services. He elaborated on the various forms of decentralization, emphasizing that in the regions countries are at different stages and levels of the decentralization process. Dr Islam explained, that for successful implementation countries need to fulfill some basic conditions like political commitment to fiscal decentralization, development of appropriate and adequate human resources, and establishment of an in built system of monitoring and evaluation. During the implementation process, countries must maintain or further improve efficiency and quality, ensuring equitable access to health care services. He explained that a step-wise implementation may be more appropriate as lessons learnt and capacity built from such implementation can help improve services in other districts or regions of the same country. The central government, particularly the Ministry of Health, needs to play a crucial role to ensure the success of decentralization. Significant achievements were made and lessons were learnt during the decentralization of health care in the Region. However, a lot needs to be achieved in sustaining political commitment and leadership, building appropriate capacity for fiscal responsibility and management, adequate human resource development and deployment for health care delivery, adequate supervision, monitoring and evaluation. The member countries in the Region, considering the prevailing socio-cultural, political and economic situation, may need to consider an appropriate mix of approaches in implementing decentralization. The Regional Office will be ready to provide evidence-based information and technical support to achieve the objectives of decentralization to improve the health of the people particularly, the poor and vulnerable section of the population.
2.
DISCUSSIONS
SEA/RC55/16 Page 2 DURING the general discussion it was clear that some form of decentralization was practiced in every country. Different countries had different experiences, successes and constrains in this process. It was clear that the question was not whether or not to decentralize health care services but how to design and implement the process taking into consideration the prevailing situations in each country to achieve set goals and objectives of the national health policies. The participants were divided into three groups to further discuss the critical issues related to decentralization. The group discussions covered the following issues: • Experiences in Member Countries Ø Ø Ø Ø • Policy formulation Implementation-maintaining equity, quality and efficiency Monitoring and evaluation Lessons learnt
Mechanisms for technical cooperation and exchange of expertise among Member Countries to improve management of health care in decentralized settings Identification of needs for evidence-based information and areas for future research needs Role of WHO/SEAR
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The following are the high lights of the group discussion: • The groups emphasized that decentralization is not a new political, administrative or management process which many other sectors had experienced. In some countries, even constitutional changes were made to achieve decentralization of health care within a given period of time. The decentralization process in the health sector is fairly new and ministries of health need to learn from other sectors where decentralization is either in place and functioning successfully or has been completed. Decentralization should take place at the centre and percolate to the periphery, within the overall governmental system across all sectors, rather than in the health sector in isolation. It was also felt that forms of decentralization may be necessary in different countries. People at the local level should be actively involved in planning, implementation and monitoring. Advocacy was needed to put health on the local priority list and increase awareness among people to demand for their rights. Partnerships with NGOs and civil society should be promoted. In the process the Ministry of Health needs to play a very important role in defining policies, setting guidelines (financial and technical), maintaining quality and ensuring equity. The ministry will need to adopt various mechanisms to deliver at least essential health care services to all sections of the population, particularly the poor and marginalized. There should be central control in regulating profit and non-profit making organizations including NGOs. Support from donors and other partners should be coordinated by the ministry.
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The health ministry should be responsible for specialized health care services and medical supplies in order to make sure the population has equitable access to necessary and quality care services. Human resource development is a critical issue for the success of decentralization and needs to go hand-in-hand with adequate resource allocations and retention of some income generated in local settings. The centre should also play an important role in basic education and training, with the local authorities taking the responsibility for in-service training or retaining the existing pool of human resources. An efficient division of responsibility among different levels is necessary but the responsibilities, particularly at the lower level, must match its capability in respect of necessary and appropriate expertise and human resources. Health sector spending at the local level was gradually decreasing because of a lack of understanding, information and advocacy regarding the importance of investment in health. It was felt that the proportion of public sector spending allocated to the health sector under decentralization needs to be determined particularly at the level of selfgoverning local authorities. The centre, in consultation with local governments may need to make appropriate legislative and/or administrative arrangements for the level and distribution of health spending and local discretion in expenditure decisions. In few countries such initiatives are already in progress. Implementation of decentralization should be a step-wise process where WHO can play an important role in providing evidence-based information and technical support in coordination with other partners. WHO may also facilitate identification of technical deficiencies and assist in human resource development. WHO needs to facilitate and promote coordination among research institutions in Member Countries through use of WHO collaborating centers and sharing of experience and information, acting as a clearing house of information. CONCLUSIONS AND RECOMMENDATIONS
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DECENTRALIZATION is not a new process in countries. Health sector decentralization, although new, needs to take into account ongoing processes of decentralization in other sectors. Health problems are not the same across societies and cultures; health and social services are organized differently; the democratic process and socio-economic conditions are different; public versus private providers, including NGOs and Community Based Organizations (CBOs), are playing different roles; and countries or even different states within a large country are at different stages of development. Therefore, the most appropriate form of decentralization will depend on the individual country situations. • WHO should assist Member Countries in reviewing and analyzing ongoing implementation of decentralization of health care services. Evidence-based information and lessons learnt should be documented and disseminated to Member Countries. Advocacy to policy makers should be intensified to increase adoption of appropriate public health policies and increased and sustained political, financial, administrative and management support. The central government, particularly the Ministry of Health, should play an important role in defining the roles and responsibilities of different levels and work
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SEA/RC55/16 Page 4 in close collaboration with local governments. • Similarly, efforts should be intensified at the community level to promote better understanding of the rationale and process of decentralization and to increase their active participation. Assessment of human resources needed for effective implementation of decentralization should be carried out and human resource development and deployment should be enhanced accordingly . An inbuilt system of monitoring and evaluation needs to be established at all levels of the health care system to ensure efficiency, quality, equity and accountability. WHO should provide necessary technical support to the Member Countries in coordination with respective governments and other partners. Adequate support should be provided to carry out appropriate research and to strengthen dissemination of research findings.
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CONTENTS Page 1. INTRODUCTION ...............................................................................................................1
1.1 Introductory Remarks by the Chairperson ........................................................................1 1.2 Introduction of the Working Paper on Management of Decentralization of Health Care ....................................................................................................................1 2. 3. DISCUSSIONS ..................................................................................................................2 CONCLUSIONS AND RECOMMENDATIONS .................................................................3