Decentralization and recentralization: effects on the health systems in Lao PDR.

In Lao PDR, lack of skilled manpower and financial resources in the central government, plus the policy urging local authorities to be self-sufficient and self-reliant caused the central government to decentralize all sectors to the provincial level in 1987. After 1987, the provinces took over all responsibilities such as planning, financing and provision of health services, only informing the Ministry of Health (MOH) about their activities. Because of economic differences between the 18 provinces, health services became unequal between the richer and poorer provinces. Some provinces generated high revenues, leading to over spending. The decentralized system had some negative impacts on the health service. The technical and planning functions managed from the ministry level became separated from management and financial decision making at the local level, and the ministry lost influence on the direction of health policy. Salaries from the local government were often delayed. Because health budgets were not allocated centrally by the Ministry of Health, there were no mechanisms by which health resources could be distributed preferentially to poorer areas with greater need. However, donors continued to support health programs through the Ministry of Health, sending drugs, vaccines, and other supplies to the provinces. The implementation of decentralization faced many difficulties due to the lack of experienced staff and insufficient training required for practicing decentralization. Similar problems in other sectors, such as agriculture, education, and communication, caused the central government to retake control from the provinces in 1992. During the recentralization period, utilization of health facilities increased. The Ministry of Health set rules and established regulations to strengthen the health system. A cost-recovery system was introduced to obtain additional funds, and conditions in the provinces gradually improved. The unique situation of decentralization followed by recentralization provides an excellent opportunity for study. We reviewed documents relating to these periods and interviewed officials at all levels who were concerned with the process.

Phommasack B ，Oula L ，Khounthalivong O ，Keobounphanh I ，Misavadh T ，Loun ，Oudomphone P ，Vongsamphanh C ，Blas E ... -  《SOUTHEAST ASIAN JOURNAL OF TROPICAL MEDICINE AND PUBLIC HEALTH》

A review of health leadership and management capacity in the Solomon Islands.

Asante A ，Roberts G ，Hall J 《-》

Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan.

Health sector decentralization has been widely adopted to improve delivery of health services. While many argue that institutional capacities and mechanisms of accountability required to transform decentralized decision-making into improvements in local health systems are lacking, few empirical studies exist which measure or relate together these concepts. Based on research instruments administered to a sample of 91 health sector decision-makers in 17 districts of Pakistan, this study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as "decision space"), institutional capacities, and accountability to local officials. Composite quantitative indicators of these three dimensions were constructed within four broad health functions (strategic and operational planning, budgeting, human resources management, and service organization/delivery) and on an overall/cross-function basis. Three main findings emerged. First, district-level respondents report varying degrees of each dimension despite being under a single decentralization regime and facing similar rules across provinces. Second, within dimensions of decentralization-particularly decision space and capacities-synergies exist between levels reported by respondents in one function and those reported in other functions (statistically significant coefficients of correlation ranging from ρ=0.22 to ρ=0.43). Third, synergies exist across dimensions of decentralization, particularly in terms of an overall indicator of institutional capacities (significantly correlated with both overall decision space (ρ=0.39) and accountability (ρ=0.23)). This study demonstrates that decentralization is a varied experience-with some district-level officials making greater use of decision space than others and that those who do so also tend to have more capacity to make decisions and are held more accountable to elected local officials for such choices. These findings suggest that Pakistan's decentralization policy should focus on synergies among dimensions of decentralization to encouraging more use of de jure decision space, work toward more uniform institutional capacity, and encourage greater accountability to local elected officials.

Bossert TJ ，Mitchell AD 《-》

Managing mental health service provision in the decentralized, multi-layered health and social care system of Germany.

Bramesfeld A ，Wismar M ，Mosebach K 《-》

Governing decentralization in health care under tough budget constraint: what can we learn from the Italian experience?

In many European countries, since the World War II, there has been a trend towards decentralization of health policy to lower levels of governments, while more recently there have been re-centralization processes. Whether re-centralization will be the new paradigm of European health policy or not is difficult to say. In the Italian National Health Service (SSN) decentralization raised two related questions that might be interesting for the international debate on decentralization in health care: (a) what sort of regulatory framework and institutional balances are required to govern decentralization in health care in a heterogeneous country under tough budget constraints? (b) how can it be ensured that the most advanced parts of the country remain committed to solidarity, supporting the weakest ones? To address these questions this article describes the recent trends in SSN funding and expenditure, it reviews the strategy adopted by the Italian government for governing the decentralization process and discusses the findings to draw policy conclusions. The main lessons emerging from this experience are that: (1) when the differences in administrative and policy skills, in socio-economic standards and social capital are wide, decentralization may lead to undesirable divergent evolution paths; (2) even in decentralized systems, the role of the Central government can be very important to contain health expenditure; (3) a strong governance of the Central government may help and not hinder the enforcement of decentralization; and (4) supporting the weakest Regions and maintaining inter-regional solidarity is hard but possible. In Italy, despite an increasing role of the Central government in steering the SSN, the pattern of regional decentralization of health sector decision making does not seem at risk. Nevertheless, the Italian case confirms the complexity of decentralization and re-centralization processes that sometimes can be paradoxically reinforcing each other.

Tediosi F ，Gabriele S ，Longo F 《HEALTH POLICY》