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Technical Seminar: Summary of key issues (28.11.97)
DECENTRALIZATION AND HEALTH SYSTEMS: AN OVERVIEW OF INTERNATIONAL EXPERIENCE
Moderator: Dr J. Kasonde, Special Programme of Research, Development and
Research Training in Human Reproduction, WHO, Geneva
Presenter: Dr K. Janovsky, Division of Analysis, Research and Assessment, WHO,
Geneva
Decentralization has been at the core of many recent health reforms, serving a
wide variety of objectives, such as improving the performance of health
systems, introducing competition and fostering solidarity. The actual meaning
and implementation of decentralization has been very context-specific. A study
was presented which assessed how countries understand and implement
decentralization strategies and what the effects in different circumstances
are. Twenty seven countries participated in the study, representing both
developed and developing nations.
There are different streams of decentralization. In some countries there are
shifts of responsibilities to district health management or to local
government
and sometimes new forms of public management (executive agencies, area health
boards, autonomous provider institutions) are established. In other countries,
decentralization has focused particularly on establishing new relations with
the private and voluntary sector. Decentralization has often been confined to
the health system, but has sometimes been part of broader public sector
reform.
Though the effects of decentralization are difficult to measure because of,
inter alia, the lack of data and often fragmented implementation,
decentralization is not a magic bullet.
**** There is no clear evidence that it has increased equity or strengthened
the focus on primary health care. ******
Though some health system functions may be better performed, it is also
evident
that other functions, such as the operation of drug programmes and research,
may benefit from centralization.
Experience indicates that regulatory frameworks and special implementation
units help to facilitate the process of decentralization. Diversity and
existing local structures have to be respected, and local capacity developed.
In addition, solutions have to be found for the often neglected dimension of
employment structures and the workforce.
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