Another argument frequently adduced for some central intervention in health care is the more efficient pricing of inputs by a single purchaser of health care. National bargaining is believed to secure more favourable contracts with service providers as compared with a situation in which local purchasers may have to accept the prices set by monopoly suppliers. https://www.york.ac.uk/media/economics/documents/discussionpapers/2005/0510a.pdf Centralization and decentralization are not "either-or" conditions. In most countries an appropriate balance of centralization and decentralization is essential to the effective and efficient functioning of government. Not all functions can or should be financed and managed in a decentralized fashion. Even when national governments decentralize responsibilities, they often retain important policy and supervisory roles. They must create or maintain the "enabling conditions" that allow local units of administration or non-government organizations to take on more responsibilities. Central ministries often have crucial roles in promoting and sustaining decentralization by developing appropriate and effective national policies and regulations for decentralization and strengthening local institutional capacity to assume responsibility for new functions. The success of decentralization frequently depends heavily on training for both national and local officials in decentralized administration. Technical assistance is often required for local governments, private enterprises and local non-governmental groups in the planning, financing, and management of decentralized functions. http://www.ciesin.org/decentralization/English/General/Different_forms.html Literature on low- and middle-income countries provides little evidence that decentralization has resulted in creation of new posts, job re-profiling, or an improved staff mix . A tightly centrallycontrolled civil service may not allow local managers to create new posts, or their budget may be insufficient to increase staffing levels, even if they have this power. Planning skills, particularly human resource skills, are generally weak at the peripheral level in most developing countries. Human resource planning responsibilities are often transferred to local managers without providing them with adequate skills for these roles. Human resource databases frequently deteriorate as a result of decentralization, further hindering local and national planning [4, 5]. In the United Kingdom, a review of historical staffing patterns did take place after decentralization to the NHS trusts, but as Buchan reports, this created a tension between local health managers concerned about costs, and health professionals whose main interest was patient care . Decentralization can threaten the concept of equal pay for equal work. National employees may be compensated differently from decentralized employees. Tang et al. report that in China, personnel working in state-owned and devolved health centers are paid differently . Evidence from the Philippines shows that salaries of devolved health workers decreased in the early years of devolution to local government units . As decentralized units are given more financial autonomy, and as flexibility in pay bargaining increases, health workers doing similar jobs but in different decentralized units will be remunerated differently. This is emerging in Uganda, where salaries are set nationally but staff benefits and allowances locally . Considerable differences in salary levels and other terms of employment have also emerged in South Africa, where salary levels are determined locally. [Personal communication with Dr. Jon Rohde.] Pensions have arisen as an important issue for health workers in countries such as Zambia, which have tried to break the rigidity of the civil service system by making health workers local employees. Public sector employees are usually included in a large national pension scheme, covering all civil servants. The contributions are paid by the national government, and are part of benefit packages that have been negotiated with labor unions. Under devolution, local authorities may be reluctant or out-right refuse to accept the financial burden of paying for the pensions of prior civil servants. Thus, a new pension fund to cover local employees may be needed. In Jamaica, for example, regionally hired health workers now belong to a private pension fund. Contributions to it come both from the regional health authority and the individual employee. Previously, the government paid the total contribution. Most health workers value job security highly. If their employment status changes from national civil servants to local employees, they want to maintain at least the level of benefits, seniority, and status that they had before decentralization. They prefer minimal changes in the location of their work, job content or reporting relationships. Decentralization and accompanying reform processes have brought an increased level of instability to employment. In countries of the Latin American region, "rationalization" of public sector personnel has resulted in a massive reduction of staff through separation, early retirement, merging of staff posts, etc. ILO reports that overall "there have been significant increases in the numbers of people employed under more precarious forms of employment contract..." and that "...traditionally high levels of job security in the health sector have changed". While more flexible employment patterns are rapidly emerging in Latin American and Asian countries, they are still rare in Africa [12, 24, 25]. Decentralization is also changing the degree of civil service protection that health workers have against unfair hiring, disciplinary and work practices. National civil service rules no longer apply, when health workers are hired under local terms and conditions of service. Where power has been devolved to local governments, health workers are more exposed than before to local political pressures and demands, even if they remain part of the national civil service. Under privatization, health workers are governed under general private sector labor laws, and no civil service protections apply to their employment. https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-2-5 The study reported a number of challenges from the perspective of SUs and providers. Problems arising from the relationship between the centre and local authorities, and within the local authorities, were also identified. Key challenges were identified at two levels—policy level and operational level. At the policy level, there was a problem of HR policy. For example, local staff are still under the control of central management. Second, there was no policy that focused on how to build institutional capacity within local bodies in terms of developing bottom-up approaches, including inclusive planning and its institutionalization. Third, coordination between and among different stakeholders both at central and local levels was problematic. At the operational level, staff career progression, lack of clarity on the role and accountability of new management committee structures, poor infrastructure, the influence of party politics, resource generation and mobilization, and central control over local priorities and budgeting were reported to be the major challenges. http://jpubhealth.oxfordjournals.org/content/32/3/406.full Political and process dimensions. As many observers have noted, decentralization is profoundly political. Groups with a vested interest in the status quo and who will lose power, influence, and resources as a result of administration or fiscal decentralization often oppose it. While there may be strong technical arguments in favor of health sector decentralization, without attention to the politics of decentralization, reforms may fail to yield the expected increases in efficiency, effectiveness, and equity. These political dynamics are especially important because decentralization reforms do not take place overnight. The reform process can be an extended one, even if the implementation strategy aims for a comprehensive, big push. Without signs of success, support for decentralization may wane, leading to reversals. The process dimension of decentralization highlights the importance of stakeholder participation, effective communication, and political will. http://www.phrplus.org/Pubs/IS1.pdf Whatever the institutions used for decentralization, the ensuing process of decision-making will be highly charged politically. The choice of representative government as a means of delivering health services locally builds constitutional politics into the decision-making process, especially the recruitment of officeholders and the choice of policy priorities. In PNG, for example, decentralization was found to be associated with increased politicization. Devolution opens up opportunities for corruption and political patronage though these are by no means the exclusive preserve of local government, being found in other forms of decentralization http://www.swisstph.ch/fileadmin/user_upload/Pdfs/swap/swap236.pdf Frumence, G., Nyamhanga, T., Mwangu, M., & Hurtig, A.-K. (2013). Challenges to the implementation of health sector decentralization in Tanzania: experiences from Kongwa district council. Global Health Action, 6, 10.3402/gha.v6i0.20983. http://doi.org/10.3402/gha.v6i0.20983 Mohammed, J., North, N., & Ashton, T. (2016). Decentralisation of Health Services in Fiji: A Decision Space Analysis. International Journal of Health Policy and Management, 5(3), 173–181. http://doi.org/10.15171/ijhpm.2015.199 Kolehmainen-Aitken, R. L. (2004). Decentralization's impact on the health workforce: Perspectives of managers, workers and national leaders. Human Resources for Health, 2(1), 1. Omar, M. (2002). Health Sector Decentralisation in Developing Countries: Unique or Universal!. World Hospitals and Health Services, 38(2), 24-30. Mills, Anne, et al., 1990, Health System Decentralization: Concept, Issues and Country Experience, Geneva, World Health Organization Prianto, B. (2014). Decentralization in the Provision of Health Care Services: Study on the Provision of Regional Health Insurance (Jamkesda) In Malang Regency East Java Province. Public Policy and Administration Research, 4(10), 57-71. First being the fact that decentralization has to be recognized as a political process. 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DECENTRALIZATION IN THE JAMAICAN HEALTH SECTOR: A PERFORMANCE PERSPECTIVE. Social and Economic Studies, 51(3), 27-39. Retrieved from http://www.jstor.org/stable/27865289 Mullings, J., & Paul, T. J. (2007). Health sector challenges and responses beyond the Alma-Ata Declaration: a Caribbean perspective. Revista Panamericana de Salud Pública, 21(2-3), 155-163. World Health Organization. (2000). Health Sector Reform: Issues and Opportunities. World Health Organization. (1989). Constitution. Couttolenc, B. F. (2012). Decentralization and governance in the Ghana health sector. World Bank Publications. Pp 21-29 Saltman, R., Busse, R., & Figueras, J. (2006). Decentralization in health care: strategies and outcomes. McGraw-Hill Education (UK). Pp 67-69 Saltman, R. B., Figueras, J., & Sakellarides, C. (1998). Critical challenges for health care reform in Europe. McGraw-Hill Education (UK). Pp308-319 Cassels, A. (1995). Health sector reform: key issues in less developed countries. Journal of International development, 7(3), 329-347. Mills, A., Vaughan, J. P., Smith, D. L., & Tabibzadeh, I. (1990). Health system decentralization: concepts, issues and country experience.