“A transfer of authority to make policies
and decisions, carry out management
functions and use resources from central
government authorities to local
government, field administration, semiautonomous corporations, area-wide or
regional development organisations,
functional authorities, sub-ordinate units
of government or specialised functional
authorities”
(Cheema & Rondinelli, 1983)
Decentralization
By
Dr Arshad Usmani
Lahore, Pakistan
Historical Perspectives
1950 – 1960 General strategy for the provision of
public services in Africa under Colonial
Administration
1970 – 1980 Under adoption of Rural Based
Strategy by Donors & Governments,
Decentralisation considered appropriate for
effective Management, Planning and Community
Participation
1980 – 1990 New-Right Thinking approach i.e.
Privatisation
Limitation of state role
Quasi- market in public sector
Decentralised service provision
1. A component of Health Sector Reforms
(HSR) programme
2. Scarce financial resources
3. Low efficiency & quality of health care
4. Political will
5. Pressure from donors
6. To improve PHC services
(Cont…)
Rationale
(Cont’d)
7. Key principle to implement Primary
Health Care policy because:

Management near to PHC facilities

Less prior permission from central government

Increased Community Participation and resource
mobilisation

Innovative approach could be adopted without
involving whole country

Effective implementation in remote area

Inter-sectorial co-ordination

Committed & motivated workforce
Rationale for Decentralization:
“Classical Agenda”
Decentralization is predicted to improve
health sector performance:
 Improve allocative efficiency
 Improve production efficiency
 Improve quality, transparency,
accountability, legitimacy
 Greater equity
Rationale for Decentralization:
“Real Agenda”
Mostly motivated by political concerns:
Part of the democratisation process as
discredited autocratic central regimes are
replaced by elected ones under new
constitution- Latin America
Spread of multi-party political systems is
creating demand for more local voices in
decision making- Africa
Pressures from regional & ethnic groups for
more control & participation in the political
process- Ethiopia
Rationale for Decentralization:
“Real Agenda”
Attempts to keep country together by
granting autonomy to all localities, by
forging ‘asymmetrical’ federation- Uganda
Absence of any meaningful alternative
governance structure to provide local
government services- East Europe
Need to improve service delivery to large
populations and the recognition of the
limitations of central administration- East
Asia
Pass on responsibility to carry out programs
to the field because the central levels have
run out of options to improve health services
- Pakistan
Elements of Decentralization
Decentralization inherently implies the
expansion of choices at the local level
Amount of choice transferred from
central level to institutions at
periphery of health systems
What choices local officials make
with their increased discretion; and
What effects these choices have on
the performance of the health system
Prerequisites for
Effective Decentralization
System of accountability that relies on
transparent information, enabling
community to monitor performance
Instruments for decentralization constitutional, legal, institutional and
regulatory framework that allow
effective & equitable services in line
with political objectives
Capacity building of local staff to
undertake new responsibilities, and
development of management & support
systems
Different forms are not mutually exclusive;any model
have characteristics of different types superimposed
upon one another
Deconcentration*
Functional
Prefectoral
• Integrated
• Un-integrated
Delegation* to semi-independent bodies
Devolution*
Decentralization to local bodies
Federalism
Public Sector Market
Fragmentation
“Transfer of functions with in the
central government hierarchy through
the shifting of workload from central
ministries to field officers, the creation of
field agencies or the shifting of
responsibility to local administrative
units that are part of the central
government structure” (Collins, 1994)
Deconcentration:
Salient Features
• Shifting of power from the central
offices to peripheral offices of the same
administrative structure
• Semi autonomy to field officers for
routine decision-making
• Some planning functions according to
central government guidelines
Example: Many Developing Countries
 Field officers directly linked &
controlled by the ministry
 Resources, guidelines and decisions
about recruitment, selection, transfer
and promotions conveyed from vertical
hierarchy
 Community need not well perceived
Example: - Ex - District Health System in
Punjab Health Department
Field Officers are Sub-ordinate to Prefect
(Commissioner, Governor)
Communication through Prefect.
Example:
British India before Independence
Where:
1. Collector/ District Commissioner exercised
powers of Finance & Judiciary
2. Double Control system i.e.
a. Technical matters of field officers e.g. recruitment,
pay, training, promotion, transfer controlled by
the Ministry
&
b. Performance accountability to the Prefect
Semi-independent Agencies
Functions are shifted to regions or functional
development authorities, parastatal organisations
or special project implementation units
Independent from central government rules &
regulations in personnel, recruitment, budgeting or
procurement
Normal attachment exists with the Central
Government
Examples:
Autonomous medical institutions in Punjab
Social Security Organisations in
Latin America
“Transfer of functions or decision-making
authority to legally incorporated local
governments, such as states, provinces,
districts or municipalities”
(Collins, 1994)
“Shifting of responsibility and authority
from central offices of the ministry of health
to separate administrative structures still
within the public administration (provinces,
states, municipalities)”
(Bossert, 1995)
Cont….
A Devolved Unit has
Cont….
Budgetary allocation
Freedom of Revenue generation &
Expenditure
Elected members
Conducive to Community Participation
More Accountability to people
Example:
LGP 2000 in Pakistan
Decentralisation to Local
Bodies With Mixed Central and Local /
Regional Representation
Local bodies (District Development Councils) or
regional bodies are decentralised units formed by
locally elected members and central government
representatives
Semi-autonomous bodies
Dependent on central government for financial
resources & planning guidelines
Bound to national policies
Varying degree of power for development functions
Example:
District Development Councils in Tanzania
Decentralised units receive powers from
national government & constitution
Example:
States in USA & India
Market mechanisms are introduced in
the health care delivery
Purchase & Providers have decisionmaking authority
Example: National Health Service In UK
 Increased Community Participation in planning
& management of health services
 Accountability of health staff about their
performance
 Increased Inter-sectoral Co-ordination leading
to utilisation of other resources for improving
health services
 Improved Efficiency, Effectiveness and Quality
of the health services
 Reduced Infant and Maternal Mortality rate
 Decreased Morbidity and Mortality
rate in the area
Decentralization: Problems & Issues
Weak Local Management
Lack of Skilled Staff
Weakening of the Ministry
Planning Implementation Problems
Equity in the delivery of services
Unequal Resources
Political domination
Local Elites Control
Decentralization: Conclusions
Inherently implies expansion of choices at
the local level
Is predicted to improve health sector
performance through increased efficiency,
quality of services, accountability, equity
Could be political, administrative, fiscal,
market - major overlaps
Conclusions:
Cont….
Is not a single transfer of a block
of authority & responsibility, but a
set of functions that pertain to
finance, service organisation,
human resources, access,
governance
Preliminary data indicates that
results have been mixed at best
Issue at hand is how to better
adopt decentralization policies to
achieve national health policy
objectives
Decentralization:
‘Not a Magic Bullet’
 Benefits: Improved delivery & utilisation of
services; enhanced capacity for district health
planning, increased funds etc
 Constraints: Conflict between civil servants
& politicians, procedures not streamlined;
retrenchment of staff undermines performance;
resistance of health personnel; problem of
defining role of DoH vis-à-vis local government
An Agenda for Effective
Decentralization
1. Why is decentralization being introduced?
2. What form will decentralization take &
how will relations of authority be set out?
3. At what level in the governmental system
should decentralization of resources &
functions been made to?
4. Has adequate attention being paid to the
role of center in the decentralized system?
5. What resources, functions & authority will
be decentralized?
Agenda….
Cont….
6. Has a program of district health
management strengthening been agreed?
7. Does decentralization facilitate the
democratization of health management &
planning?
8. Does decentralization contribute to the
development of intersectoral
coordination?
9. How does decentralization fit into the
development of national planning?
10.What provisions have been made to
ensure the compatibility of
decentralization with the principle of
equity?
Conclusions:
Cont…
Decentralized small management
units are:
• Faster
• More Focused
• More Flexible
• More Friendly, &
• More Fun
(Handy 1994)