1. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Decentralization and Governance in Health Thomas Bossert, Ph.D. Harvard School of Public Health Health Governance Workshop Washington DC June 13, 2007

2. Decentralization and Our Governance Model Decentralization changes who in the state makes decisions: Local elected officials (devolution) Local district or provincial officials (deconcentration) It also defines who has authority over some providers and other health system entities And who can be held accountable and who is responsive to local patients/citizens, local participation, local NGOs

3. Why do countries decentralize? Political decision to reduce opportunities for concentration of power by authoritarian rulers Core Aquino in Philippines Improve the accountability and responsiveness of the local officials to preferences of the local population Better knowledge about the local conditions = better policies for addressing specific local needs. Improve the equity of allocations to localities

4. Decentralization also defines: How Much Choice over What Functions : Decision Space Approach Rules of governance

7. Decision Space Challenge What is the appropriate range of decision space that local officials should have? Need some choice to reflect local preferences and needs but not so much as to make poor technical choices May depend on the capacities (skills, education, staffing levels) of localities to make and implement good choices May depend on how accountable local officials are to the local patients.

8. Decentralization and Financing If done right, decentralization can improve equity of allocation of central government transfers to localities – appropriate policy process Decentralization can also improve the mobilization of local funding for health – an indication of local accountability. Responsibility for financing is a political decision

9. Expenditure Gap in Colombia: Financing and Equity

10. Some Best Practices Decentralization in Chile Equitably financed municipal primary health care systems Local financing around 30% Maintained highly effective control of communicable diseases and MCH Much of the system still dominated by central decisions Governance practices (low corruption, high transparency, respect for laws) are in evidence throughout the Chilean state

11. Some Best Practices (2) Decentralization of logistics systems in Guatemala and Ghana Better performance evident with: More local control over budgeting and forecasting More central control over inventory and information systems More local control over procurement under certain conditions (central bidding for decentralized procurement)

12. Capacity and Accountability Improvement PAIMAN study in Pakistan Study of variations in decision space, capacities and accountability in districts in Pakistan Find lack of congruence suggesting some districts need increased capacities in relation to decision space while others have sufficient capacities to take on more decision space Use findings to tailor capacity building and accountability and for evaluating the performance of interventions to increase capacity or change decision space

13. Pakistan Decision Space

14. One District: DG Khan Indicator TableFindingRecommendation Decentrali zation Decision Space1Above-average for all but HRSuggest more choice in HR Capacity2Below-average for HR and G&LPCapacity-building in HR and G&LP Accountability3Below-average for G&LPIncorporate accountability into capacity-building Above-average capacity 4Below-average for SO, S&OP, G&LP Capacity-building in SO, S&OP, G&LP for all staff OutcomesHR management 5Below-average for all staff, LHV and THQ hospital Capacity-building in HR Budget management 6Below-average for % health in district budget Suggest senior officials increase health budget Service delivery 7Below-average for RHC, SBA and ANC2 Specific PAIMAN advocacy and training SummaryNeed special initiatives in HR and accountability: develop a specific capacity-building program with more emphasis on HR and G&LP, incorporating more attention to accountability and participation and advice that can make more independent choices in HR Advocacy program for senior officials to increase health budget Link special initiatives and/or target PAIMAN training especially for RHC, SBA and ANC

15. Final Thoughts Decentralization processes are evolving in most countries – adapting and changing We need to know more about the relationships among: Decision space Capacities at local and central levels Accountability – conditions under which it works How do these relationships relate to improved governance: better performance, more responsiveness, better rule enforcement?