1. Felix Awantang Matar CAMARA Vincent Joret Improving Health Services in a Devolved Government System DISC Décentralisation et Initiative de Santé Communautaire « Decentralization and Community Health Initiatives »

2. Three key questions s What were the key elements of decentralization in Senegal? s What were the major issues for the central and local governments and how were they resolved? s How has the USAID program supported the decentralization process?

3. Elements of Decentralization s Administrative/technical s Political: democratically elected leaders s Budgetary/fiscal: transfer of budget authority

4. Senegal Profile - 1999 data s Population: 9,529,029 (estimated) s GNP per capita: $550 s GNP Per Capita Growth Rate: 1.6% per year s Urbanization Rate: 45% s Adult Female Illiteracy Rate: 70% s Infant Mortality Rate: 68/1000 s Total Fertility Rate: 5.7 s Maternal Mortality: 510/100,000

5. Decentralization before 1996: A favorable environment for health development (1) s Strengthened local health services: the PHC agenda Î Sine-Saloum rural health project supported by USAID Î Pikine periurban experience supported by the Belgian Cooperation Î Reorientation of public interventions in health towards preventive and outreach services Î Strengthening the rural health infrastructure and human resources

6. The 1996 Decentralization Reforms: Strengthening local decision-making s A new political local government unit (LGU) is created, the region - 10 regions in Senegal s The region, the commune and the rural community ‘freely administer’ their local affairs s There is no hierarchical relationship between LGUs s Central Gov’t monitors budget compliance for various govt units. Corrective guidance for future.

7. The 1996 Decentralization Reforms: Devolution of 9 sectors to LGUs including health and population s Primary financial mechanism was to transfer affected Ministry funds directly to LGUs through the “Fonds de Dotation” s The design of the devolution reforms did not take into account the organization and financing of the health system s These changes were occurring in an environment where health improvements were slowing down or reversing

8. Pre-project situation assessment (2) s The local government units did not take responsibility for health services. Î No new ideas, no local health planning s The MOH did little to adapt to the new order. Î District and Regional Medical Officers were poor politicians Î District Medical Officers demonstrated no real management skills (process over substance) s Local representatives of the central government (Preféts, Governors, etc.) did not play their roles.

9. Technical linkage Urban LGU Rural LGU Health post Health hut Urban LGU The money allocated to all health structures of the district is transferred to the mayor of the LGU where the referral hospital is located Health district Organization in Senegal

10. Project Strategies s Budgeting as a political tool s Increasing Communication s Implementing the new vision s Putting District Associations (G.I.C) in place s Re-inforcing the « Comités de Gestion » s Financing scheme (Matching)

11. Budgeting as a Political Tool s DISC works with DMOs to develop global budgets in 15 districts. Î Opportunity to train DMOs, locally elected officials and representatives of central Gov in devolution of health s These 15 DMOs become much stronger in their political debates with local officials. s DMOs become more able to defend budgets in the new political environment.

12. Increasing Communication s Initially done person by person. s Regional, District and Communal level meetings to discuss the place of health in the devolved system of governance. s As understanding between the various parties grows, conflicts are reduced. s Goal is to find middle ground with a mutual respect for the responsibilities and needs of all sides.

13. Implementing the New Vision s Going to the level of the Health District is not sufficient. s The community, through its existing systems of governance, is now contributing in real ways: Î Mobilizing new local key players( women,youth ) Î Assessing and planing local health needs and affordable solutions Î Promoting ownership through $ contributions

14. Putting District Associations in place s Composed of elected representatives from all local government units in the geographical area of one health district. s MOH has a consultative role. s Should evolve to a “Groupement d’Intêret Communautaire (GIC) of the health District”, which will have legal standing

15. Re-inforcing the ”Comités de Gestion” s Defined by decentralization texts. Î Mayor or Rural Community President Î Another representative of LGU Î DMO or ICP Î President of Health Committee Î Health Committee Treasurer s Sous-Prefêts working to help establish the committees.

16. Financing Scheme (Matching) s Co-payments are based on locally generated tax revenues, sliding scale of USAID match ranges from 400% to 25%. s Central “fonds de dotation à la décentralisation” are also matched at 20% if the health part is entirely used for local health needs s Community plans financed through both above mentioned sources require signed agreement among multiple actors at local, district and regional. s Community plans become the building stone of Health District Plans. s Overall System is Performance-based.

18. Successes to Date s By providing “real” data, the project contributes greatly to shaping the discussion on the impact of devolution on the periphery. s By discussing these real data in public meetings, the project contributes greatly to foster good governance and transparency. s MOH now involved after early disinterest. s High participation by LGUs in the financing scheme. s Other donors (notably the KFW) are following USAID’s lead.

19. Linkage between DISC’s and USAID/Dakar’s Strategic Objectives s DISC’s activities directly address the third Health and Pop I.R. - health financing, increased local revenue generation for health, etc. s The financing scheme also meets quantitative targets for improved services through the “performance” aspect of the grants system s The DISC activities directly address all 4 of the I.R.s in the Mission S.O., which addresses improved governance in a decentralized system.

20. Challenges: s Increase the understanding by all actors involved in decentralization process. s Increase communication among the various actors. s Explain and advocate Decentralization laws and regulations. s Unify competing “visions”. s Have the actors (MDOs,LGUs and Central Gov. Representatives) play their roles. s Development of budget allocation formula