2 FRAMEWORK FOR HEALTH CARE REFORMS
2.3. DECENTRALIZATION OF HEALTH CARE
2.3.2. Benefits of Decentralization
Access rules
Targeting Defining priority populations Law or defined by higher authority
Several models for local choice
No limits
Governance rules
Facility boards Size and composition of boards
Law or defined by higher authority
Several models for local choice
No limits District offices Size and composition of
local offices
Law or defined by higher authority
Several models for local choice
No limits Community
participation
Size, number, composition, and role of community participation
Law or defined by higher authority
Several models for local choice
No limits
Table 2.2: Map of Decision Space (Bossert 1998: 1519)
Figure 2.5: Benefits of Decentralized Management of Health Care
2.3.2.1. Community Participation
The benefits of decentralization include primary health care goals. “Local Voice” can be translated as community participation, which is also one of the central demands of the Primary Health Care Approach (see above). The aim of community participation is eminent in most of the decentralization literature (Metzger 2001; Eckardt 1998), even if it is hidden under the heading of accountability (Cohen/ Peterson 1997). Metzger defines participation as the active involvement of population in one area in assemblies, data generation activities and transmission of information to local administration (Metzger 2001: 80). He further uses the Cornell framework for the analysis of participation (see above, Uphoff et al. 1979). In his opinion, participation is needed for the functioning of decentralization, because it facilitates accountability. To forecast the extent of participation researchers have to ask four questions: (1) to what extent is the population interested in participation; (2) how much participation is possible with the actual educational status of the population; (3) which possibilities for communication and information transfer for the implementation of participation exist; and (4) how can motivation for participation be made sustainable (Metzger 2001: 83). The questions already stress the importance of interest, knowledge, communication channels and motivation. Metzger uses the rational choice theory for the interpretation of interest in participation. Following this theory he concludes that participation takes place in anticipation of the benefits of social recognition, new communication channels, and to take pleasure in tasks associated with participation (Ibid.:
Source: Atkinson et al. 2000: 620 Quality
of Health Care Responsiveness
To Local Needs (Effectiveness/ Equity)
Accountability of Care and
Resources (Efficiency/ Equity) Autonomy
Benefits of Decentralization
Local Voice
Empowerment
84). It is crucial to distinguish between extrinsic motivation (expected benefits at the end) and intrinsic motivation (benefits through action as such). Therefore, participation can only take place in association with motivation. Eckhardt sees participation not only positive since the legitimation of participating individuals and groups is often diffuse (Eckhardt 1998: 39). However, she also acknowledges that more participation is positive if it generates more information. Hence, participation cannot replace political delegation but as an additional tool can enhance efficiency and rationality of planning for local provisions.
2.3.2.2. Prerequisites for Successful Participation
The large amount of theory on community participation as discussed in 2.2.1.2. and 2.3.2.1. points out several indicators which could be useful for the analysis of prerequisites for successful community participation. Indicators for this analysis have to be different from indicators like those measuring the degree of participation, because they assess conditions and not status (see 2.2.1.2.; Murthy/Klugman 2004; Table 2.1). Metzger identified interest in participation, actual educational standard, communication and information transfer, motivation, and sustainability as the guiding principles (see above;
Metzger 2001). Individual responsibility and education was also linked by Green, whereas information as the key to community participation was highlighted by Rifkin as well (Green 1992; Rifkin 1996; 2.2.1.2.). Further indicators include control over resources (Westergaard 1986; Rifkin 1996), accountability (Murthy/ Klugman 2004), and responsiveness (Atkinson et al. 2000).
While educational standard is important for questioning the extent of participation in communities; it is less essential for the analysis of predefined groups9. Interest in participation and motivation are connected (see above). Additionally it is experience of participation which affects motivation and interest, because experiences influence actions.
All indicators mentioned above are prerequisites for successful participation and have been discussed in detail in previous sections. Even though their value is clear, the question of measurability remains.
Table 2.3 defines a range for each indicator from low to high according to Rifkin’s approach of “top-down” and “bottom-up” community participation (Rifkin 1996; 2.2.1.2.).
Low on the one hand stands for a low chance for successful participation. No interest in participation, “top-down” communication within an organization and no information transfer between organizations, no responsiveness to community needs, no incentives or benefits for motivation, accountability only to higher government authorities, a “top-down”
approach in sustainability, control over resources as defined by law as well as no or bad experience of participation indicate that the prerequisites for successful community participation are not fulfilled. High on the other hand means a high chance for successful participation and is determined through the “bottom-up” approach. Interest in “bottom-up”
participation, “bottom-up” communication and information transfer, open responsiveness to all community needs, extrinsic and intrinsic motivation through incentives and benefits,
9 - Predefined groups for this analysis are NGOs and public health personnel. It can be rightly assumed that they have the required education, because their position requests it.
accountability to the community, sustainability which is determined through the “bottom-up” approach and community involvement, free control over resources and good experiences with participation signify that the prerequisites for successful community participation are satisfied. The moderate range of indicators describes a situation inbetween; first steps towards “bottom-up” community participation have taken place but the “top-down” approach is still influential. The practical usefulness of these indicators will be tested in chapter 4.
Table 2.3: Map of Participation
(adapted from Atkinson 2002; Murthy/ Klugman 2004; Metzger 2001; Rifkin 1996;
Westergaard 1986)
Indicator for successful participation
Range of indicators
low moderate high
Interest in participation
No interest Interested in top-down participation
Interested in bottom-up participation
Communication and Information Transfer
within an organization Top-down, limited information
Top-down and within the same hierarchy, selected information
Top-down, bottom-up and within the same hierarchy, all information between organizations No communication, no
information transfer
Top-down, only programme related
Top-down, bottom-up, demand oriented and culturally sensitive Responsiveness No responsiveness to
community needs
Responsiveness to community needs as defined by the
programme (top-down)
Open responsiveness to all community needs
Motivation for participation
No incentives/ benefits Incentives/ benefits by government (extrinsic)
Incentives/ benefits by government and
community (extrinsic and intrinsic)
Accountability To higher government authorities
To local government authorities
To community
Sustainability Top-down approach Top-down with
community involvement
Bottom-up approach, community involvement Control over resources Defined by law or higher
authorities
Several models for control over resources
Free control over resources Experience of
participation
No or bad experience Indifferent experience, participation was not helpful
Good experience, participation was helpful
2.3.2.3. Accountability
Participation also empowers people to demand better services and, thus, increases accountability through monitoring of services through the clients themselves. Cohen and Peterson state that political and legal oversight, institutional competition, and administrative mechanisms are needed to promote accountability (Cohen/ Peterson 1997:
12). Administrative mechanisms include monitoring systems (Ibid.). Monitoring can be done by a superior agency (the principal) or by the clients. All monitoring mechanisms need a sound information and knowledge basis. Accountability in turn “promotes the efficient and effective mobilization and management of resources.” (Cohen/ Peterson 1997: 5). While “effectiveness examines the benefits of healthcare measured by improvement in health; efficiency relates these health improvements to the resources required to produce them.” (Aday et al. 1998: 1). In the economical sciences efficiency is analysed through administrative costs. Administrative costs can be divided into coordination costs, organizational costs and information costs (Eckhardt 1998: 20).
Coordination costs arise when different administrative units have to work together. They incorporate costs between resorts within a political subdivision or local authority and costs between different authority levels. The more authority levels participate in decision making, the higher are the coordination costs (Ibid.). Organizational costs are expenses for establishment and maintenance of political and bureaucratic institutions. Therefore, administrative units need a minimum size to be viable. Information costs are the costs for investigation of demand for public services. The higher the degree of decentralization, i.e.
the closer the contact between the decision making levels of administration and the end users of services, the lower are the information costs (Ibid.).
2.3.2.4. Responsiveness
Responsiveness to local needs (effectiveness) and quality of health care are the two remaining indicators from Atkinson’s framework (see Figure 2.5). In health care research effectiveness has a clinical perspective where the emphasis is on “contribution of medical care to improving the health of individuals” and a population perspective where “the contribution of medical and non-medical (e.g. environmental and behavioural) factors to the health of communities” is assessed as a whole (Aday et al. 1998: 2). However, Atkinson attaches more importance to responsiveness of the health care system, therefore highlighting demand. This demand-orientated approach reminds of the Primary Health Care Approach which calls for primary health care “to respond to the expressed health needs of community” (see Box 1: 7). It is also in line with the equity goals of primary health care, namely equal access and equal utilization according to need (see above). Quality of health care incorporates the concepts of effectiveness, efficiency, and equity which have been described above. Hence, it is the extent of effectiveness and efficiency and of equity in health care which determine the quality of health care services.