Country Profile Case Study

Country Profile Case Study

ASSESSING THE RATIONALE FOR, AND FORMS OF, DECENTRALISATION

LucyGilson

CentreforHealthPolicy UniversityoftheWitwatersrand Johannesburg,SouthAfrica

Acknowledgement:This case studywas prepared bythe Centre for Health Policyfor the World Bank

Institute,aspartoftheFlagship Program on Health Sector Reform and Sustainable Financing.

This case studymaybe copiedandusedinanyformal academic programme. However, it must bereproducedwithappropriate acknowledgmentofthe author(s).

Assessing the rationale for, and forms of, decentralisation

OBJECTIVES

• toreviewthedifferingexperiencesofselectedcountrieswithrespecttotheir rationaleforinitiatingdecentralised healthmanagement andthetypesof decentralisationinitiated;

• tocompareandcontrastexperiencesofthecountriesprofiledwithparticipants’

ownexperiences;

•toprovideanalyticalframeworksforunderstanding differenttypesof,and approachesto,decentralisation.

PROCESSOFANALYSIS

Participantsaredividedintosmallgroups,eachof whichis thenallocated2-3country profiles.Itis suggestedthateachindividualreadsoneof theprofilesallocatedtotheir groupinadvance ofthesession,andsocomesprepared todiscuss withgroup colleagues. Groupworktimewillfocusoncomparingandcontrastingdifferent country experiences.The following questions provide a starting point for these discussions.

QUESTIONSTOCONSIDERINANALYSINGCOUNTRYPROFILES

Pleaseconsiderthesequestionswhilstreadinganddiscussing thecountry experiences, drawingalsoyourownknowledge ofanyofthecountriesunderreview intothisdiscussion.

Typeofdecentralisation:

• Whatdifferentstreamsortypesofdecentralisation havebeenintroducedwithin eachcountry?

• Foreachcountry,wastheredecentralisation ofpoliticalortechnical/managerial authority,orboth?

• What,ifany, structuresorbodieswereaffectedbydecentralisation,orestablished intheprocessofdecentralisation(e.g.localgovernment,hospitalboards,etc.)?

• Inwhatwaysaretheexperiences ofthecountriesrevieweddifferentorsimilarto othercountriesrepresented inthegroup? Haveanyothertypesoffunctionsor bodiesbeenthefocusofdecentralisationintheseothercountries?

Rationale:

• Whataretheexplicitstatedreasonsormotivationsfordecentralisation andwhat, if any,implicitreasonsaresuggestedtounderliedecentralisation?

• Dothereasonsormotivations differbytypeor‘stream’ofdecentralisation? How andwhy?Isthereanyconflictbetweenthedifferentmotivations?

• Ifyouknowanycountryunderassessment, doyouagreewiththeanalysisofits experience? Ifnot,whatdoyouthinktherationale(s)fordecentralisation inthe countrywas?

• Arethesecountryexperiences’differentorsimilartoothercountriesrepresented inthegroup?

Drawingconclusions:

• Doesthetypeofdecentralisation haveanyinfluenceoverwhethertheobjectives establishedfordecentralisation areachieved?Ifso,whichtypeappearsmore appropriateasamechanismtoachievewhichgoal?

• Whatotherkeyfactorsinfluencetheachievementofobjectives?

• Doyouseethetransferofauthority ofanyfunctiontobodiesoutsidethepublic sectorasaformofdecentralisation?Why/whynot?

Lucy Gilson, Centre for Health Policy, University of the Witwatersrand1

DECENTRALISATIONINKENYA

Extractedfrom:CohenS.,MwanziaJ.,OmeriI.,Ong’ayoS.Decentralization and healthsystem changeinKenyaCasestudyprepared aspartoftheWHOmulti- countrystudyondecentralisationandhealthsystemchange(1996)

Countryexperiencereporteduntil1995

BACKGROUND

Anoutlineofhealthsectorreformin Kenya1970-1995

Afterindependence inKenyain1963,thehealthsectorwasmanagedbyboththe MinistryofHealth,whichranthehospitals,andtheelectedLocalAuthorities which wereresponsible fortheclinicsandruralhealthfacilities.By1970therewas increasing concernoverthevariablequalityofcareprovidedbythelocalauthorities andasaresulttheMOHtookovertheruralhealthfacilities andmostoftheurban clinics.

TheMinistryofHealthmanagement systemwasbasedontheDistrictHealth Management Team(DHMT).TheBritishintroducedDHMTsduringthecolonialdays andafterindependencethepracticewascontinued. However,itwasnotuntilthe

1970sunderthedonorsupportedRural HealthDevelopmentProject(RHDP)that the DistrictHealthManagement Teamtookontheircentralroleinhealthservice management. Theirrolewasfurtherenhancedwhen,in1983thegovernment introduceditsbroaddecentralisationpolicy,theDistrict FocusforRuralDevelopment andtheDHMTwasusedasavehicletoimplementthispolicyinthehealthsector.

Sinceindependenceinadditiontodecentralisation, therehavebeenthreeother importantpolicydevelopmentsin thehealthsector.Firstly,in 1986theKenyan government adoptedthePrimaryHealthCareApproach andthishasremained a majorplankoftheirhealthcarepolicytodate. Secondly, attheendofthe1980’s, largely as a result of global economicconditions,the governmentcame under pressuretoreducepublicspending. Asaresultgovernment spendingonhealthin realtermswascutandin1989feesforhealthcaregovernment facilitieswere introduced. Lastly,in1992DistrictHealthManagementBoardswereintroduced primarilytooverseeuseoftherevenuegeneratedbyfeeschargedathealthfacilities.

Overallgovernmentpolicyframework

Sinceindependencein1963akeytenetofthegovernmenthasbeenthepromotion ofcommunity self-helpor‘Harambee’. However,intheseventies andearlyeighties there was a tendencyfor politiciansto use this Harambeespirit to initiate the constructionofcapitalprojectsintheirownconstituencies.Theresultwasthathealth facilities,schools,cattledips,bridgesetcwereerectedalloverthecountry. Thisled tovariablestandardsofbuildingandtheinequitable distribution offacilities countrywide. Moreover,althoughcommunities providedcapitalrevenue,the governmentwasexpectedtoprovidestaffforfacilitiesandmeetanyrecurrentcosts.

Itwasthissituationintheearlyeightiesthatpromptedthegovernment todevelopa strategythatcouldutilisetheharambeespirit,butat thesametimeco-ordinateinputs and ensurestheequitabledistributionoflimitedresources.Thestrategywasto:first, ensurethatall districtdevelopmentplanswereco-ordinated,prioritisedanddealtwith inanequitablemanner;andsecondly,toestablishanadministrative systemwhich encouragedgrassrootsparticipation.Thiswasthebasisforthedecentralisation of administrative structurespromotedinKenyathroughtheDistrictFocusforRural Developmentstrategy.

Theseventiesweremarkedbothbyachangeinleadership inKenyaandchanging economicfortunes. Kenya’seconomy, likemanycountriesintheregionhasbeen stronglyinfluencedbytheinternationaleconomicclimate. Theoilcrisisin1972 markedadownturn intheeconomy. Thiswaspartiallyreversed duetothecoffee boomin1976/77. However,thisimprovement wasshortlivedbecauseofthesharp increaseincrude oilprices thatoccurredin1978. By1984theGDP growthratehad fallentolessthat1%. Internalbudgetarycontrolsledtosomeimprovement inthe situation inthemid-eighties,butthiswasnotsustainedandtheeconomydippedtoa lowpointin1992. Thiswaspartlyasaresultofpoorperformance inthedomestic marketandaresultofadonorfreezeonaidin1991.

The declineinKenya’seconomyled tothe implementationofaStructuralAdjustment Programme. This had a severe impact on financing for the health sector, as acknowledgedinKenya’s1994HealthPolicyFramework.

Theearlyninetiesalsowitnessed somesignificant politicalchanges.In1992Kenya heldits firstmultipartyelectionsandPresidentMoiwasreturnedto power. In addition,Kenyaexperienced substantialpressurefrommajordonoragenciesto institutepoliticalandeconomicreform. Itisdebatablewhethersignificantpolicy changes,forexampleinthepublicsector,haveresultedfrom domesticadjustmentto theneweconomicclimateorconditionalityofdonorfundstogovernment. The importantpointforthisstudyistoacknowledgebilateralandinternationalagencies assignificantactorsinthepolicyarena.

MAINFEATURESOFDECENTRALISATIONPOLICY

Majorsteamsofdecentralisation

•Decentralisationtolowerlevelsofthegovernmentacrossallsectors: TheDistrict

FocusforRuralDevelopment(1983)

•DecentralisationtolowerlevelsoftheMinistryofHealthadministration:The

DistrictHealthManagementTeams(1975/79)

•DecentralisationtolaymanagementboardswithintheMinistryof Health: The

DistrictHealthManagementBoards(1992)

Minorstreamsofdecentralisation

•Decentralisationtoproviderinstitutions:TheKenyattaNationalHospital(1990s)

•Decentralisationtocommunity-basedgroups:TheBamakoInitiative(1989)

•Decentralisationtoprivatesectorinstitutions.

Decentralisationtolowerlevelsofthegovernmentadministrationacrossall sectors.

TheDistrictFocusforRuralDevelopment-1983

TheDFRDstrategywas toshift theresponsibilityforplanningand implementingrural development fromtheheadquarters ofministriestothedistricts.TheDistrict DevelopmentCommittee(DDC)became thefocalstructureforimplementationofthe DFRDandwasabodymadeuppredominantlyofdistrictcivilservants,MPsand localcouncillors.Ithadabroadrangingroleincludingruraldevelopmentplanning andco-ordination,projectimplementation, managementoffinancialandother resources,overseeinglocalprocurementofgoodsandservices,management of personnelandprovisionofpublicinformation. Itwasalsointendedthatthestrategy wouldimprovecommunication betweenlocalcommunityandgovernmentofficers throughDevelopmentCommitteesatsub-locational,locationalanddivisionallevels.

Theprimaryobjective oftheDFRDwasthedesiretoseeamoreequitableapproach toruraldevelopment inKenya.Thus,theexplicitobjectivesoftheDistrictFocusfor RuralDevelopmentwere:

•equitabledistributionofdevelopment,bearinginmindregionaldisparities;

•decentralisationofdecisionmaking;

•greaterinvolvementofthebeneficiariesindevelopmentactivities;

•toensurecontinuationoftheHarambeespirit;whichwasalreadysupplementing governmentofKenya(GOK)financedcapitalprojects.

Thestrategyrepresented amajorpolicyshifttakenbytherelativelynew administration ofPresidentMoi.Whilstthepolicyframeworkwasdevelopedbythe OfficeofthePresident, eachMinistrywasexpectedtoimplement thepolicyintheir respectivesector.

DecentralisationtolowerlevelsoftheMinistryofHealthadministration.

TheDistrictHealthManagementTeams-1975/79

ThemembershipoftheDHMT,itsfunctionsandresponsibilitieswereonlyclearlylaid outduringthe1970’saspartoftheRuralHealthDevelopmentProjectandwere identifiedas:

•formulationofrelevanthealthobjectivesforthedistrictinsupportofnational healthpolicies

•participationinthetotaldevelopmentofthedistrictthroughtheDDC.

•identificationoftargetpopulationsand‘atrisk’groupsinordertomeettheirneeds

•trainingdeploymentanddevelopmentofstaff

•preparationofbudgetsandauthorisationofexpenditure

•initiatingandsupportingcommunitybasedhealthactivities

•monitoringandsupportingruralhealthfacilities

•determiningthestaffingcapacityandlocationofhealthfacilities

•liasingwithnon-governmentorganisationsinvolvedinhealthactivitiesatthe district

•developingandmaintainingamanagementandhealthinformationsysteminthe district.

Itishardtoobtainaclearpictureoftheoriginalobjectives fortheformation ofthe DistrictHealthManagementTeamsbutitwasprobablyorganisational -awayof providinganintegratedapproachtothemanagement ofdistricthealthservices. Whethertheoriginal‘DHMT’approachwasactuallyviewedas‘decentralising’ is unclear.TheideaofmakingtheDHMTthefocalpointofadecentralisedhealthcare systemappearsinsteadtohavebeenassociatedwiththeintroductionoftheDFRD.

DecentralisationtolaymanagementboardswithintheMinistryofHealth

TheDistrictHealthManagementBoards-1992

TheDistrictHealthManagement Boardswereformedin1992tooverseetheuseof fundsgeneratedthroughthenationalcost-sharing policy.TheDHMBsoverseethe management ofhealthservicesinthedistrictinordertoensureproperuseand accountabilityofpublic funds,andprovidethelinkbetweenthepublicandthedistrict healthcaresystem.Theirresponsibilitiesinclude:

•reviewingandsanctioningplanningproposalsincludingthosesubmittedtoDDC

forapproval.

•settingperformancetargetsandensuringthatservicesarebeingprovidedin accordancewithTreasuryinstructions.

•monitoringtheperformanceofDHMTsthroughreviewofprogressreports.

•receiving reports on Exchequer allocations to the district and ensuring that

“voted”(allocated)fundsareusedfortheirintendedpurpose

•visiting health institutions and handling matters raised by patients including complaints/dissatisfactionaboutqualityofcare.

•approving the use of the facility improvement fund in accordance with the accountingofficer’sinstructions.

•ensuringfinancialreportsaresubmittedtotheministryofhealthintime.

Originally,itwasintended thattheDHMBsshouldonlymonitorthecost-sharing programme. However,the1994HealthPolicyFramework suggestedthattheirrole shouldbeextended topermitthemtooverseeallhealthsectoractivities withintheir districts-andthe1995DHMBoperationguidelinesgavethemtheresponsibility of reviewingandapprovingoverallrecurrentanddevelopmentbudgets.

However,themainobjectiveofDHMBestablishment wasnottoincrease decentralisation inthehealthsector.Insteaditwastoestablishamechanismto overseethecost-sharing programmeinthreeways.First,itwashopedthatthe DHMBs wouldensurethatmoneyraisedthrough userfeeswouldbeproperly accounted forandwouldnotbemisused. Secondly, itwashopedthattheDHMBs wouldrepresentthepublic’sviewsonthemostappropriate waytospendthecost- sharingfunds. Thirdly,theDHMBwasseenasawatchdog forthepublicoverthe standardofcareofferedintheMinistry’shealthfacilities.Although thecreation of DHMBsledtoamoredecentralisedsystem,thiswasnotaprimeobjectiveofthe initialpolicy.

Otherformsofdecentralisation

TheKenyattaNationalHospital-1990s

InKenya,theKenyattaNationalHospital,thenationalreferralhospitalisgivena blockgrantandismanagedbyaboardoftrustees. Asimilararrangementexistsfor Kenya’sMedicalTrainingCentres.

TheBamakoInitiative-1989

TheBamakoInitiativewasintroduced inKenyain1989.Itisseenasanimportant mechanism for strengthening Primary Health Care Services in Kenya. Decentralisation isseenasbeingcentraltotheimplementation ofthisprogramme- referringtothetransferofpowerfromthedistrictcentretothecommunity level. Therefore,BI takesdecentralisationastepbeyondthedistrictlevel.

Decentralisationtoprivatesectorinstitutions.

Itisestimatedthattheprivatesector,bothforprofitandnotforprofitaccountfor

approximately 40%ofhospitalandoutpatientprovisioninKenya. Kenyanlawhas alwayspermittedprivatepracticeaslongaspractitioners areregisteredandhave obtainedaprivatepracticelicense. However, untilrecently,therehasnotbeenany specificpolicydirectedtowardstheprivatesector.

Althoughthereislegislation inplacetoregulate theprivatesector,therehasbeena growthinunregisteredclinicsandthe qualityofcareinthis sectorisveryvariable.As aresultthe1994HealthPolicyFrameworkhighlightedtheneedtoimproveregulation oftheprivatesectorevenwhilstseekingtoencouragecollaboration betweenthe privateandpublicsectors(through,forexample,incentives fortheprivatesectorto movetounder-servedareas.)

FORMOFDECENTRALIZATION

Newandrestructuredlevelsandinstitutions

TheDistrictAdministration

TheDFRDcreatedanewadministrativesystem, whichfocused ontheDDC.Certain featuresofthissystemareworthnoting. Firstly,theDDChas assumedapivotalrole intheDistrict. TheDDCreviews alldistrictplans,decides ondistrictdevelopment priorities and draws up annual budgets. All departmental heads have to seek approvalbytheDDCfortheirplans. TheintentionisthattheDDCshouldco- ordinatedistrictplansandmaximisesuseofresources. However,theperformance ofDDCsvariesagreatdealbetweendistricts. Effectivenessdependsonthecalibre andenthusiasmof keymemberssuchas theDCandMPs.Workcanalsobeslowed downiftheCommittee isunabletoresolveconflictsbetweencompeting interest groups. Conflictsmayoccurnotonlybetweenpoliticiansfromdifferentpolitical positionsbutalsobetweenpoliticalrepresentativesandcivilservant.

Secondly,itwasintendedthatthesub-districtdevelopmentcommittees,inparticular thelocationalandsub-locational DCshouldcarryoutneedassessmentsoftheir population andactasasourceofprojectideasfortheircatchment areas. However, theseCommitteesareoftenunder-resourced, forexampletheymaynothavebasic stationery,sothatinmanycasestheyareunabletofulfiltheirresponsibilities.

Thirdly,althoughitwasintendedthatsomepersonnel managementfunctionsshould bedecentralised,undertheDistrictFocus,strategic planningforpersonnelremained withtheDirectorate ofPersonnel Management. Thisisanationalbodyunderthe OfficeofthePresident. TheDPM determinesstaffingcomplementsforeach ministry andsalaryscalesforeachjobgroup. Allappointmentsaboveacertainrankare decidedonbytheDPM. Asecondnationalbody,thePublicService Commission dealswithotherpersonnelissuessuchasrecruitmentandstaffdiscipline.

TheHealthSector

Theorganisationofthehealthsectorstructuresisperhapslessclearthanthedistrict administration. Thisisprobably because theyhavebeenchangedandadaptedover anumberofyearsratherthanhavingundergone asinglerestructuringprocess. For thisreasontheremaybesomedisputeabouttheexactrelationship betweencertain structures.

Therearetwotypesofbodiesinthehealthsector. Management Teamswhichare madeupoftechnicalMOHstaff,andavariety ofcommitteesandboardsmade upof communityrepresentatives withlimitedtechnicalinputfromMOHstaff.The managementteamarethePHMT,DHMT,theHospitalManagement Committee (HMC)andtheHealthCentreManagementTeam(HCMT).

ThePHMTshouldbeinvolvedinmonitoring andevaluation ofdistrictactivitiesand althoughtheteamwasstrengthenedwiththereturnofthepostofProvincialHospital Secretary,itisstillhandicappedbylimitationsinfundingandstaffing. Inparticular themoneyallocatedfor transportandallowances(about11%ofeachteam’sbudget) isinadequateforthemtotravelaroundtheProvinceandprovidesupervision.

Despitetheshortage ofstaffthePHMTisinastrategicpositiontostrengthenDHMT operationsifadequatelyfunded. Appropriatetaskscouldincludeco-ordinatingall typesoftrainingforDHMTsandsupervisingdistricthealthserviceoperations.

TheDistrictMedicalOfficer ofHealth (DMOH)leadstheDHMTs.TheDMOHmaybe relatively junior and have very little management experience, whereas an experiencedMedicalSuperintendentmayleadtheHospitalManagementCommittee. Intheory,theDMOHshouldoverseeallexpenditure inthedistrictincludingthe hospital. HoweverbecauseoftherelativeseniorityoftheMedicalSuperintendent, thelattermaybeunwilling toaccepttheauthority oftheDMOH. Insomecasesthis situationhasledtotensionbetweenthesecadres.

Lastly,eachhealthcentreshouldhaveaHealthCentre ManagementTeam(HCMT), responsible forplanningandmanaginghealthservicesnotonlywithinthehealth centrebuttheentirecatchment area(theRuralHealthUnit). However, theseHCMT arenotalwaysconstitutedoractive.

Animportantfeatureofthehealthsystemistherelationship betweenthetechnical DHMTsandthebodieswhicharemadeupofnon-MOH staff,theDHMBs,theHCC, andtheVHC. TheDHMBsareformallyconstitutedandtheirrelationshiptothe DHMTisclearlyspeltout,whereastheHealthCentreCommittees andtheVillage HealthCommittees membership maybeeithernominatedorelectedbythelocal communityandtheirrelationship toformalstructuresinthehealthsectorisfarmore nebulous.

MostofthedistrictshaveoperationalDHMBs. Eachteamismadeupof9members whorepresentavarietyofcommunity interestswithinthedistrict. Members maybe retiredseniorcivilservants,localNGOmembers, women’sgroupsrepresentative, localbusinessmen. BoardmembersarenominatedbytheDCandDMOHand appointedbythe MinisterofHealth.Atthe timeof thisstudy,theselectionprocedure was overseenby the KenyanHealthCare FinancingSecretariat(KHCFS).The DMOHandDistrictCommissioner arealsomembersoftheBoard. Inordertowork moreeffectively, theBoardsoperatethroughthreesub-committees.Thefinanceand generalpurposescommittee,thequalityofcurativeservicescommittee,andthe publichealthcarecommittee.

In the sameway as theDHMBsmonitorandsupporttheDHMT,somehealth facilitiesaresupportedbyHealthCentreCommittees.Thesecommitteeshavearisen fromcommunityself-helpgroupswhichinitiatedtheconstructionof localhealth centresanddispensaries. Thecommunity interestinthesefacilitiesstillexistsand someofthesecommitteesarenowexploring waysofmaintainingtheservices ofthe facilityorsupporting serviceslikeprovidingsecurityandpurchasing kerosenefor sterilisationofequipment.

VillageHealthcommitteeswereformedinmanycommunities inthelate`80’swhen KenyastarteditsPHCProgramme. In1991someVHCswereretrainedandtookon additionalresponsibilitiesaspartoftheBamakoInitiativeProgramme.

ResponsibilityandAuthority

DHMTshaveresponsibility infourprincipalareas:populationneedsassessment; personnelmanagement andin-servicetraining;districtplanning;andbudgetingof districtservices. Inpractice authority islackinginseveralkeyareas.TheDHMThas nocontrol oversalaryscales andonlyverylimited control overthehiring,firingand postingofpersonnel. Inaddition,trainingisfrequently organised throughcentrally controlledverticalprogrammes. Secondlytheresponsibility forpreparingbudgetsis notmatchedbytheauthoritytodecideallocations withinthedistrict’srecurrentand development budgets. ThisisstilldonecentrallyandmayalsoaffecttheDHMT’s authorityinplanning.

DHMBshaveresponsibilitiesinfourmainareas:representation oftheviewsofthe community intheplanningofhealthservicesatdistrictandnationallevel;approving FIF,AIErequests,recurrentanddevelopment budgets;supervisingservicedelivery; promotinghealthawarenessin thegeneralpublic.At present,themainareainwhich responsibility isnotmatchedbyauthorityisintheapprovalofrecurrentand developmentbudgets. OnlytheFIFbudgetcan currentlybeapprovedbytheDHMB, andalthoughthisdecisioncanbealteredbytheKHCFS,thisrarelyhappens.

DISCUSSIONOFTHEFORMDECENTRALISATION

Onecanpickoutspecificfeaturesoftheformofdecentralisation thathavebeen influencedbyboththepolicyformulationprocessand themeansthat werechosento implementdecentralisationinKenya.

Firstly,thetwopolicystreamsofdecentralisation inthehealthsectorandthepolicy streamofdecentralisation ofthedistrictadministrationhasresultedintwoparallel structuresdeveloping atthedistrictlevel. Therearebothformalandinformallinks betweenthesesystemsandalthoughitmayleadtoratheralotofcommitteesatthe districtlevel,byandlargethelinkages between thesesystems seemtoworkwell. However,theresponsibilitiesandrelationshipsofthesub-districtstructuresbothin thehealthsectorandthedistrictadministrationarelessclearlydefined. This may be becausecommunitystructureswerecreatedtoimprovegrassroots representation ratherthanfororganisationalreasonsandduringimplementationinadequatetime andresourceswereinvestedinmakingthesestructuresworkeffectively.

Secondly,theimplementation processdidnotadequatelyaddressissuesof restructuringintheMOHHQ.Theresultisthatlinkages,communication, co- ordinationandaccountabilitybetweennationalanddistrictlevelsarecomplexandat timesconfused. Thissituationmayhavebeenalleviated iftheProvincial levelhad maintaineditsimportanceandactedasaco-ordinatingbodybetweenthenational anddistrictlevels.

DECENTRALISATIONINNICARAGUA

Extractedfrom:SandifordP.Decentralisation andhealthsystemchange:Nicaragua casestudyCasestudypreparedaspartoftheWHOmulti-country studyon decentralisationandhealthsystemchange(1995)

Countryexperiencereporteduntil1995

Background

This paper describesthe most recent efforts to decentralisehealth servicesin Nicaragua, beginningabout1991undertheleadership ofthethenMinisterofHealth DrSalmeronandcontinuingatanevenfasterpaceunderhissuccessor, MsMartha Palacious.

Nicaraguahashadaturbulentpoliticalhistoryoverthelast20 yearscharacterisedby revolution,civilwar,andchangefromthelong-standing dictatorshipoftheSomoza familytotheradicalleft-wingnationalistgovernmentoftheSandinstasandfinally,in

1990,toademocratically electedgovernmentwithamixofneo-liberalandsocial democratic policies. Over the same period, the country’s economy contracted severelyasaconsequence oftherevolution,thewar,theUSeconomicembargo, hyperinflation and property confiscation, all of which were aggravated by the inevitableflightofcapital andtechnicalexpertise.ThefirstprioritiesfortheChamorro government werethenegotiation ofadefinitivepeacesettlementandstabilisingthe economy. Theformer wasachievedrelativelyswiftlyalthoughbandsofdiscontented ex-combatants(frombothsides)continuedtocauseproblemsuntilveryrecently.

Turningtheeconomyaroundtook alittle longer.The Sandinistasleftalegacyofvery highinflationandaweakcurrencycausedtoalargeextentbyanenormous budget deficit. Thepeacedividendallowedreductionsinthesizeofthearmedforcesbut cutsinsocialsectorspendingwerealsonecessary,particularly giventhatthe economywasstillcontracting. Withinternational assistance,inflationwasgradually reducedanditbecamepossibletoachievesome exchangeratestabilityafterinitially introducing anewcurrencyandtheninJanuary1993devaluingby20%againstthe USdollar(althoughapolicyofslidingdevaluation, currentlyrunningat12%per annum,hasbeeninplaceforalmostthreeyears).Othereconomic liberalisation measureshaveincludedtheremovalofexportandpricecontrols,privatisation of certainstatecorporations(ofteninfactreturningthemtotheirpreviousowners),and allowingprivatebanksandcurrency exchangehousestooperate, allgoodexamples ofthegenerallyfavourable attitudetoprivateenterprise thatnowprevailsinthe Nicaraguangovernment.

As was to be expected, the structuraladjustmentpackage producedrecessive effectstobeginwithwhichwerefeltmostacutelyby thepoor.However,therewasat lastsomemodesteconomic growthof3.2%in1994andabout4%in1995. Unfortunately,governmentprojectionsforcomingyearsdonotenvisageveryhigh percapitagrowthrates.

Twomajoreconomic problems haveyettobefullyaddressed. Oneistheenormous externaldebt which,at750%ofGDP(in1992),isthe highestinthe world. Theother isthelargenumberofoutstanding disputesoverpropertyownershipcausedbythe Sandinistaconfiscations, andespeciallytheso-calledpinatainwhichthousandsof titlesweregiventoFSLNsupportersaftertheylosttheelectionsin1990.

Withanestimated44%ofhouseholdssurvivingunder conditionsofextremepoverty, noNicaraguangovernmentcan ignoreissuesofequity,andindeedthe government’s socialpolicyimploresthatthematerialandspiritualbenefitsofsocietybetakentothe historicallymarginalisedand exploitedsectorsof Nicaraguansociety.`However, havingwitnessedtheeffectsoftheprevious government’sattempts tocreategreater socialjustice,theChamorroadministration hasbeencarefultoavoidmeasuresthat mightfurtherundermine confidence inpropertyrightsorthegovernment’s commitment tofiscalprudence.HencethegeneraldirectionoftheNational programmeforSocialDevelopmentandPovertyReductionwerenotredistributive persebutratheradvocatedadministrativedecentralisation andintersectoralaction mainlyitseems,toimproveallocativeefficiency. Decentralisation mayhavebeen viewedasameanstotargetvulnerableandimpoverished populationsbyallowing decision-makingatlocallevelwherethereisgreaterknowledge ofwhoandwhere thesegroupsare. Inotherrespectsgovernmentpolicyhasattemptedtoincreasethe roleoftheprivatesectorandmovethecountry towards amorefreemarketmodel, whilststrengtheningdemocraticinstitutions.

Decentralisationexperience

To understandthe recent decentralisationof health services in Nicaraguait is necessary to see how their organisation has evolved under the previous governments. InthetimeofSomoza,healthserviceshadbeenprovidedbythe19

LocalSocialWelfareBoards,administeringthehospitalandambulatorycareclinics ineachofprovinces,theNationalSocialandPublicWelfareBoardwhichran25

`National’hospitals,and the NicaraguanSocialSecurityInstitutewhichin 1976 coveredless than 10% ofthepopulationbutwaswellfinancedandprovidedservices ofgoodquality.

OneofthefirstdecreesoftheGovernmentofNationalReconstructionestablished theNationalUnifiedHealthSystem(Decree35,28August1979),whichbrought underthedirectcontroloftheMinistryofHealthalltheLocal(actually provincial) SocialWelfareBoardsandtheNational SocialSecurity andWelfare Board(which betweenthemranhospitalsandhealthservicesthroughout thecountry),aswellas theservicesownedandoperatedbytheSocialSecurityInstitute.Afterdefence, healthandeducationwerehighprioritiesfortheSandinistagovernment which perceivedthesesectorsashavingbeenneglectedundertheSomozagovernment andalsosawthemasimportant sourcesofpopularsupport. Inthenameofequity, theprivilegesenjoyedbytheinsuredinaccesstohealthservicesoriginallyowned andrunbytheSocialSecurityInstitutewereabolished andhencethesefacilities becamenodifferentfromanyoftheothersrunbytheMoH.Moreover, 9%ofthe socialinsurancecontributionscollectedfromtheinsuredwashandedtotheMinistry ofFinanceostensibly tobepassedovertotheMinistryofHealthbutinpracticethe fundssimplyformedapartof thetreasury’sgeneralrevenues.IndeedtheSandinista government,likeothersintheregion,usedthepensionfundasasortof‘pettycash’ supply,seriouslyjeopardisingtheactuarialstabilityoftheINSS. Thegovernment of PresidentChamorrothereforeinheritedahighlycentralisedhealthsystem.

Beginningaroundthemid-1980sthegovernment, followingWHO/PAHO guidelines, attemptedtoreorganise healthservicesintodistricthealthsystemsor‘LocalIntegral HealthCareSystems’(SILOS)astheyhavebeencalled. Intheory,thismeant decentralising thehealthsystem,butinpracticethehandingoverofresponsibilities was not matched by loosening central control over resources. Though some hospitalsandregionsdidexperiment withlocalbudgetingattheendofthe1980sa number of problemswere encounteredand the previous system was soon re- established.TheHealthMasterPlanfor1991-1996 proposedtoextendthe decentralisationprocessandstated:

“AspartofthedevelopmentoftheSILOS,theprocessofdecentralising budgeting, administration, planning delivery and evaluation of services, programmes and projectsatmunicipalandregionallevelswillbereinforcedanddeepened.”

Thedecentralisation processreallybeganinearnestduringtheChamorro government. Itmustbeseenhowever,asjustonecomponent,albeitthemost important,ofamuchbroaderprocessofreformtothesectorasawhole. Akey elementpromotingthedecentralisationof healthserviceshasbeena desireto democratisemanagement,which in practice meant providingan opportunityfor inputsintohealthpolicyfromcommunityorganisations,localgovernment,theprivate sector,NGOs,unionsandsoon. Itisdifficulttoseewhysuchanemphasis was placedonthisnotionofdemocratisationbutonereasoncouldbethatitwasa strategyusedtogainthesupportofstakeholders whomightotherwiseopposethe changes,byofferingmechanisms thatwouldallowtheirinputintopolicyformulation (whichinfacttheydid).

On the otherhand,theredoesappeartohavealsobeenagenuinedesireon thepart ofpolicy-makers tocreatealesspoliticisedhealthsystem,onewithgreater accountability tothepublicandonewhichwasmoreresponsivetotheneedsand desiresofserviceusers. Inthissensedecentralisation servedanotherkeyareaof overall government policy, namely that of securing peace within the country. Followingtheelectionsof1990,thenewministerofhealthDrSalmeron,gained somesupportfromtheSandinista controlledhealthworkersunionbycontinuing the previousgovernment’s healthpolicyandbynotmakinglargenumbersofpolitical appointmentswithinthisministry. Thiscreatedafavourableclimatetoallowthenew minister, Ms Palacios who took office in January 1993, to implement more substantive changes within the organisation. In particular, she was keen to depoliticizetheexistingmechanisms forcommunityparticipation inhealth,which consistedofoneorganisation understrictSandinistacontrolandanotherledbythe liberals. Itappearsthatherdesirewasnottogaincontroloverthesechannels for volunteerhealthworkerparticipation,butrathertotakethemoutofthepolitical arena. Indeedsomeofherproposalsintendedtoencourageparticipationatlocal level were consideredthreateningby the SandinistaCommunityMovementand therefore werenotadopted,buteventuallythisaimwasachievedbydecentralisation becauseitwasnolongerpossiblenorappropriate forsuchgroupstonegotiatewith thecentralministryofhealthastheyhadbeenaccustomedtodo.

Athirdrationalefordecentralisation doesappeartobepurelytechnicalanditwas based on the recognitionthat the health system had becomea set of vertical programmesoperatingindependently ofeachotherandofthehospitals(thelatter absorbingalargeproportionofthegovernment’sbudgetforhealth). Adecentralised healthsystem,itwasfelt,wouldintegratetheverticalprogrammes andaddressthe healthneedsoftheentirepopulation, withanemphasisonwomen’sandchildren’s health. Greaterallocativeefficiencywouldhelpthegovernmenttodealwiththe financialstrainscausedpartlybytheepidemiologicaltransitioninthepopulationthat isincreasingdemandforexpensivecurativeandpalliativehealthservices.

Criticsofthedecentralisation policiesarguedthatthegovernmentwas‘passingthe buck’byhandingresponsibilityfortherunningofhealthservicesovertotheBoards ofDirectors. Tosupportthisviewtheypointedtothecutbackingovernment health spendinginrealterms.Whilethearchitectsofthedecentralisation denythis,the governmenthadhopedthatdecentralisationwouldfacilitatemoreactioninhealth fromsomeoftheother sectors,andoriginallyitwasintendedthatmeans-testeduser

chargeswouldbeintroducedasoneaspectofthechange. Financialconsiderations werethereforeimportantfactorsinthedecisiontoundertakethesechanges.

Nicaraguainitiallyoptedtodecentralise totheprovinciallevelbysettingup(legally) independentboardsofdirectors. SinceJuly1995however,therehavebeenmoves tofurtherdecentralise tothelevelofthemunicipality whilstretainingtheprovincial structures. However, thepreciseformofmunicipal authorityinhealthremains undefined.

Thepolicyformulationprocessfordecentralisationbeganon26February1991with aministerialresolution(No.91)“initiateaprocessofreorganizationofhealthservices withtheaimoforganizingtheLocalSystemsforIntegratedHealthCare”. These SILAISastheybecameknown,wereaNicaraguanvariationonthePAHOpromoted conceptofLocalHealthSystemsorSILOS. Theresolutionwasfollowedbya nationwideconsultationprocessthroughRegionalHealthForainwhichtheministry’s proposalswerediscussedbyrepresentativesofcivilsocietyandparticularlythelocal governmentauthorities. Thesewerenotjustmeetingsforgovernment toinformthe differentgroupsoftheintendedchangesbutrealinterchanges ofopinionandideas whichformedimportantinputsintothefinalpolicy. Forexample,itwasoriginally proposedtoformLocalHealthCouncilswithanessentially advisoryrolebutthe representatives oflocalgovernmentmadeitclearthattheywantedamoreactive involvement withrealdecision-makingpower. Itwashencefromthesediscussions thattheideaoftheProvincial HealthBoardsarose. TheRegionalHealthForawere followedbyaNationalHealthForuminwhichthefinaldecentralisationproposalwas presented. This was ratified by central government at the National Health ConferenceinJune1991.

Fromtheoutset,externaldonorsandlendingagencies weresupportiveoftheseand otherhealthsectorreforms, andloansfromtheWorldBankandInteramerican Development Bankweresecuredtoassistintheprocess. However,thechanges werebeingdrivenverymuchby theMinisterof Healthandin factifanything,external agencieswere recommendingthattheyproceedataslowerpace thantheydid. The consultation processsucceededinwinningthesupportofmunicipalgovernments, communityorganisations,churches and a number of NGOs but the Sandinista dominatedunions(i.e.theFederation ofHealthWorkers,theWomen’sAssociation LuisaAmandaEspinoza,the NationalUnionof FarmersandCattleRanchersandthe CommunityMovement)stillopposedmanyoftheproposals. Forexample,itwas originally hoped that decentralisationwould open up possibilities for alternative financing methods buttheunionsfeltthatthiswouldsimplybeafirststeptowards privatisation andtheiroppositionmeantthattheseideaswereeventuallydropped. Othercriticismsweremadeofthecutinthehealthbudget,thereduced accessto medicinesduetoprivatisation ofpharmacies, thedecreaseinthenumberof employeesbroughtaboutbythegovernment’s voluntaryseveranceprogrammefor thecivilservants,theequityimplications ofrevivingdifferential carefortheinsured, reducedopportunities forcommunityandworkerinputstohealthpolicy,andpoor managementskills of SILAIS directors. Nevertheless,after an agreementwas reachedwiththeFederation ofHealthWorkerstoendastrikeaperiodoflabour stabilityfollowed.

Theotherstakeholdersfromwhomresistancetothedecentralisation wasfeltwere staff inthecentralministryofhealthand regionallevelstaff,prior totheeliminationof this level. Infactitwasdueto thisresistancefromtheregionalhealthauthoritiesthat thislevelinthesystemwaslaterabolished.

FormofDecentralisation

Nicaraguaeventuallyoptedforaformofdecentralisation thatcreatedsemi- autonomous provincial (departamento level) health authorities (SILAIS) run by Boards of Directors made up of representativesof civil society including local governmentofficials,churches,and‘distinguished membersofthecommunity’. Managuathecapital wasdividedintothree healthauthorities.Each provincialhealth authority hadanetworkofprimarycareclinicsandahospitalwiththefourbasic specialities (generalmedicine,generalsurgery,paediatrics, andobstetricsand gynaecology).

TheBoardofDirectorsincludes themembers oftheHospitalExecutive Committee (oneofwhosemembersis thedirectorof theSILAIS).Thisexecutivecommitteeis in chargeofthedaytodayrunning ofthehospital. TheBoardsofDirectors havethe roleofensuringthatresourcesareusedappropriately andthatqualityofcareis optimised. Theirspecificfunctionsatprovinciallevelrequirethemtoapprovethe strategichealthplan,the serviceprogrammeandthebudgetdevelopedby the SILAISstaff,andtomonitortheirimplementation. TheBoardsofDirectors arealso responsiblefornamingthelocalhealthauthorities. TheBoardsremainanswerable totheMinistryofHealthfortheuseofcentralgovernment fundsbymeansofa contract signedbetween theministryofhealthandthedirectoroftheSILAIS(after approvalbytheBoardofDirectors).Inthiscontractthedirectoragreestomeet service productivity,health and user satisfactiontargets (for all health services includingthehospital),inreturnforthefundsandtechnicalassistanceprovidedby the Ministry. Moreover, each health unit within the jurisdiction of the SILAIS negotiatesitsownbudgetandcontribution tomeetingthecontractual obligations. Executivepowerintheprovincialhealthauthorityrestswithateamcomposed ofthe director,ahealthadministrator,anepidemiologist, afinancialadministratoranda nurse.

Aminorvariation fromthisstructure occursfortheNorthandSouthAutonomous AtlanticRegionswherethedirectoroftheSILAISanswers totheregional governor andwheretheRegionalCouncilplaysthesameroleastheBoardofDirectors.

ABoardofDirectorswasalsoformedforeachnationalreference hospital(in Managua) with equivalentfunctions to those of the Boards of Directors of the provincialhealthauthorities. Thusthehospitaldirectorsignsacontractwiththe ministryofhealthsimilartotheonesignedbyprovincialhealthauthorities. The hospitalisassignedabudgetbasedonsatisfactionofdemandandefficiencycriteria.

Provincialhealthcouncilsweresetupascoordinating bodieswithparticipation from othersectorsandsocialgroups. InMarch1993aNationalHealthCouncilwas formed,headedbytheminister ofhealthandmadeupoftheNational Assembly’s healthcommission,representatives ofcivilsociety,theunions,privateenterprise, communityorganisations,women’sorganisationsandchurches.TheNationalHealth Councildevelopedanationalhealthpolicywithasetofguidingprincipals.

Withdecentralisation,theSILAIStookoverfunctionsofhealthneedsassessment andplanning(localprogramming)withintheframeworkofnationalprioritiesdefined bytheministryofhealth,appointmentanddistributionofstaff. Theplanforthe province,whichmustbeapprovedbytheBoardofDirectors, issetoutintheannual contractnegotiatedwiththeministryofhealthandincludesperformance targets,as wellasabudgettocovertheoperatingcostsoftheenvisaged activities. Inpractice however, theactualleveloffundingdepends uponthetotalministry ofhealthbudget providedbytheMinistryofFinance, whichmeansthatthefinalbudgetforeach provincehastobedecidedcentrally.

DECENTRALISATIONINZAMBIA

Extracted from: Choongo D and Milimo J. Decentralisation and health system change:ZambiaCaseStudy.Casestudyprepared aspartoftheWHOmulti-country studyondecentralisationandhealthsystemchange(1996)

Countryexperiencereporteduntil1995

BACKGROUND

PoliticalandEconomicContext

Atthetimeofindependencein1964,Zambiahadapopulationofabout3.5million andapercapitaincomeofK450(inconstant 1977kwacha), alevelcommensurate withmanymiddle-incomeCountries. Today,thepopulationhasrisentonearly9 millioninhabitants andapercapitaincomehasdroppedtoK250. According toa recent World Bank study, 68% of the population now lives in poverty. The assessmentalsoindicatedthat88%ofruralhouseholds werepoor,76%(corepoor) comparedto44%inurbanareasat29%(corepoor). Evenifonetakesamore conservative definitionofpoverty,almostonethirdofhouseholdsspend70-85%of theirincomeonfood. The1992.DemographicandHealthSurveyshowedthat economicdeclinehasbeenassociatedwithdeteriorating ratesofinfant,childand under5mortality.

From1964to1975, GDPgrew faster thanpopulation.Copperproductionandprices werehighandtheincomewasusedtofinancearapidexpansion insocialservices. However,thesituationchangeddramaticallyinthemid1970’s. Thecombination of fallinginternationalcopperprices,growingcompetitionfrommoreefficientproducers, reduceddemandresultingfromtheworld-wide energycrisisandthegrowingcostof productionfromageingmines,ledtoamassivedeclineinrevenues. Failureto diversifytheeconomy meantthat,whilecoppercontinues toaccountforthemajority of export earnings(90%in 1989),its contributionto governmentrevenueshas droppedfromover40%atindependencetolessthan1%today.

Thesituationwasmadeworsebythefactthat,ratherthanintroduce necessary economicreforms,theUNIPGovernmentreactedtothecrisisbyextensiveborrowing fromthedomesticandinternationalcapitalmarkets. Thestate-dominatedeconomy of the 1970’s and 1980’s was characterised by an overvalued currency, price controls,exportrestrictionsandconsumersubsidies. Thenetresultwasthatby

1993externaldebtstoodatmorethanUS$7billion. Inaddition,foodsubsidies to urbanareasandthefailuretodevelopagriculturalpolicyexacerbated out-migration fromruralareasandledtoagrowingconcentration ofpopulationandservicesin urbanareas.Between1974and1990,Zambia’sGDPgrewatanaveragerateof1% peryear,whilepopulationgrewatover3%peryearduringthesameperiod.

Attemptstointroducereformbeganin1985,butlittleprogress wasmadeuntilthe MovementforMulti-PartyDemocracy(MMD)formedanewgovernmentin1991. Thefirstdemocraticelectionsfollowingindependence notonlysignalledthe population’s rejectionofaone-partystateandaconcernforamoredemocratic systemofgovernment,buttheMMDwaselectedonthebasisofitspledgeto address the Country’s economic problems. The current Economic Reform Programme (ERP)aimstopromoterecoveryfromtheprolongedrecessionandto mitigatethemostseriousproblemscausedbyZambia’smassivedebt. TheERP formsthebasisofRightsAccumulation ProgrammewiththeIMF,throughwhich Zambiahasearnedrightstofutureborrowingtofinanceitarrears. Keyareasof

progressincludeliberalisation offoreignexchangesystemsandremovalofprice controlsandlicensingrestrictions. Thefiscaldeficithasbeenreduced,butinearly

1993alossofmonetarycontrolledtoaveryhighinflation. Fortunatelythiswas broughtundercontrollaterintheyearandinflationiscurrentlyrunningatabout35-

40%. Cash-based budgetinghashadtheeffectofcontrollingpublicexpenditure but revenuecollectionremainsweak. Recentliquidityproblems havetherefore, resulted insignificantreductionsinthefunds availableforrecurrentspending. Areasinwhich thepace ofreformhasbeen slowincludedtheplannedprivatisationprogrammeand, mostparticularly,thePublicSectorReformProgramme.

Zambiacontinues toreceivethelargestamountofaidofanyrecipient underSPAII, butmuchofitcontinuestoflowouttoInternational FinancialInstitutionswithoutany impactonthelocaleconomy.

Zambia’sdebtandothereconomicproblemsaresuchthatsubstantialprogramme aidwillbeneededatleastfortherestofthedecade toprovide theimports essential foreconomic recovery. Whilstfurtherstructural andeconomic reformisundoubtedly required,itwilltakeplacedinthefaceofaccumulationevidenceoftheextentofrural poverty,andatatimewhenthenewgovernment ispreparing forthenextelection scheduledfor1996.

DecentralisationPolicy

Aconcernfordecentralisation hasbeenalong-standingfeatureofpublicpolicyin Zambia,asevidencedbytheestablishment ofelectedlocalgovernmentcouncils immediately after independence. However, the form and objectives of decentralisationhavechangedsignificantlyoverthelastthreedecades.

UntiltheLocalAdministration Actwaspassedin1980,muchofthefocusofearly attemptsatdecentralisationhadconcentratedontheProvinces. The1980Act, however,shiftedattentiononceagaintothe Districts.Theelectedlocalcouncilswere abolishedand,intheirplace,newpoliticalbodieswereformed. Thenewdistrict councilswerecomposedofcentralgovernment andUNIPofficials,locallyelected representativesof theparty,traditionalchiefsandrepresentativesof community organisations. Althoughthecouncilhadgreateradministrativepowersthantheir predecessors, itwasgenerallyagreedthatthemainobjectiveofthepolicywasto strengthenthepositionofUNIP,throughtheappointment ofitssupporterstokey positionsthroughouttheCountry.

Thedistrictcouncilsestablished underthe1980Actprepared theirownbudgetsfor nationalapprovalandweretohavecontrolovermostgovernmentstaffworkingin the area. However,stronglinksweremaintainedwithtechnicalministriesinLusaka. Furthermore,theinfluenceofdistrictcouncilsoverthehealthsectorwasconstrained bysubsequentdevelopments, whichplacedgreaterfinancialcontrolinthehandsof ProvincialPermanentSecretariesandtheProvincialAccounting andControlUnits. Underthesearrangementswhichexisteduntiltheimplementation ofthecurrent reforms,theProvincereceivedanearmarkedgrantwhichwaschannelledtothe officeoftheProvincialMedicalOfficer.

Forthepurposeofthecurrentanalysisitisusefultodistinguishtwomainstreamsof decentralisationpolicy. Thefirstconcernsdecentralisationtolocalgovernmentas partofthePublicSectorReformProgramme.Thesecondstreamofdecentralisation policyisspecifictothehealthsector,and issetoutintheMMDGovernment’sHealth Reforms.

Decentralisationtolocalgovernment

Whilethepoliticalobjectiveshavechanged,theformofdecentralisation tolocal governmentbuildsonsomeaspectsoftheprevioussystem.Thekeydifference being that local councilsare now elected,and thus seen as a mechanismfor increasingpopularinvolvementindevelopment initiativesandensuringthatlocal governmentofficialsareheldaccountabletocommunityrepresentatives.

Localcouncilswillin futurebe fundedaccordingto aformulabasedonthepopulation they serve. However,the ProvincialAccountingControl Unit (PACU) under the ProvincialPermanent Secretarywillcontinuetoplayasignificant roleincontrolling disbursements. Beforethehealthreformsallmattersconcerningcontrolof communicable diseaseswereunderthecontroloftheLocalGovernmentforurban districtcouncils.ForruralonestheMinistryofHealthwasresponsible, inactualfact whenever therewasanoutbreak ofadiseasetheMinistryofHealthhadtoprovide resourcesandlogistics. Thesameappliedfortheotherservicessuch as,sanitation, watersupplies,foodinspection,andlicensingoftradingpremises.

UndertheNational HealthServices Act,No.22of1995,therehasbeendivision of activitiesor responsibilitiesbetweenthelocalauthoritiesandtheDistrictHealth Boards. IntheNationalHealthServices Act1995,issuesrelatingtotheprovision of clinicalcarehavebeenaffected bytherepealofitem40a,ofthesecondscheduleof theLocalGovernmentAct. Alltheotherservicessuchasenvironmenthealth, sanitation,waterengineering,buildinginspectionsandlicensingwillbeperformedby localauthorities.However,whilstlargercitiesmaybeabletoimplement their responsibilities, smaller cities may have neither human resources nor logistics supportfacilitiestodoso.

Decentralisationandthehealthreforms

HealthBoards

Thedocument“NationalHealthPoliciesandStrategies”, whichsetsoutpolicies underlyingthereformprocess,receivedcabinetapprovalinOctober,1992. The reformsarecentredaroundthreekeythemes:

•Leadership:The Ministryof Healthprovidedpoliticaland right leadershipat district,province,centraland hospitallevelsin the implementationof health programmeshencethecapacitybuildingfortheHealthManagementTeams.

•Accountability:Thereformsshouldaimtomakeprovidersofhealthcaremore accountabletothosethatusetheservicesandaccountabletowhatever theyare doing.e.g.useofresources, havingresourcesinplacethatpromote accountability.

•Partnership:Isperceivedintermsofuserscontributingtowardsthecostofcare, andintermsofgovernmentworkinginpartnershipwithdonorsandagenciesin theprivateandvoluntarysectorintheimplementation ofthereformprogramme andsectoralMinistriesinthegovernment.

Intermsofdecentralisationpolicy,thehealthreformsaimtoachievetheirobjectives throughtheestablishmentofAutonomousHealthBoards. Thesewillbeconstituted ineachdistrictandforallprovincial,generalandcentralhospitals. TheCentral BoardofHealthwillbeestablished tocarryoutaspecifiedrangeoffunctionsas outlinedintheAct.TheCentralBoardofHealthisinstitutionallyseparatefroma muchreducedMinistrywhich,undertheMinisterandPermanent Secretary,is responsible forpolicy,andfornegotiation withtheMinistryofFinanceandCabinet Officeforthehealth budget.TheCentralBoard is,inturn,responsibleforoverseeing theimplementationofpolicy,throughitscontrolofthecontractsnegotiatedwith districtandhospitalboards. Theobjectivesofthesearrangementistoreduce