Actions Shares. Embeds 0 No embeds. No notes for slide. Decentralization of basic education le thu huong 1. Source: Visual Economics. October Fiscal Decentralisation and Equity: the case of China Partly, the problem in some countries is that basic education is not adequately prioritised.
This generates both allocative and technical inefficiencies within the education sector as the local governments have very limited decision making power over the funds that they want to spend. Thank you Questions?
You just clipped your first slide! Clipping is a handy way to collect important slides you want to go back to later. Now customize the name of a clipboard to store your clips. Visibility Others can see my Clipboard. Studies from across the globe have addressed the financial and impact level effects of decentralization mostly through macro analyses, but we came across very limited India-specific empirical studies examining effects of local decision making on health system performance.
Mills et al.
They argued that decentralization was never easily implemented and rarely brought immediate gains. Case studies from across the Globe also provide a series of practical and human-related determinants of success of reforms [ 60 ]. Tashobya et al. The study advocated for consultative development of a frameworks for health system assessment, as it was found that there existed marked differences between the structure and content of frameworks among countries depending on their per capita income [ 61 ].
Savoia et al. Kok et al. It concluded that research on CHW programs often did not capture the context in which CHW interventions take place, and that future health systems research recognize and address the complexity of contextual influences on programs [ 63 ]. Bardhan argued that control rights in governance structures should be placed with local people for better health outcomes [ 64 ].
Decentralization and Financing
Kogan et al. Anhang et al. Tawfik-Shukor et al. Collins and Green proposed a set of warning questions and issues to be taken into account to ensure that decentralization genuinely facilitates the Primary Health Care orientation of health policy [ 59 ]. Measurement functions comprise numerators and denominators; the numerator consists of the population with the characteristic under study, while the denominator contains the target population.
Evaluating performance is a significant task [ 68 ]. Often the central problem with assessment of performance is lack of reliable data. Studies on performance measurement of decentralization have heavily applied principles of economics and of clinical medicine.
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For instance, expenditure analysis and per capita spending are used as an indicator of equity [ 69 ]. On the other hand, based on clinical medicine parameters, the processes, the immediate results and the outcomes are measured. Processes: What activities were carried out to deal with a case individual or an episode community?
Immediate results: Was the patient cured? What was the cure rate and mortality rate among patients? Outcomes: What changes have taken place in the survival, morbidity, and disability patterns in a given population? This is considered as the final outcome of the health system [ 70 ]. But such measurements are generally difficult to carry out and less frequently done.
Tools for measurement of decentralization were studied in different contexts. Veillard J et al. Second, cases could be compared based on the degree of centre-state policy fluctuation over time. The author encouraged scholars to scale down to the municipal level, comparing cases based on the following variables: historical state-municipal fiscal relations, institutional innovations, and the policy-making process [ 72 ].
Balanced scorecard system is advocated for close monitoring of health systems strengthening interventions. In Zambia Mutale et al. The study found this tool could be valuable in monitoring and evaluation of health systems [ 73 ]. Edward et al. The study found, among many other key results, the joint interface meeting facilitated transparent dialogue between the community and providers that resulted in creative and participatory problem solving mechanisms [ 74 ]. The determinants of performance are factors related to i health workers; ii health facilities; iii agents of decision making, patients and the community [ 75 ].
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From the point of view of patients and the community in general, their knowledge about illnesses, health seeking behavior, demand for services, and accessing appropriate care are vital. Measurement of health system performance should include each of these components of multi-dimensional elements that eventually contribute to the overall functioning of health systems. Assessing the influence of decentralization on health system performance pose four-fold challenges: i measuring the nature and quantum of local decision making requires mixing a process nature with a product quantity and the inherent challenges of doing so; ii suitable blending of macro and micro level analysis is another challenge in measuring efficiency and quality; iii quality has multi-faceted dimensions and multi-layered elements that act through input-process-output continuum; therefore measurement of quality could envisage reflection of some of its key elements in quantitative terms; and finally, iv in situations where a reference base-line is not available, which is often the case, the researcher finds it extremely difficult to finalize a suitable evaluation study design.
The WHO has acknowledged the challenges of assessing health systems, assessing outcomes of interest and comparing attainments with what the system should be able to accomplish performance [ 76 ]. If the principal question of investigation is whether or not the performance of the health system improves after introduction of decentralization; and whether there is a cause-effect relationship, one would ideally conduct a randomized controlled trial RCT.
However adopting an experimental study design would not only be costly but also not feasible in most settings. Newer health interventions are constantly designed and implemented by state governments. The damage of depriving a community from such programs would outweigh the benefits of scientific rigor of evidences generated from a classical study design. By segmented decentralization we mean decision-making is often mixed among various layers of government.
For example, decisions related to financial allocation may be centralized, while provision of public services may be decentralized. Taxation and expenditure responsibilities may not be clearly assigned to the central and peripheral governments. The extent to which any particular decision is decentralized may not be clear. Less extensive forms of administrative and fiscal decentralization include deconcentration or mere deployment by the central government of employees to the local level to establish shared governance systems. In all above instances, the researcher invariably comes across methodological challenges in assessing the performance of such systems.
Given its various dimensions, measuring decentralization in public health sector in an aggregate manner is a non-linear, complex task. One may apply governance indicators to different layers of government as proxies, but in recent times, more objective indicators describing different aspects of governance have been offered [ 77 — 79 ].
For instance, studies have focused on cross-country indicators as proxies for various aspects of governance, including accountability, political stability, and control of corruption, among others [ 80 ]. In principle, each of these aspects can also be applied to decentralized structures, but such governance indicators pose challenges in adjusting for poor coherence and non-comparability of data.
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Measurement of corruption based on perceptions , for example, poses difficulties to compare scores between regions. Despite these shortcomings, there is fair deal of agreement about the indicator to be used for various research questions. For example, political decentralization may be captured by the tiers of elections; administrative decentralization could be approximated by the degree of sub-division of nation states, and fiscal decentralization could be assessed by the share of sub-national expenditure in total expenditure. However, all these types of proxy indicators have their own deficiencies [ 81 ].
A corollary to this is the difficulty in attributing improvement of indicators to a specific health sector reform. Healthcare in general and medical service delivery in particular is dynamic; therefore, quality is ought to be dynamic. Defining quality under such circumstances remains a major challenge.
Most definitions rest on two basic concepts: i appropriate processes of care; and ii patient outcomes or end results of care. The assumption is that when applied properly, the former will maximize the latter [ 82 ]. As often is the case in a country like India, where patients are unfamiliar with the larger organizations from which they are seeking care, suspicion and mistrust are frequently reported. There is also rising criticism about the use of clinical outcomes in the evaluation of quality of the care, particularly the mortality rates; it is argued that administrative data do not provide a transparent perspective on quality [ 86 — 89 ].
Finally, the clinical dimensions are themselves expanding, and the definition of quality of health care encompasses the whole of health system, not just the physician alone; health care is increasingly seen as a team effort. Thus, the entire focus on quality of care is getting broadened. This presents a constant challenge as to how we eventually perceive and define overall quality of care.
It is now well accepted that in health sector, there are demand- and supply-side characteristics; both operate through a relatively complex interplay of factors. The locus of control of many such factors is often outside the direct purview of the health department. We have considered the supply side characteristics as i institutional frameworks and supporting rules and regulations to operationalize institutions; ii service providers, their knowledge, skills, perceptions and satisfaction; and iii health system characteristics that are contingent upon the processes being adopted at various levels of the decision making hierarchy.
The demand side characteristics on the other hand constitute i patients who are the principal beneficiaries of the health system; and ii the community in general Fig.
Country experiences in decentralization in South Asia. Report of the subregional workshop
Relationship among inputs, processes and outputs through supply and demand-side factors. An efficient health system is considered as a critical input for success of public health service delivery. Compliance of health units with national quality benchmarks, such as, Indian public health standards IPHS or international standards organization ISO could be construed as symbolic of a well-functioning health system.
Hence, study of compliance may be considered as an important question of enquiry in the discourse of decentralization. Institutional processes, such as, management practices including decision making norms, knowledge, perception and experience of decision makers and service providers and decision space including involvement and interest of stakeholders are critical bridges between the community and the health units as to make the health units responsive. The socio-economic characteristics of patients and the community, their perception, health seeking behavior and satisfaction about the health care services that they receive could serve as critical sub-elements of enquiry at output level.