Decentralization

WHO definitions

WHO Health Systems Strengthening Glossary [1]

Political reform designed to promote local autonomy, decentralization entails changes in authority and financial responsibility for health services. Hence, decentralization can have a large impact on health service performance. There are several forms of decentralization affecting the health sector in different ways:

1. deconcentration, which transfers authority and responsibility from the central level of the Ministry of Health to its field offices;
2. delegation, which transfers authority and responsibility from the central level of the Ministry of Health to organizations not directly under its control;
3. devolution, which transfers authority and responsibility from the central level of the Ministry of Health to lower-level autonomous units of government;
4. privatization, which involves the transfer of ownership and government functions from public to private bodies, which may consist of voluntary organizations and for-profit and not-for-profit private organizations, with varying degree of government regulation

WHO health laws and universal health coverage website [2]

Health systems decentralization involves moving decision-making away from centralised control and closer to the users of health services. Many countries have embarked on a process to decentralize their health systems as a means to improve their responsiveness and performance.

In practice, decentralization involves the transfer of authority and power from:

• Higher to lower levels of government or from national to subnational levels of government.
• Government to legally independent autonomous state organisations.
• Government to the private sector (whether “for profit” or “not for profit”).

There are four main types of decentralisation: political, administrative, fiscal, and market decentralisation.

European Observatory on Health Systems and Policies [3]

The transfer of formalresponsibiliy and power to make decisions regarding the management, production and/or financing of health services, usually from a smaller to a larger number of geographically or organizationally separate actors

Other Definitions of Decentralization

UNDP [4]

Decentralization, or decentralizing governance, refers to the restructuring or reorganization of authority so that there is a system of co-responsibility between institutions of governance at the central, regional and local levels according to the principle of subsidiarity, thus increasing the overall quality and effectiveness of the system of governance, while increasing the authority and capacities of sub-national levels.  [...] Decentralization could also be expected to contribute to key elements of good governance, such as increasing people's opportunities for participation in economic, social and political decisions; assisting in developing people's capacities; and enhancing government responsiveness, transparency and accountability.

UNHCR Glossary and Abbreviations [5]

Decentralization: The establishment of institutional and legal frameworks for decision making and the empowerment of sub-national institutions at the provincial, district, city, town and village levels in terms of fiscal, administrative, political and legal processes.

Urban Institute [6]

The concept of decentralization as ‘empowerment of people over the public sector’ further recognizes that there should be a balance between discretion and accountability at the local government level (and in the design of intergovernmental systems at all levels), and that achieving effective local empowerment requires the political, administrative and fiscal dimensions of decentralization to work hand-in-hand." (p.3)

Primary reference: Boex J, Yilmaz S. An analytical framework for assessing decentralized local governance and the local public sector. Urban Institute Centre on International Development and Governance. 2010 Dec 27:2010-06.

German Development Institute (DIE) [7]

"Decentralisation can generally be understood as "[...] the process by which authority, responsibility, power, resources and accountability are transferred from the central levels of government to sub-national levels [...] Conceptually, decentrlisation relates to the role of, and the relationship between, central and sub-national institutions, whether they are public, private or civic." The sub-national entities provide a number of basic public services and exercise basic administrative functions." [8,9,10]

Cases of Decentralization

• Brazil: Leite, V. R., de Vasconcelos, C. M., & Lima, K. C. (2011). Federalism and decentralization: Impact on international and Brazilian health policies. International Journal of Health Services, 41(4), 711-723. Retrieved from http://utsph.idm.oclc.org/login?url=https://search.proquest.com/docview/964245174?accountid=7134
• Europe: Saltman, R. B. (2008). Decentralization, re-centralization and future european health policy. European Journal of Public Health, 18(2), 104-6. doi:http://dx.doi.org/10.1093/eurpub/ckn013

[1] WHO Health Systems Strengthening Glossary https://cdn.who.int/media/docs/default-source/documents/health-systems-strengthening-glossary.pdf

[2] https://www.who.int/health-laws/topics/governance-decentralisation/

[3] Saltman RB, Bankauskaite V, Vrangbaek K (eds). Decentralization in health care. European Observatory on Health Systems and Policies Series. New York, McGraw-Hill Open University Press.

[4] UNDP, Decentralized Governance Programme:  Strengthening Capacity for People-Centered Development,  Management Development and Governance Division, Bureau for Development Policy, September 1997, p. 4[1] https://www.who.int/health-laws/topics/governance-decentralisation/

[5] Glossary. Handbook for Planning and Implementing Development Assistance for Refugees (DAR) Programmes. UNHCR

[6] Boex J, Yilmaz S. An analytical framework for assessing decentralized local governance and the local public sector. Urban Institute Centre on International Development and Governance. 2010 Dec 27:2010-06

[7] https://www.die-gdi.de/uploads/media/Studies_16.pdf

[8] Grävingholt J, Doerr B, Meissner K, Pletziger S, Rümker JV, Weikert J. 2006. Strengthening participation through decentralisation: Findings on local economic development in Kyrgyzstan. DEU.

[9] UNDP, Decentralized Governance Programme:  Strengthening Capacity for People-Centered Development,  Management Development and Governance Division, Bureau for Development Policy, September 1997, p. 4

[10] UNDP (United Nations Development Programme) / BMZ (Bundesministerium für wirtschaftliche  Zusammenarbeit  und  Entwicklung)  (2000):  The  UNDP  Role  in  Decentralization  and  Local  Governance  :  A  Joint  UNDP-Government  of  Germany Evaluation, New York: UNDP