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      How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya

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          Abstract

          Background

          A common challenge for health sector planning and budgeting has been the misalignment between policies, technical planning and budgetary allocation; and inadequate community involvement in priority setting. Health system decentralisation has often been promoted to address health sector planning and budgeting challenges through promoting community participation, accountability, and technical efficiency in resource management. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, and a substantial transfer of responsibility for healthcare from the central government to these counties.

          Methods

          This study analysed the effects of this major political decentralization on health sector planning, budgeting and overall financial management at county level. We used a qualitative, case study design focusing on Kilifi County, and were guided by a conceptual framework which drew on decentralisation and policy analysis theories. Qualitative data were collected through document reviews, key informant interviews, and participant and non-participant observations conducted over an eighteen months’ period.

          Results

          We found that the implementation of devolution created an opportunity for local level prioritisation and community involvement in health sector planning and budgeting hence increasing opportunities for equity in local level resource allocation. However, this opportunity was not harnessed due to accelerated transfer of functions to counties before county level capacity had been established to undertake the decentralised functions. We also observed some indication of re-centralisation of financial management from health facility to county level.

          Conclusion

          We conclude by arguing that, to enhance the benefits of decentralised health systems, resource allocation, priority setting and financial management functions between central and decentralised units are guided by considerations around decision space, organisational structure and capacity, and accountability. In acknowledging the political nature of decentralisation polices, we recommend that health sector policy actors develop a broad understanding of the countries’ political context when designing and implementing technical strategies for health sector decentralisation.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12939-017-0649-0) contains supplementary material, which is available to authorized users.

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          Most cited references23

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          The terrain of health policy analysis in low and middle income countries: a review of published literature 1994–2007

          This article provides the first ever review of literature analysing the health policy processes of low and middle income countries (LMICs). Based on a systematic search of published literature using two leading international databases, the article maps the terrain of work published between 1994 and 2007, in terms of policy topics, lines of inquiry and geographical base, as well as critically evaluating its strengths and weaknesses. The overall objective of the review is to provide a platform for the further development of this field of work. From an initial set of several thousand articles, only 391 were identified as relevant to the focus of inquiry. Of these, 164 were selected for detailed review because they present empirical analyses of health policy change processes within LMIC settings. Examination of these articles clearly shows that LMIC health policy analysis is still in its infancy. There are only small numbers of such analyses, whilst the diversity of policy areas, topics and analytical issues that have been addressed across a large number of country settings results in a limited depth of coverage within this body of work. In addition, the majority of articles are largely descriptive in nature, limiting understanding of policy change processes within or across countries. Nonetheless, the broad features of experience that can be identified from these articles clearly confirm the importance of integrating concern for politics, process and power into the study of health policy. By generating understanding of the factors influencing the experience and results of policy change, such analysis can inform action to strengthen future policy development and implementation. This article, finally, outlines five key actions needed to strengthen the field of health policy analysis within LMICs, including capacity development and efforts to generate systematic and coherent bodies of work underpinned by both the intent to undertake rigorous analytical work and concern to support policy change.
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            Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space.

            This study reviews the experience of decentralization in four developing countries: Ghana, Uganda, Zambia and the Philippines. It uses two analytical frameworks to describe and compare the types and degrees of decentralization in each country. The first framework specifies three types of decentralization: deconcentration, delegation and devolution. The second framework uses a principal agent approach and innovative maps of 'decision space' to define the range of choice for different functions that is transferred from the centre to the periphery of the system. The analysis finds a variety of different types and degrees of decentralization, with the Philippines demonstrating the widest range of choice over many functions that were devolved to local government units. The least choice was transferred through delegation to an autonomous health service in Ghana. Uganda and Zambia display variations between these extremes. There was insufficient evidence of the impact of decentralization to assess how these differences in 'decision space' influenced the performance of each health system. The authors suggest that this is a major area for future research.
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              Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance.

              T Bossert (1998)
              Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that is transferred from central institutions to institutions at the periphery of health systems, (2) what choices local officials make with their increased discretion and (3) what effect these choices have on the performance of the health system. This article proposes a framework of analysis that can be used to design and evaluate the decentralization of health systems. It starts from the assumption that decentralization is not an end in itself but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality and financial soundness. Using a "principal agent" approach as the basic framework, but incorporating insights from public administration, local public choice and social capital approaches, the article presents a decision space approach which defines decentralization in terms of the set of functions and degrees of choice that formally are transferred to local officials. The approach also evaluates the incentives that central government can offer to local decision-makers to encourage them to achieve health objectives. It evaluates the local government characteristics that also influence decision-making and implementation at the local level. Then it determines whether local officials innovate by making choices that are different from those directed by central authorities. Finally, it evaluates whether the local choices have improved the performance of the local health system in achieving the broader health objectives. Examples from Colombia are used to illustrate the approach. The framework will be used to analyze the experience of decentralization in a series of empirical studies in Latin America. The results of these studies should suggest policy recommendations for adjusting decision space and incentives so that localities make decisions that achieve the objectives of health reform.
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                Author and article information

                Contributors
                Btsofa@kemri-wellcome.org
                Smolyneux@kemri-wellcome.org
                lucy.gilson@uct.ac.za
                Catherine.Goodman@lshtm.ac.uk
                Journal
                Int J Equity Health
                Int J Equity Health
                International Journal for Equity in Health
                BioMed Central (London )
                1475-9276
                15 September 2017
                15 September 2017
                2017
                : 16
                : 151
                Affiliations
                [1 ]ISNI 0000 0001 0155 5938, GRID grid.33058.3d, KEMRI Wellcome Trust Research Programme, , KEMRI Centre for Geographic Medicine Research Coast, ; P.O. Box 230-80108, Kilifi, Kenya
                [2 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, Global Health Department, , Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine, ; London, UK
                [3 ]ISNI 0000 0004 1937 1151, GRID grid.7836.a, Health Economics Unit, School of Public Health and Family Medicine, , University of Cape Town, ; Cape Town, South Africa
                [4 ]ISNI 0000 0004 1936 8948, GRID grid.4991.5, Centre for Tropical Medicine and Global Health, Nuffield department of Medicine, , University of Oxford, ; Oxford, UK
                Author information
                http://orcid.org/0000-0003-1000-1771
                Article
                649
                10.1186/s12939-017-0649-0
                5599897
                28911325
                7e303d83-4e05-43a4-8fcc-58003b827afa
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 10 January 2017
                : 14 August 2017
                Funding
                Funded by: The Welcome Trust
                Award ID: ##092654/Z/10/C
                Funded by: RESYST
                Award ID: N/A
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

                Health & Social care
                decentralization,devolution,planning and budgeting,financial management,kenya
                Health & Social care
                decentralization, devolution, planning and budgeting, financial management, kenya

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