DECENTRALIZATION AND COMMUNITY INVOLVEMENT ARE TOO SLOW

Decentralization is not a unitary concept, but simply a shorthand for various forms of structural arrangements to distribute power. Decentralization implies a transfer of planning, decision making, or administrative authority from a central to peripheral units. A strong basis for decentralization can be found in one of the Alma-Ata declarations which states that, "People have the right and duty to participate in the planning and implementation of their health care."

The process of decentralization is, therefore, closely linked to the process of community empowerment. Since decentralization implies a change at the national level, the protection of status quo is a major reason why decentralization doesn't happen. The process of decentralization must include not only a clear definition of roles and responsibilities at the periphery, but also a clear definition of the policy- making and technical support at the national level. Other factors which are appear to be linked to successful decentralization in health projects are discussed in Box 3.

Box 3

"D" IS FOR DECENTRALIZING PRIMARY HEALTH CARE

In the alphabet of primary health care, "D" should be for decentralization. Many countries now have decentralization policies, usually with a focus on creating geographically defined health districts. Few countries, however, have truly succeeded in establishing functional decentralized health systems. Below are some factors which appear to be associated with the successful creation of decentralized health districts.

1) A project/program should be designed with objectives and indicators defined in terms of what happens at the decentralized level (e.g., health district), rather than in terms of capacity building and a "trickle down" effect from the national level.

2) Poor communication and transportation systems can actually be positive factors in promoting decentralization. This is one reason why decentralization of health zones was successful in Zaire and has yet to be implemented in Burundi.

3) Non-Governmental Organizations (NGOs) can promote decentralization by establishing management precedents which are subsequently adopted by government managed programs, e.g., cost recovery mechanisms and autonomous financial management. The geographical definition of health districts should not be limited to administrative boundaries. The existing health infrastructure, population size, ease of supervision from the reference hospital, and health seeking behaviors of the population should be determinants of health district boundaries.

4) Over-planning at the national level leads to "centralized decentralization". Ministries of Health and partner agencies should strive to create a "project of projects" environment to facilitate the development of health districts individually without dictating all the implementation details.

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