Embracing decentralization in health systems must be a philosophical and pragmatic imperative
- Latera Tesfaye
- Dec 27, 2023
- 6 min read
I penned the following paper for one of my PhD classes, and it struck me so profoundly that I felt compelled to share it here. This discourse is purely about health systems, decidedly not AI. Yet, humor me for a moment: if health policymakers were AI scientists, perhaps they'd have 'debugged' the system much sooner, averting a cascade of calamities. Or they might've changed health systems with the zeal of overfitting a neural network — brilliantly precise but perhaps tripping over the practicality of everyday life. Sharing, useless thoughts, haaa.
1. Introduction
In a world where health systems face unprecedented challenges, decentralization emerges not merely as a policy alternative but as a philosophical and pragmatic imperative. In this position paper I advocate for a strategic shift towards decentralization in health systems, by tunneling experiences from other countries. The paper underscores the need for an approach that passes a mere administrative restructuring and embraces a more inclusive, participatory, and context-sensitive model of health governance (5,6,7,8).
Traditionally, centralization in governance has been equated with control and uniformity, often at the expense of local autonomy and diversity, inefficiency, and inequality (2). No doubt, this historical pattern has resulted in systems that are rigid, unresponsive, and, at times, oppressive. In contrast, decentralization embodies a philosophical shift towards pluralism and empowerment. Decentralization is pivotal in promoting self-responsibility and competency, as it empowers individuals and communities to actively participate and make informed decisions in a diverse and complex societal landscape (1). It advocates a vision of governance that values local knowledge, encourages community engagement, and fosters a sense of ownership among stakeholders at all levels (8,9,10,11,12).
2. The need for centralization
From the Philippines to Ghana, experiences of decentralization in health systems present a spectrum of positive outcomes. Where implemented thoughtfully, it has led to significant improvements in service delivery and local governance. The need for decentralization and its broader health return can be analyzed into the following thematic topics[1] (5, 13,14):
Local empowerment and responsiveness: Decentralization places decision-making closer to the ground realities, leading to policies and services that are more fitted to local needs.
Equitable health resource distribution: By enabling local authorities to manage resources, decentralization can address imbalances and lead to more equitable health outcomes.
Diversity and innovation: Decentralized systems are better positioned to harness local innovations and adapt to diverse cultural contexts, enriching the overall health system.
Enhanced accountability in health system: With decision power distributed more horizontally, there is a greater likelihood of accountability and transparency in the health system in how health services are delivered and managed.
Decentralization in health systems, while offering potential benefits, also faces significant challenges. Variability in the decision-making authority across different levels can lead to inconsistent quality of health services and resource allocation, as observed in countries like Zambia (15,16). This inconsistency often stems from the difficulty in defining and allocating authority precisely, leading to inefficiencies and confusion. Furthermore, decentralization's impact on health outcomes is mixed; without proper design and implementation, it does not uniformly improve health services, partly due to limited capacity at lower levels, lacking necessary expertise. Additionally, challenges in coordination and resource management across governance levels, particularly in resource-constrained settings, can hinder effective decentralization. This complexity might result in losing sight of broader health policy goals, potentially exacerbating inequities in healthcare, especially in financially weaker regions, where decentralization can inadvertently lead to reduced service quality (15,16).
However, I argue against points made in the above papers. I believe there are other confounding factors at play. The lack of proper planning and implementation of this policy, combined with insufficient consideration of context and mechanisms, is to blame (5). A realist evaluation of this policy, coupled with an in-depth analysis of all decision spaces[2] in the decentralization process, points, quite clearly, to our implementation strategies (designs and evaluations), quality of its implementation, as the critical factor. Therefore, drawing conclusions based solely on these instances is not accurate. Instead, the focus should be on designing and implementing decentralization policies tailored to specific contexts and diverse administrative and population needs, moving away from centralization. Unplanned decentralization, in already broken, fragile, and weak health system, can have paramount damages.
2. A strategic opportunity: Ethiopia as an example
Ethiopia's socio-cultural diversity and the geographic spread demand a health system that is not only efficient but also equitable and responsive to its population's varied needs. Decentralization, in this context, should be approached not merely as a health policy shift but as a transformative process that aligns with the country’s broader goals of social justice and national unity (2,5).
For example, the centralized decision-making process in the health system, in the Expanded Program on Immunization (EPI), has led to significant disparities and inefficiencies[3] (3). Despite prioritization, immunization coverage has stagnated, with wide regional variations (20.6% in Afar to 91.7% in Addis Ababa) and low overall rates (39% fully vaccinated in 2016), indicating systemic implementation barriers (3). If millions of children are dying from vaccine-preventable diseases, and vaccines are a national health priority consuming a significant portion of national health expenditure, then it is imperative to question our vaccine delivery methods. These methods are often found to be ineffective stemming from the ineffectiveness of the vertical decision making.
3. Philosophical implications beyond policy to paradigm shift
As described above, decentralization in health systems is not just a policy choice; it is a paradigm shift towards a more democratic and equitable model of governance (2,3). It challenges the traditional hierarchies of power and promotes a more humane and just approach to health care, in addition eradicating power control, inequality, and corruption. For example, centralization in health systems can exacerbate pay and skill gaps by concentrating resources and expertise in central locations. In Ethiopia, for instance, where there is one doctor for every 10,000 people (4), the centralization of healthcare resources has led to a situation where hundreds of medical doctors remained unemployed in the capital, in which some of these doctors, rather than working in remote regions with challenging living conditions, often choose unemployment until alternative opportunities, such as in research become available. Moreover, the centralized health system in most African countries has increasingly drawn politicians into roles as leaders and decision-makers[4]. Unfortunately, their decision-making is often influenced by personal/their governments interest and limited by a narrow, self-serving perspective. This mixing of politics and healthcare, marked by compromised moral values and a focus on personal gain, has led to inefficient policymaking. It is a tragic situation where millions could have been saved by more effective policies and by entrusting decision-making to those genuinely capable, committed to the public good, and know the local contexts. The obvious and feasible solution is to decentralize the health system, which will eventually weakness those who are with too much power in health.
4. Conclusion
Decentralization presents an opportunity to reimagine health systems that are more resilient, equitable, and aligned with the diverse needs of the population. For countries in Africa, I believe this is not just a policy decision but a commitment to a future where health systems are grounded in the principles of democracy, equity, and pluralism. Embracing decentralization is, therefore, both a pragmatic choice and a moral imperative, a step towards creating health systems that are not only efficient and effective but also just and humane.
Consider this, if we had robust and self-sufficient local health systems, empowered to generate their own demands, craft their own strategies, and set competitive salaries, we might not face a reality where hundreds of trained doctors divert to research in larger or central organizations/institutions or other education in public health, often leading them away from primary care and, frequently, out of their country. Imagine a health system where each local hub is a powerhouse of capability, innovation, and opportunities, creating where healthcare professionals are not just trained, but passionately engaged in transforming the health landscape of their communities that they live in. If that seemed tantalizing, you do not have to look far, the answer has been in this paper all along.
Recommendations for a health system I know better - Ethiopia - beginning the journey of decentralization– what worked for others!
To undertake the transition towards decentralization, which is indeed a long and resource-intensive journey, I recommend the following multi-step processes (13,14):
Contextualized decentralization framework: Spend more time in design and preparation phase. Develop a decentralization framework that is tailored to Ethiopia's unique demographic, socio-political, and economic context.
Empowering local health systems: Before enrolling the implementation of decentralization, design helper polices to strengthen local health systems by providing them with the necessary authority, resources, and capacity-building support.
Specific program and location-focused decentralization: Rather than system-wide decentralization effort, implement program/location-based strategy coupled with hierarchies of pilot testing. This helps in studying the acceptability and feasibility of decentralization strategies.
Rigorous monitoring and evaluation: Implement robust systems for continuous monitoring, evaluation, and iterative learning to refine and adapt decentralization strategies.
Footnotes
[1] These thematic areas are summarized from realistic evaluation of decentralization program as intervention and comparative analysis using decision space theory.
[2] Finance, human resources, service organizations, governance, and access rules.
[3] Poor micro planning has led to where a vaccine coverage in some districts is extremely low, however, the wastage rate in other districts is extremely high.
[4] Currently, politicians see health as a never-ending source of money and if all the money is going to be channeled through a narrow, centralized system, rather than being widely distributed horizontally, it can create a convenient node for corruption and exploitation.
References
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