Analyzing the decentralization of health systems in developing countries: Decision space, innovation and performance
Analyzing the decentralization of health systems in developing countries: Decision space, innovation and performance
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DOI：
10.1016/s0277-9536(98)00234-2
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发表时间：
1998-11-01
影响因子：
5.4
通讯作者：
Bossert, T
中科院分区：
文献类型：
--
作者：
Bossert, T
长期以来，权力下放一直被倡导为改善卫生系统的一个理想过程。然而，我们仍然缺乏一个足够的分析框架来系统地研究权力下放如何实现这一目标。我们没有足够的方法来分析权力下放的三个关键要素：（1）从中央机构转移到卫生系统边缘机构的选择量；（2）地方官员利用其增加的自由裁量权做出了哪些选择；（3）这些选择对卫生系统的绩效有什么影响。本文提出了一个分析框架，可用于设计和评估卫生系统的权力下放。它从这样一个假设出发，即权力下放本身不是目的，而应根据其实现卫生改革更广泛目标（公平、效率、质量和财务稳健性）的能力来进行设计和评估。本文以“委托 - 代理”方法为基本框架，但融合了公共行政、地方公共选择和社会资本方法的见解，提出了一种决策空间方法，该方法根据正式转移给地方官员的职能集和选择程度来定义权力下放。该方法还评估了中央政府可以为地方决策者提供的激励措施，以鼓励他们实现卫生目标。它评估了也会影响地方层面决策和实施的地方政府特征。然后确定地方官员是否通过做出与中央当局指示不同的选择来进行创新。最后，评估地方的选择是否提高了地方卫生系统在实现更广泛卫生目标方面的绩效。文中用哥伦比亚的例子来说明该方法。这个框架将用于分析拉丁美洲一系列实证研究中的权力下放经验。这些研究的结果应该会为调整决策空间和激励措施提出政策建议，以便地方做出实现卫生改革目标的决策。（C）1998年爱思唯尔科学有限公司。保留所有权利。
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. (C) 1998 Elsevier Science Ltd. All rights reserved.