Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines
Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines
复制标题
DOI：
10.1186/s12961-018-0402-1
复制
发表时间：
2019-01-10
影响因子：
4
通讯作者：
Wyss, Kaspar
中科院分区：
文献类型：
--
作者：
Liwanag, Harvy Joy;Wyss, Kaspar
背景几项关于分散化的研究使用了决策空间的方法来评估卫生系统较低级别的决策者可以获得的空间的广度。然而，为了更好地了解权力下放如何对卫生部门有效，分析应该超越评估决策空间，并包括能力和问责的层面。在Bossert早期关于这些维度协同作用的工作的基础上，我们分析了菲律宾自1992年以来政府卫生服务移交给地方政府的决策。方法采用定性研究设计，我们采访了菲律宾卫生系统不同级别的27名关键决策者，并代表了不同的地方环境。我们探讨了他们对卫生部门的决策空间、能力和问责制的看法，这些职能包括规划、筹资和预算分配、方案执行和服务交付、设施、设备和用品的管理、卫生人力管理以及数据监测和利用。结果在所有职能中，地方决策者的决策空间被评估为中等或狭窄，尽管权力下放了25年。为改进这些职能的决策，在个人一级，地方能力的调整应包括战略规划、管理、确定优先事项、循证决策和服务提供方面的创新的技能。在机构一级，这些所需能力应包括采取多方利益攸关方办法、从当地来源创收、与私营部门结成伙伴关系以及促进地方卫生机构之间的合作。另一方面，问责的调整应侧重于中央层面可以执行的各种机制，不仅是为了建设所需的能力和弥补地方一级的不足，还应该激励地方政府在履行移交给他们的职能时取得成功并规范失败。结论要优化卫生部门的分权，扩大地方决策者的决策空间，必须同时对能力和问责进行相应的调整，以促进下放职能中较低级别的良好决策。从这一协同作用的角度分析卫生系统，有助于探讨菲律宾以及其他国家的具体政策调整。
BackgroundSeveral studies on decentralisation have used the decision space' approach to assess the breadth of space made available to decision-makers at lower levels of the health system. However, in order to better understand how decentralisation becomes effective for the health sector, analysis should go beyond assessing decision space and include the dimensions of capacity and accountability. Building on Bossert's earlier work on the synergy of these dimensions, we analysed decision-making in the Philippines where governmental health services have been devolved to local governments since 1992.MethodsUsing a qualitative research design, we interviewed 27 key decision-makers at different levels of the Philippine health system and representing various local settings. We explored their perspectives on decision space, capacities and accountability in the health sector functions of planning, financing and budget allocation, programme implementation and service delivery, management of facilities, equipment and supplies, health workforce management, and data monitoring and utilisation. Analysis followed the Framework Method.ResultsAcross all functions, decision space for local decision-makers was assessed to be moderate or narrow despite 25years of devolution. To improve decision-making in these functions, adjustments in local capacities should include, at the individual level, skills for strategic planning, management, priority-setting, evidence-informed policy-making and innovation in service delivery. At institutional levels, these desired capacities should include having a multi-stakeholder approach, generating revenues from local sources, partnering with the private sector and facilitating cooperation between local health facilities. On the other hand, adjustments in accountability should focus on the various mechanisms that can be enforced by the central level, not only to build the desired capacities and augment the inadequacies at local levels, but also to incentivise success and regulate failure by the local governments in performing the functions transferred to them.ConclusionTo optimise decentralisation for the health sector, widening decision spaces for local decision-makers must be accompanied by the corresponding adjustments in capacities and accountability for promoting good decision-making at lower levels in the decentralised functions. Analysing the health system through the lens of this synergy is useful for exploring concrete policy adjustments in the Philippines as well as in other settings.