High on the list are reducing infant and maternal mortality and lowering the incidence of major diseases. Chronic
and noncommunicable diseases are increasingly prevalent in many of the region’s low-income countries, with
some indications that these diseases are worse in rural areas with poor municipal services. However, other key objectives include reducing the financial risk to individuals
and families when they become ill—the reason for universal health insurance—and responding to citizen and
patient demands for better health systems and providers.
Untangling Impact
Akey distraction to the debate is that, for many governance experts, more emphasis is placed on decentralization as a process rather than evaluating its impact on health outcomes. For instance, many consider decentralization crucial to strengthening government accountability
and transparency. While these objectives are important, it is not clear that decentralization actually leads
to beneficial health policy outcomes such as improvements in the quality of health services, greater access to
these services by high-risk populations and reductions
in the financial burdens on the poor who are other wise
unable to afford expensive treatment or surgery. Nor is
it clear that such processes lead to greater patient and
citizen satisfaction with the health system. In fact, few
scientific studies show clearly how decentralization—
or more appropriately, what type of decentralization—
would lead to these better outcomes.
There are good reasons for this lack of persuasive evidence. Decentralization is usually implemented along
with other changes that might influence the achievement of policy objectives.
For instance, the major decentralization of health
systems in Colombia and Chile in the 1980s and 1990s
was accompanied by changes in the insurance system—
which in Chile brought the introduction of an option
for wealthier citizens to opt out of social insurance programs and to purchase private insurance. Colombia introduced a “managed competition” model of public and
Thomas John Bossert, PhD, is director of the
International Health Systems Program in the
Department of Global Health and Population at the Harvard School of Public Health.
private insurance, which required uniform premiums
for a basic package of required health coverage. In addition, the economic crisis that severely reduced Colombia’s budgets in the late 1990s represented a further
complication for analysts. It’s possible that the introduction of new insurance programs in Colombia, combined
with its economic crisis, may have had more of an effect
on health objectives than did decentralization, in part
by directly changing the payments to health providers.
Second, and perhaps more important, decentralization is implemented in complex forms in different countries and changes over time. Thus, its impact is likely
to vary according to the type of decentralization that
is implemented.
Many comparative studies have made gross comparisons of significantly different types of decentralization—the usual categories are fiscal, administrative
and political decentralization. Fiscal decentralization
focuses on loosening the requirements imposed by intergovernmental transfers from the central government
to the local government, as well as increasing the ability
of local governments to contribute from their own tax
revenues to their health systems. Administrative decentralization involves enabling local governments to decide on hiring, firing, service delivery organization, and
standards for services. Political decentralization involves
increasing the accountability of local officials to their
constituency through elections or local citizen groups.
These categories, though, mask significant differences.
It is likely that the differences within each category are
more important to understanding the effectiveness of
decentralization than whether a country has implemented decentralization at all.
One way to address this problem is by asking who
gets more authority under decentralization for making
policy and implementation choices—local governments
or local offices of central ministries—and how much
choice over what types of functions they are granted.
Public policy analysts call this a “decision space” analysis. In a number of previous studies, a team of Harvard
researchers that I lead has attempted to define the different ranges of choice that decentralization has brought to
countries such as Chile, Colombia, Bolivia, Nicaragua and
Mexico, as well as to other countries outside the region.
We have developed a “map of decision space” that is
used to display the different degrees of choice that local officials are allowed, through laws or informally, to
make over key functions of financing, service delivery,
human resources, and governance. This is a complex
