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. 2018 Nov 5;13(11):e0206809.
doi: 10.1371/journal.pone.0206809. eCollection 2018.

What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines

Harvy Joy Liwanag  1   2   3 , Kaspar Wyss  1   2
Affiliations

What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines

Harvy Joy Liwanag et al. PLoS One. .

Abstract

Background: Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago.

Methods: Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions.

Results: These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner.

Conclusions: The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Simplified overview of the administrative structure of government health facilities in the Philippines before and after devolution.
Fig 2
Fig 2. Present and previous areas of health sector-related work of the 27 decision-makers.
Locations indicate assignments that were ≥3 years. (Map tiles by Stamen Design, under CC BY 3.0. Data by OpenStreetMap, under ODbL.).
Fig 3
Fig 3. Durations of government service of the 27 decision-makers, the institutions they worked in, and their levels of decision-making.
Selected events in the Philippine health sector are also indicated.
Fig 4
Fig 4. A conceptual diagram inspired by the image of decentralization and centralization as movements between two opposite poles.
Various conditions to be considered for decentralization to be effective in improving the health system are proposed.
See this image and copyright information in PMC

References

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