A district health officer sits at her desk in her office in Uganda.
Napak District Assistant District Health Officer, Sister Reginah Narus in her office at the district headquarters, Lokitede, Uganda.

Decision space and decentralisation

In the previous steps we identified some of the challenges that District Health Systems (DHS) face in providing flexibility and responsiveness to the health needs and demands of their populations. A key factor in determining the ability of the DHS to be flexible and responsive is the extent of decision-making authority or ‘decision space’ given to a District Health System.

What is decision space?

Decision space is a concept put forward by Tom Bossert (Bossert, 1998). He describes it as having three elements:

  1. Who decides?
  2. Over what?
  3. And with how much choice?

Who decides?

Decision making power in each health system rests with certain people or organisations; who has the power largely determines the structure of the health system. Is it the Ministry of Health, other national agencies (Civil Service Commission, Ministry of Finance), the local government, the district health service manager, the facility manager?

Over what?

Decisions may cover a range of aspects of health system functioning, including:

  • allocation of resources (money, workforce);
  • management of the workforce (appointment, transfer, promotion, dismissal);
  • purchase and procurement of supplies, medicines;
  • construction and renovation of facilities;
  • organisation and allocation of roles in service delivery;
  • priorities and innovations.

With how much choice?

The level of choice allowed to decision makers is critical to their ability to effect change.

  • What programs or services are open to change (are there obligatory programs or services? Are there optional services?).
  • What sources of finance or types of workforce/workforce positions might be open to change, and to what degree?
  • Are there national rules or regulations which govern choices on finance/workforce?
  • What is the process for making decisions?
  • Who is held accountable for these decisions and how?

We can conceptualise decision space as a table like this

Decision space table

Table adapted from: PHRPlus, 2002, pg.5

What is decentralisation?

Increasing the level of autonomy and thus broadening the decision space of subnational levels of government or of government agencies is commonly referred to as decentralisation. It has become a very popular reform which aims to improve the accountability of subnational agencies and governments to the populations they serve; and to improve the efficiency, responsiveness and appropriateness of the services provided.

There are two main types of decentralisation:

Deconcentration – where increased authority for decisions is transferred to the regional or subnational branches/offices within a given government department or agency. This is the right hand side of the diagram below

Devolution – where increased authority is transferred to subnational levels of government, often associated with increased accountability to local populations through election of government officials; the offices/branches of national agencies within the subnational government area come under the authority of the subnational government. This is the left hand side of the diagram.

Two main types of decentralisation

What is the impact of decentralisation on health?

The impact on performance depends on many other factors in the context, including the capacity of the region/institution in management, the resources available, and the extent of decision space that is available in practice – which may depend on the local politics, relationship with local political leaders, or with national leaders.

Accountability is a key theme in decentralisation – often the process is initiated to increase accountability of local health services to their local community or government – but national governments and Ministries of Health may still be held politically accountable for health system performance, and often seek to retain various means of keeping subnational health systems accountable for their performance.


Thinking about the context of a country that you are familiar with,

(1) Assess the extent of decision space at district/subnational level in terms of

(a) management of human resources;

(b) adding or removing specific health services;

(c) collecting or using finances. For each decision area, categorise the decision space as wide, moderate or narrow/limited.

(2) Has this country introduced any policy or strategy to increase decision space at district or subnational level? If so, is the approach deconcentration or devolution? Do you think it has impacted on decision space or performance?


References
Bossert, T., 1998. ‘Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance’. Social science & medicine, vol. 47, no. 10, pp. 1513-1527.
Brinkerhoff, D. & Leighton, C., 2002. ‘Decentralization and health system reform’. Insights for Implementers, no. 1, pp. 1-12.

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