Decentralization of health services in Uganda, driven by the structural adjustment programme of the World Bank, was embraced by government as a means to change the health institutional structure and process delivery of health services in the country.Arising from the decentralization process, the transfer of power concerning functions from the top administrative hierarchy in health service provision to lower levels constitutes a major shift in management, philosophy, infrastructure development, communication as well as other functional roles by actors at various levels of health care.This study focused its investigation on ways and levels to which the process of decentralization of health service delivery has attained efficient and effective provision of health services.The study also examined the extent to which the shift of health service provision has influenced the role of local jurisdictions and communities.Challenges faced by local government leaders in planning and raising funds in response to decentralized health service delivery were examined.The study used a descriptive survey research design employing qualitative techniques, namely questionnaires, structured interviews, observation, and document analysis to establish the extent to which the decentralized approach to health service delivery has impacted on local governments and the vulnerable target groups such as the rural and urban poor, children, mothers, HIV/AIDS victims, orphans and refugees.Key respondents were government officials in health related management in the country at various levels.Health workers and beneficiaries of health services were interviewed to share their views and experiences of decentralized health care service provision.iii Using a conceptual framework of "Community as Client", the findings illustrate that while some local governments in the country have extended health units closer to some communities, the pursuit of a decentralized health service delivery system in Uganda over-assumed the benefits of decentralizing health care.The observations indicated that health care is not better organized; neither has decentralization provided greater involvement of local communities in mobilization and capacity building of community-based health workers.The acclaimed cost containment and reduction through duplication of services, reduction of inequities, integration of activities of different agencies and organizations involved in health care have not been achieved in concert with original expectations and assumptions of decentralization.These include: strengthened health policy and planning functions of the ministry of health, improved implementation of health programmes, greater community control and financing (ownership) and improved inter-sectoral coordination.From the findings, it would appear that the motivation for decentralizing health care was not intrinsically guided by how the decentralized health system can better serve the poor majorities in the country.The study concludes that the decentralization of health services in Uganda was not matched with commitment for provision of necessary health supplies, and delivery of health care services through a centrally coordinated national network of health facilities.The Ugandan Government in particular Ministry of Health and the government needs to evaluate the achievements and challenges faced by the health care system under decentralization within the broader perspective of health for all, as a means to establish appropriate refocusing of health care delivery for optimal benefit of the client communities.
Mário Fortuna, José António Cabral Vieira, Margarida Mendes
One objective frequently found in models of decentralized financing is that of equalization. The concern is that poorer jurisdictions receive enough resources for basic services and for development promotion, thus eliminating horizontal and vertical imbalances. In Portugal, decentralization has occurred at two levels: the local, for the whole country and the regional for the autonomous regions of the Azores and Madeira. Decentralization to local governments has undergone several changes in recent decades. The current paper focuses on testing for the presence of an equalization effect in the models adopted to finance municipalities in Portugal, since the nineteen nineties. Using the theoretical background that maintains that for the presence of an equalizing effect it is necessary that, on a per capita basis, poorer regions or localities receive relatively more transfers than the richer jurisdictions, a test is made using a data set that includes all municipalities of Portugal. The situation of the two autonomous regions is controlled with dummy variables. The hypothesis that the models used have an equalizing effect is tested through the sign of the coefficient of the regression of per capita transfers on per capita own resources. In the presence of an equalizing effect the sign will be significant and negative. It is confirmed that, for the period under analysis, the municipalities with lower per capita own revenues are those that receive more transfers per capita. There is, therefore, an equalizing effect in the current transfer system to municipalities. Using pooled data, one can also conclude that the equalization effect has become stronger with the 1998 and 2002 reviews of the system, when compared to the system in effect in 1991.
We examine the pyramidal ownership structure of a large sample of newly listed Chinese companies controlled by local governments or private entrepreneurs. Both types of the owners use layers of intermediate companies to control their firms. However, their pyramiding behaviors are likely affected by different property rights constraints. Local governments are constrained by the Chinese laws prohibiting free transfer of state ownership. Pyramiding allows them to credibly decentralize their firm decision rights to firm management without selling off their ownership. Private entrepreneurs are constrained by their lack of access to external funds. Pyramiding creates internal capital markets that help relieving their external financing constraints. Our empirical results support these conjectures. Local governments build more extensive corporate pyramids when they are less burdened with fiscal or unemployment problems, when they have more long-term goals, and when their firm decisions are more subject to market and legal disciplines. The more extensive pyramids are also associated with smaller "underpricing" when the firms go public. Entrepreneur owners construct more complex corporate pyramids when they do not have a very deep pocket - as indicated by whether they are among the top-100 richest people in China.
India has set out ambitious goals for itself in the health sector in its Tenth Five Year Plan (2002-07). It is also a signatory to the United Nations Millennium Development Goals. Attainment of these goals which are time-bound will require a massive scaling up of investment in health, especially in public primary health care. We argue for a ‘Health for All’ initiative on the part of the government akin to the ‘Education for All’ scheme which was launched nation-wide in 2001. The large amount of resources required for scaling up public investment in primary health need not be the constraint it is purported to be. We discuss several options that are available to the government for generating the necessary funds. Among the options that can generate resources domestically are reform of the government’s subsidies regime including implementing life-line tariffs, ear-marking taxes and disinvestment of loss-making public sector units. Health for All can also be financed by raising more resources via external assistance. Official development assistance to India at present is rather low given India’s per capita income and the scale of its needs in human development terms. The scale of official development aid to India should increase several folds and committed use of funds should be made by the government in health and other priority sectors. With the 73rd and 74th amendments to the Indian Constitution which created a third tier of government comprising of elected local bodies at the village and town ward levels, a decentralized system of service delivery will eventually become a reality in India and needs to be a part of any debate on the means and modes of improving human development outcomes in India. The current system of planning and allocation of funds at the sub-national level however needs to be over-hauled if fiscal decentralization is also to become a reality.
Omar Khadeer Hussain, Elizabeth Chang, Farookh Khadeer Hussain, Tharam S. Dillon · 5 authors
Risk is associated with almost every activity that is undertaken on a daily life. Risk associated with Trust, Security and Privacy. Risk is associated with transactions, businesses, information systems, environments, networks, partnerships, etc. Generally speaking, risk signifies the likelihood of financial losses, human casualties, business destruction and environmental damages. Risk indicator gives early warning to the party involved and helps avoid deserters. Until now, risk has been discussed extensively in the areas of investment, finance, health, environment, daily life activities and engineering. However, there is no systematic study of risk in Decentralised communication, which involves e-business, computer networks and service oriented environment. In this paper, we define risk associated with trusted communication in e-business and e-transactions; provide risk indicator calculations and basic application areas.
One of the limitations of cross-country health expenditure analysis refers to the fact that the financing, the internal organization and political restraints of health care decision-making are country-specific and heterogeneous. Yet, a way through is to examine the influence of such effects in those countries that have undertaken decentralization processes. In such a setting, it is possible to examine potential expenditure spillovers across the geography of a country as well as the influence of the political ideology of regional incumbents and institutional factors on public health expenditure. This paper examines the determinants of public health expenditure within Spanish region-states (Autonomous Communities, ACs), most of them subject to similar financing structures although exhibiting significant heterogeneity as a result of the increasing decentralization, region-specific political factors along with different use of health care inputs, economic dimension and spatial interactions.
The French health-care system is almost totally under the supervision of the government, which defines the general orientation of health policy. For example, a health-care policy for cancer treatment will be developed in France within the next 5 years. The government organizes the initial formation of all categories of health professionals and so controls the number of professionals in each category. In France, 4500 medical students graduate each year. Demographic problems at the present time are caused by the quota for all medical professions. The government also ensures that the number and location of hospitals are adequate for the needs of the French population. It supervises public hospitals and the management of private clinics, with the objective of providing a consistent standard of care in all health-care structures. The government also proposes the health budget for parliament's approval. In 1996, in line with the concept of decentralization, which means ‘to think globally but act locally’, regional agencies for hospital care were created in each administrative region. They are responsible for the strategic and economic supervision of hospitals, and for the organization of regional health care. However, they have no authority with regard to ambulatory care, thus creating a gap between hospital and ambulatory care in France, which represents a great obstacle to the coordination of care for disabled and elderly people. The French health-care system is a mixed system, being both etatic and liberal. There is a collective health insurance program in place based on incomes; the premium payments are automatically deducted from salaries. The rate is determined each year by the government for an equilibrated budget. Patients have completely free access to all medical care, including hospitals and choice of practitioners. They can have as many consultations and hospitalizations as they want. Furthermore, public and private health structures coexist. Sixty-five percent of hospitals are public and 35% are private. Ambulatory care structures are mainly private (95%). Therefore, although the French system is complex, comprising etatic and private organizations, it functions well. Furthermore, freedom and heterogeneity are probably the main guarantees of quality of health care in France, even if the cost is high and constantly increasing. In France, the number of available hospital beds for acute care (short-stay units), rehabilitation, long-term care and psychiatry is high (Table 1). The rates per 1000 people are the highest in Europe. However, the number of beds for disabled geriatric patients is low: 400 000 beds in retirement homes and 68 000 beds in long-term care units. There is a very long queue to get into such establishments. For psychiatric institutions, there are a total of 6430 beds. The number of health professionals is quite high (Table 2), but they are growing older and demographic problems will arise in the next 10 years. To finance the health-care system, including ambulatory and hospital care, a budget is approved by parliament annually. Ten percent of the gross domestic product (GDP) is devoted to the health-care system (130bn euros), including public hospitals, private hospitals, ambulatory care organizations and pharmacies (Table 3). The budget is being constantly increased. Patients can get a refund of the total cost of health care. For example, refunds for hospitalization costs are between 80% and 100%. For ambulatory care, refunds are between 70% and 100% and for drugs, between 35% and 100%. Health care is free for the homeless and poor people (100% refund). There is a list of 30 severe diseases, including Alzheimer's disease (AD), for which patients are entitled to a 100% refund. Last year, the treatment of AD was listed as a national priority and the government established a care program for the disease. Two main initiatives were proposed. The first one is diagnosis, particularly early diagnosis, as only half of the patients are diagnosed in France. In regard to this, the program proposed the development of memory clinics and regional expert centers. The second initiative is to provide better care for people with AD. This covers ethical issues, the possibility of family caregivers benefiting from some help, financial aid, and the creation of social day-care centers. Hospital care for people with AD is totally paid for by the social security system. Various options are available: short-stay units, rehabilitation units, and day hospitals (of which there are too few) for diagnosis and rehabilitation. Furthermore, people with AD are generally not very welcome in traditional short-stay and rehabilitation units, and it is very difficult to get them a place in such units. Memory clinics are being developed and regional expert centers will be created next year to assist in the early diagnosis of the disease. An expert center must meet specific defined criteria. It must have a multidisciplinary team (neurologists, geriatricians, psychiatrists, and neuropsychologists) and a day hospital for disease diagnosis (capable of handling at least 100 new patients a year). It must also be a source of expertise in research, possess postgraduate knowledge about dementia, and be the centre of a network including general practitioners, ambulatory neurologists and memory clinics of the first degree. Ambulatory care for people with AD is provided by neurologists and psychiatrists (both in insufficient numbers), and by general practitioners, who are not accurately trained for dementia care. Very few geriatricians are included in ambulatory care. Nurses, orthophonists, and physiotherapists are also involved, but again, they are insufficient in number. In other words, social day-care centers should be developed. Social support for patients is financed by a new prestation, the ‘APA’ (personalized prestation for the promotion of autonomy). This prestation was defined in 2002. The amount of the prestation is calculated according to the loss of autonomy. Patients are classified into six groups upon evaluation of their autonomy. It is possible for patients to buy the time of professional social workers and caregivers. The highest level of financial aid they can obtain is 1200 euros per month. Today, 50% of patients are being looked after only by family caregivers. Nursing homes are currently evolving in France. Retirement homes and long-term care units now belong to a single category. The total living expenses comprise three parts: food and housing costs are borne by the patients (through family or social aid); nursing costs are covered by the APA prestation and patients (or their families); and the total cost of medical care is covered by social security (100%). In conclusion, the French health-care system is quite unique since it involves both etatic and liberal organizations. It is an excellent system for patients because of low medical costs, but it requires a high cost of maintenance.
In America free public education is a constitutional value. Yet, although free public education
for all is a constitutional value, America's public schools remain ravaged by savage
inequalities, many of which are the direct result of significant financial disparities. Given
the obvious conflict between the constitutional value of free public education for all and the
funding parities created by the States' school finance systems, it is not surprising that the
courts have been asked to intervene and vindicate the constitutional value of free public
education for all by declaring that the current system of financing the schools is
unconstitutional. However, a judicial solution to the problem has proved as elusive as a
legislative or executive solution. Paradoxically, a major reason for the States' failure to adequately finance the
achievement - the constitutional value of quality education for all - is the existence of other
constitutional values. In other words, there are values within the American constitutional
system that make it extremely difficult to achieve another constitutional value. This article
explains how two American constitutional values - judicial restraint and decentralization -
work together to prevent adequate funding of another constitutional value - a quality education
for all.
What is best strategy to reach the Millennium Development Goal of basic education for all will depend on the specific country context.This paper introduces an input-output method to estimate the financial inputs required to achieve the MDG for primary education and an additional target of enhancing access to secondary education. 1As such the approach followed here is not new, but the innovative element is combining educational demand and supply variables considering both cost dimensions and quality of services as measured among others through test scores (outcomes), quality of school inputs and the nature of delivery of services (privatepublic, centralized or decentralized).We take the following analytical steps: (i) define a production function for specific education outputs (enrolment), (ii) isolate the main determinants of such output (considering both demand and supply factors); (iii) estimate costs per unit of producing such output, and -based on estimated elasticity's and unit costs ensuing from the education production function -(iv) calculate the financing needs of reaching key education goals.We find that determinants of access to schooling are significantly different for urban and rural and for poor and non-poor children.Furthermore, the determinants also differ when referring to access to primary or secondary education.Quality of school inputs does matter in all cases though to varying degree.Particularly, class size, shares of trained teachers and greater school autonomy (in hiring teachers and managing schools) are relevant.Quality of education outcomes, i.e. test scores, while very poor in Ecuador does not seem to influence school enrolment.The upshot is that with a more cost-effective use of resources for primary education, the MDG target of 100% of net primary school enrolment in urban areas is within reach in a period of 4 to 5 years at virtually no additional budgetary cost.Meeting the target for the rural population seems more complicated.In secondary education, important progress can be made to reach a target of 70% net enrolment (with important expected positive externalities for economic growth) by enhancing the share of trained teachers, expand coverage of school demand subsidies and improve class infrastructure.This target is within reach for the poor and non-poor urban population by 2007 at an estimated additional cost of 1 Vos is with the Institute of Social Studies (ISS), The Hague and the Free University Amsterdam.Ponce is with FLACSO-Ecuador and is also a PhD candidate at ISS.
OBJECTIVE: To assess the equity and fairness of the Mexican health system reform that occurred in the late 1990's. MATERIAL AND METHODS: The Mexican reform process was evaluated using the benchmark-system designed by Daniels et al. This benchmark system was adapted to the Mexican setting by adding specific indicators. A documentary review of the Mexican reform process was conducted to score its performance for each benchmark. RESULTS: Except for housing and nutrition components, the reform included few actions related to health determinants. For health care, the main reform initiatives were those related to extending the coverage of essential health services and decentralizing health care provision to the states. Reform initiatives included few activities related to fair financing, tiering, emphasis on second and third level care, accountability, and transparency. CONCLUSIONS: The late nineties reform of the Mexican health system had some positive effect on access of the poor to health care and administrative efficiency, but little impact on fair financing, quality of care, and democratic governance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.
For a variety of reasons, many developing countries especially since the 1990s have embarked on programmes of democratic decentralization that are aimed at creating local self-governing systems that are democratic, relatively autonomous and effective in delivering services.Finding independent sources of financing for these emerging, locally based organs of governance has been one of the central challenges that confront these efforts in most countries.The literature suggests that sources of independent local government revenue are few in poor countries.As a result, most countries design decentralization programmes that depend heavily on intergovernmental transfers from national to local governments.Given widespread poverty that exists in most developing countries, this is a crucial strategy.However, the problem is that many central governments are engulfed in a systemic financial crisis and are desperately exploring strategies for reducing their expenditure commitments.One outcome is that revenue transfers are often irregular or fall much below the levels of expenditure decentralization, leading to serious fiscal gaps at the local level.Even where transfers are adequate and reliable, a fiscal regime which compels local actors to depend so heavily on central financial arrangements for practically all of their expenditure requirements undermines the development of lateral (local state-citizen) rather than vertical (central-local state) relations within the state, with serious implications for public participation and effective accountability.In the meantime, cities of developing countries continue to grow phenomenally in a way that makes conventional strategies for financing urban infrastructures unsustainable.Many analysts view this rapid urbanization as fatally aggravating the problem of urban/local governance.This paper suggests a different and more positive view.It reviews the literature which concedes that property taxation remains largely untapped and might indeed be progressive in developing countries.This literature highlights mainly the technical constraints to progress-assessment, valuation and collection.In contrast, this paper contends that the tax suffers from a combination of political and technical factors where the latter are dependent not independent variables.The paper undertakes an analysis of the key stakeholders in implementing successful property taxation policies based on research conducted in four countries-India, Nigeria, Republic of South Africa and Zimbabwe in the early 1990s.The paper suggests that willingness, opportunity and capacity remain critical factors and demonstrates how opposition to the tax can be overcome by strategic partnerships between central and local governments, public and private and domestic and external actors.
This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state.
Each year, up to three million deaths due to malaria and close to five billion episodes of clinical illness possibly meriting antimalarial therapy occur throughout the world, with Africa having more than 90% of this burden. Almost 3% of disability adjusted life years are due to malaria mortality globally, 10% in Africa. New information is presented in this supplement on malaria-related perinatal mortality, occurrence of human immunodeficiency virus in pregnancy, undernutrition, and neurologic, cognitive, and developmental sequelae. The entomologic determinants of transmission and uses of modeling for program planning and disease prediction and prevention are discussed. New data are presented from the Democratic Republic of the Congo, Tanzania, Ethiopia, and Zimbabwe on the increasing urban malaria problem and on epidemic malaria. Between 6% and 28% of the malaria burden may occur in cities, which comprise less than 2% of the African surface. Macroeconomic projections show that the costs are far greater than the costs of individual cases, with a substantial deleterious impact of malaria on schooling of patients, external investments into endemic countries, and tourism. Poor populations are at greatest risk; 58% of the cases occur in the poorest 20% of the world's population and these patients receive the worst care and have catastrophic economic consequences from their illness. This social vulnerability requires better understanding for improving deployment, access, quality, and use of effective interventions. Studies from Ghana and elsewhere indicate that for every patient with febrile illness assumed to be malaria seen in health facilities, 4-5 episodes occur in the community. Effective actions for malaria control mandate rational public policies; market forces, which often drive sales and use of drugs and other interventions, are unlikely to guarantee their use. Artemisinin-based combination therapy (ACT) for malaria is rapidly gaining acceptance as an effective approach for countering the spread and intensity of Plasmodium falciparum resistance to chloroquine, sulfadoxine/pyrimethamine, and other antimalarial drugs. Although costly, ACT ($1.20-2.50 per adult treatment) becomes more cost-effective as resistance to alternative drugs increases; early use of ACT may delay development of resistance to these drugs and prevent the medical toll associated with use of ineffective drugs. The burden of malaria in one district in Tanzania has not decreased since the primary health care approach replaced the vertical malaria control efforts of the 1960s. Despite decentralization, this situation resulted, in part, from weak district management capacity, poor coordination, inadequate monitoring, and lack of training of key staff. Experience in the Solomon Islands showed that spraying with DDT, use of insecticide-treated bed nets (ITNs), and health education were all associated with disease reduction. The use of nets permitted a reduction in DDT spraying, but could not replace it without an increased malaria incidence. Baseline data and reliable monitoring of key outcome indicators are needed to measure whether the ambitious goals for the control of malaria and other diseases has occurred. Such systems are being used for evidence-based decision making in Tanzania and several other countries. Baseline cluster sampling surveys in several countries across Africa indicate that only 53% of the children with febrile illness in malarious areas are being treated; chloroquine (CQ) is used 84% of the time, even where the drug may be ineffective. Insecticide-treated bed nets were used only 2% of the time by children less than five years of age. Progress in malaria vaccine research has been substantial over the past five years; 35 candidate malaria vaccines are in development, many of which are in clinical trials. Development of new vaccines and drugs has been the result of increased investments and formation of public-private partnerships. Before malaria vaccine becomes deployed, consideration must be given to disease burden, cost-effectiveness, financing, delivery systems, and approval by regulatory agencies. Key to evaluation of vaccine effectiveness will be collection and prompt analysis of epidemiologic information. Training of persons in every aspect of malaria research and control is essential for programs to succeed. The Multilateral Initiative on Malaria (MIM) is actively promoting research capacity strengthening and has established networks of institutions and scientists throughout the African continent, most of whom are now linked by modern information-sharing networks. Evidence over the past century is that successful control malaria programs have been linked to strong research activities. To ensure effective coordination and cooperation between the growing number of research and control coalitions forming in support of malaria activities, an umbrella group is needed. With continued support for scientists and control workers globally, particularly in low-income malarious countries, the long-deferred dream of malaria elimination can become a reality.
The severe acute respiratory syndrome (SARS) crisis in China revealed not only the failures of the Chinese health-care system but also some fundamental structural deficiencies. A decentralized and fragmented health system, such as the one found in China, is not well-suited to making a rapid and coordinated response to public health emergencies. The commercial orientation of the health sector on the supply-side and lack of health insurance coverage on the demand-side further exacerbate the problems of the under-provision of public services, such as health surveillance and preventive care. For the past 25 years, the Chinese Government has kept economic development at the top of the policy agenda at the expense of public health, especially in terms of access to health care for the 800 million people living in rural areas. A significant increase in government investment in the public health infrastructure, though long overdue, is not sufficient to solve the problems of the health-care system. China needs to reorganize its public health system by strengthening both the vertical and horizontal connections between its various public health organizations. China's recent policy of establishing a matching-fund financed rural health insurance system presents an exciting opportunity to improve people's access to health care.
"A silent, and in my opinion revolutionary, reform of the budget, to truly become a management tool and an instrument for short-term economic and social programming." This is how the participatory budget was cataloged by a senior official from the Ministry of Economy and Finance. "They are a disaster, with this spending has been atomized... In addition, the MEF has acted against the law", affirms emphatically and harshly -and as a balance, a year later- the main person in charge of the National Decentralization Council (CND).
This paper concerns redistribution and public good provision in an economic federation with two levels of government: a local government in each locality and a (first mover) central government. Each locality is characterized by two ability-types, and the ability-distribution differs across localities. The central government redistributes via a nonlinear income tax and a lump-sum transfer to each local government, while the local governments use proportional income taxes and provide local public goods. We show how the redistributive role of taxation is combined with a corrective role, and how the central government can implement the second best resource allocation. Copyright 2008 Blackwell Publishing, Inc..
This study aims at assessing the performance of local government in Palestine in regard to fiscal and administrative decentralization. Data was gathered from the Ministry of Local Government, Ministry of Finance and a questionnaire was sent to 12 municipalities' key officials. It was found that the government is organized into the central government headed by the president, the cabinet, the governorates, mayors and village councils. The main functions of the local governments are to provide the necessary needed services. It was found that there is a degree of decentralization in providing the intended services as the functions of each level is clearly defined by the law, even though there is an overlapping amongst these functions due to the current situation instability The study explains several aspects including organization of the local government, decision making process, functional responsibilities, partnership among local government and the performance of these partnerships, employment, training programs, the most urgent issues regarding decentralization process, local government finances, financial standing of municipalities, relationship between central and local governments, and decentralization reforms under preparation, The study ends up with conclusions and recommendations. تهدف هذه الدراسة إلى تقييم أداء الهيئات المحلية في فلسطين فيما يتعلق باللامركزية الإدارية والماليـة. وقد تم جمع البيانات اللازمة للدراسة من وزارة الحكم المحلي ووزارة المالية، إضافة الى استبانة كانت قد أرسلت إلى 12 مسئولاً من مسئولي 12 بلدية. وتبين من البحث أن التنظيم الإداري للحكومة يتكون من الحكومة المركزية والمحافظات والبلديات والمجالس القروية. ووجد أن وظائف الهيئات المحلية تتركز في تقديم الخدمات الأساسية للمواطنين. وتبين أن لدى هذه الهيئات درجة كبيرة من اللامركزية في تقديمها لهذه الخدمات، لأن وظائف هذه الهيئات محددة بشكل واضح في قانون الحكم المحلي الفلسطيني، إلا أن هناك بعض التداخل في بعض الصلاحيات نتيجة للظروف الحالية. وأوضحت الدراسة العديد من القضايا الخاصة باللامركزية المالية والإدارية منها: التنظيم الإداري للهيئات المحلية، وعملية اتخاذ القرارات، والمسئوليات الوظيفية، والتعاون بين الهيئات المحلية في تقديم الخدمات، القوى العاملة في الهيئات المحلية والتدريب والحوافز، والقضايا الملحة فيما يتعلق باللامركزية، وتمويل الهيئات المحلية، والأوضاع المالية لهذه الهيئات وعلاقاتها بالحكومة المركزية، والإصلاحات الجارية الخاصة باللامركزية. وانتهت الدراسة بالخلاصة وعدد من التوصيات.
Decentralization policies are an integrated component of health sector reform in an increasing number of countries. The ability of such policies to improve the health system's quality and efficiency is backed up by limited scientific evidence. This study intends to evaluate the impact of decentralization on a specialized field of disease control (leprosy control) in Colombia and Brazil. It analyses the respective juridical base, epidemiological indicators and local publications. Furthermore, 39 semi-structured interviews with key informants were conducted. In both countries, the devolution of technical responsibility and financial resources to the municipalities was the implemented form of decentralization. Access to preventive and curative health care and the community participation in decision-making improved clearly only in Brazil. The decentralization to private providers in Colombia had dubious effects on service quality in general and still more on public health. The flow of finances (including finance collection through state-owned taxes instead of insurance companies) seemed to be better controlled in Brazil. Leprosy control in Brazil took advantage of the decentralization process; in Colombia, it came close to a collapse.
Japan is stuck between lots of rocks and several hard places. It confronts the escalating costs of the world's most rapid pace of ageing with a low and declining birthrate and virtually no support for mass immigration. Moreover, the country faces these costs while severely handicapped by a public debt 1.5 times its GDP plus dramatic declines in the high rate of savings that has hitherto financed it. In addition to all this, the poorly performing economy is in its fourth year of deflation with little hope of producing a recovery in tax revenues. Indeed, deflation and minimal economic growth have eroded national income- tax revenues to their lowest level since the collapse of the bubble economy.
Support for integrated capacity building focusing on learning support for government organizations, communities, networks and small business is the most important contribution foreigners can make to local development.Excessive equipment and action assistance with minimal learning support, is more likely to create dependence.However learning support without locally financed working resources and improved motivation is hardly effective.Decentralization of authority requires decentralization of skills.Learning support focusing on specialist and management training without integrated courses for all staff limits organizational effectiveness.Aid/ cooperation should be much better integrated.This can only be achieved through deeper dialogue and better strategies.To seek a reasonable future for the region
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
Background: Health account is one method to acquire information about financial situation in the district or the state. Based on the information, the analysis on the policy can be made, such as priority setting and equity. The information is also used for policy decision and financial planning. Complete health finance data can be acquired in condition when there is a district health account.\nObjective: To describe health financial before and after the decentralization was implemented (1998 to 2002) in Sinjai District.\nMethod: This research is a quasi experiment research with before and after design. Method of health account development, is adopted from National Health Account.\nResult: This research showed that there was an increase of health funding since 1998 to 2002 in Sinjai District obtained from the government. Before decentralization central government role in health finance was high (11,6% to 60%), but after decentralization, the role of central government decreased and district government role increased (24% to 83%). From finance intermediary site the role of hospital as finance intermediary increased since 1999 to 2002 (11% to 40%). District Health Official still! took prominent finance intermediary point in Sinjai District. From health provider site, health expenditure allocation at community health center showed a trend to decrease. Health care administration and investment function showed escalation trend. Public health action constantly decreased since 1998 to 20002.\nConclusions: Sinjai District Health Finance increased since 1998 to 2002. Due to the increase of hospital health financial allodation, hospital finance intermediary also increased. On the other hand, the financial allocation in public health programs decreased. This pattern of health finance should be reserved for a pro-poor resource allocation.\n\nKeywords: health finance, District Health Account
If the political climate is stable, local elections in Croatia take place every four years. Budgets are planned for three years, while strategic development programmes cover periods of five to ten years. Technically, the political, financial and developmental programming cycles can be matched, and implementation of the programmes ensured. However, political programmes are generally vague, budgets are every so often fictive and revised mid year and development programmes grow into visionary shopping lists. Reality shows that programmes and plans are elaborated, presented in public and then neatly put into drawers. In the aftermath, local politicians are concerned mainly about the financing flows and this is what they are usually fighting for at council meetings and in various ministries. Regularly, local administration proceeds according to the wishes of the political decision makers, without referring to any program in the end. Consequently, political accountability is lacking, fiscal management is not transparent and development is lagging behind. The main aim of this paper is to show how strategic development programmes, budgetary plans and political programmes can be linked in the Croatian socio-economic and institutional environment. Also, in line with the initiated process of decentralization in Croatia, local governments have to improve their fiscal management in order to be able to take over new functions and responsibilities. Since by now a number of local development programmes exist in Croatia, where a participatory and strategic development planning approach was applied, an analysis of the political programmes, local budgets and development programmes can be done. The purpose of this research is to demonstrate that if local governments better understood the interdependencies between these three segments, they could create reference points for their actions visible in their programmes and budgets. In this way a platform could be created to enhance the political accountability, improve fiscal capacity and fulfil developmental goals in line with real needs and potentials of the local population.