Decentralisation of the Health Sector

Dr Richard Tambulasi and Bakhethisi Mlalazi

Presentation to the Mid-Year ReviewMHSP-TA

27 April 2015

Presentation outline

• Introduction and background• Decentralised health services delivery • Resourcing for health at district level• Human resource for health • Governance in the decentralised framework

Introduction and background

• Review of issues related to decentralisation of the health sector

• Objective is providing Technical Assistance to support the implementation of HSSP for enhanced health service delivery

• Focus on : General Background on Decentralisation, Service Delivery, Human Resource , Resourcing , and Governance

Introduction and Background continued

• Methodology: chiefly an in-depth qualitative analysis carried, data gathered through in-depth interviews conducted with key informants both at policy making and implementation levels .

• Acknowledgements: Decentralisation Group based at the MOH - Chair Mr Masache, and the Director of Planning Dr Kabambe and all members of the DEG for rich feedback and support

Why Decentralisation

• To enhance health service delivery • Find local solutions for local health problems • Increased resource mobilisation for health• Improve primary level and secondary level service

delivery

Why Decentralisation

1. Second Health Plan 1973-1998 to Fourth Heath Plan, National Health Policy Framework of 1995, Joint Program of Work for a Health Sector Wide Approach 2004-2010, HSSP 2011-2016, Republic Constitution 1995, The Local Government Act, 1998, Decentralisation Policy 1998

2. MOH Devolution guidelines 2004, MOH guidelines for the management of devolved health sector 2004, MLGRD guidebook on decentralisation 2005, Draft Health policy

Progress so far for devolution of functions

• All the sectors have not fully devolved their functions to the councils

• Human resources management still centralised • The ministry of health has done some strides:

Progress so Far for Devolution of Functions contn.

1. Finance: Health is the only ministry that has devolved to districts more than 80% of all “sector funds”. Health, has deconcentrated about 40% of its budgetary resources – Some challenges: DHO in some cases not signatory and inter-

borrowing happens without his/her knowledge

2. Procurement: The council has one procurement committee at the district level and all sectoral committees were dissolved– infrequent meetings lead to leads to delays in purchasing

Gaps and inconsistences in policy, legislation and implementation

• Conflict on the role of zonal offices in a decentralised set up among MOH, MLGRD and DHRMD

• No articulation of the responsibility allocation for district hospital

• Policy and guidelines do not spell out the operationalization of division of labour on service delivery between cities and district assemblies.

Gaps and Inconsistences in Policy, Legislation and Implementation

• There seems to be no agreement between the MOH and MOLGD on the implementation modality of decentralisation: big bang approach vs incremental approaches

• Some laws preserve centralisation, while others promote decentralisation. The Public Health Act (1948) s 142; Vs Local Government Act S10 and S 25).

Institutional and Legal Framework of Decentralisation in Other Countries and Lessons for Malawi

• Cases Reviewed: Uganda, South Africa, Tanzania, Norway

1. Clear division of responsibilities among levels of health service to avoid duplication, role confusion and ensure value for money.

2. Coordination, partnership and agreement between the Ministry of Local Government and Ministry of Health on critical aspects of local government

3. Synergies between laws, legislation and policies to avoid conflict.

Institutional and Legal Framework of Decentralisation in Other Countries and Lessons for Malawi cont

4. Regional level structures are not against decentralisation but complement it. Role of Zones in the Malawian context 5. Decentralisation is a process: It can be implemented in a phased manner with districts and sectors that are seen to be ready to start first and the rest can follow 6. There is no one blue print for decentralisation. It is rather context specific. 7. Decentralisation is not a magic bullet to effective service delivery.

Decentralised Health Services Delivery

Levels of care delivery 1. Community 2. Primary 3. Secondary 4. Tertiary

The Proposed Decentralised Services Delivery 2. Directorate of Health and Social Services to do the following:

a. preventive health services; (c) curative services;b. social welfare services ; (d) Manage waste disposal

2. District hospitals to be managed by a separate team from the rest of the district with Hospital Management Team

Issues and Recommendations on Support structures for decentralization framework

1. Primary Health Care systema. Clarify various functions and roles of the Directorate of Health

and Social Service to avoid overloading of services and overlooking of critical health issues.

b. reinvigorate health planning function at the district level: Directorate of Planning and Development at the district level should have planning desk officers responsible for health

c. Primary health services: MOH consider establishing the deputy directorate responsible for primary health care within the curative directorate at the central MOH so as to have a dedicated person to provide professional advice on primary health services to the councils.

2. Secondary health care • The district hospital though managed by the Hospital management

team will need to be provided with technical leadership in health delivery by the: Directorate of Health and Social welfare, Central Hospital, Zonal office

3. Tertiary health care • According to Decentralisation policy and Local Government Act, not

part of the decentralisation agenda • Central hospitals will need to have autonomy to deliver tertiary level

services and remove the current inefficiencies • Since the central hospital has health experts it should be able to

provide technical advice and supervise the district hospitals and directorate of health and social welfare at the district level.

Recommendations on Health Service Delivery in Cities

• The health issues for district and city are not homogenous and hence there is need to establish a function Directorate of health and social welfare at both the District and City Councils.

• The district council director will have jurisdiction over the District while the City one will be responsible for the city. Thus all the health centres and facilities within the City will have to be managed by the City.

• City Director of health will need to have his own budget and vote. Thus the city council will need to be receiving finances for the population of the city as it is currently the case with the district council.

• Proper guidelines will need to be drawn in-terms of coverage of service delivery for the city and rural directorates

Recommendations on Health Service Delivery in Cities cont.

• City Director of health will need to have his own budget and vote. Thus the city council will need to be receiving finances for the population of the city as it is currently the case with the district council.

• Proper guidelines will need to be drawn in-terms of coverage of service delivery for the city and rural directorates

RESOURCING FOR HEALTH AT DISTRICT LEVELCurrently, local councils in Malawi generally obtain their finances from four main sources as follows:1. Locally generated revenue, Government grants; 2. Donor and project funds for specified activities; and 3. Fund-raising from well-wishers

Challenges of Resourcing for Health • Resources are not evenly distributed in all the districts. • Partners do not follow local levels plan when coming up with

activities• Some cases the few available providers are over concentrated in

one health problem • Providers get over concentrated in one corner of the district • Some partners do not disclose their budgets to the District

Council for proper planning. • Capacity challenges in financial management: but capacity follow

resources !!!

Recommendations • The SWAp arrangement should be decentralised so that partners

provide resources for health at the local level to ensure that resources are available

• District councils need to ensure that projects at the district level are well distributed in-terms of areas of need and location

• District Councils need to ensure that partners provide funding in relation to the district health implementation plans

• MOH need to provide policy guidelines on availability of partners within a district to avoid a situation where one district is over concentrated with resources while others are resource constrained

• Capacity building in finance management

Recommendations cont.

• District Councils need to ensure that partners provide funding in relation to the district health implementation plans

• MOH need to provide policy guidelines on availability of partners within a district to avoid a situation where one district is over concentrated with resources while others are resource constrained

• Capacity building in finance management

HUMAN RESOURCE FOR HEALTHContext of staff devolutionStaff devolution being considered in the context of–Progress in implementation of decentralisation –Public sector reforms – creation of a public service–Desired end state is a PS, that is harmonised and allows

for effective performance and professional growth– Staff devolution is still at the discussion stage, so the

health sector can join in the dialogue and influence direction and events

Architecture of HR Management in public service

• Several institutions, complex relationships• Key Commissions in considering decentralisation –CSC, LASCOM,

HSC• Commission responsibilities - conditions of service, recruitment,

promotion, discipline • DHRMD responsible for establishment, deployments, payroll• Classification of staff according to services• Movement between services is restricted• Key role for LASCOM in devolution, but it has constraints

Decentralised service delivery structures

• Key concerns, Health and HRM• Proposed Directorate of Health and Social Welfare offers positives in

service delivery• Necessary to review proposed functions and structure to reflect

best practice• The functioning of the Appointments and Disciplinary Committee• The responsibility burden responsibly of the HR function will need

extensive review• Recommendation for reviewed functions and new structures

Envisaged staff devolutionProcess

• MoLGRD will coordinate, working with DHRMD• Devolution will be based on the 2004 functional review and recommended

establishment• Piloting of establishment data and HRMIS in 6 Districts• MoLGRD will fill non-established posts by June 2015• No date set for devolution as yet, need for government approval • Once go ahead is given, MoLGRD will engage with devolving sectors and

District Councils• There will be a functional review after staff have been devolved to the

Districts

Envisaged staff devolution Issues

• Proposed dialogue before devolution is good• Timescales envisaged by MoLGRD (December 21015) are not

realistic• Decentralisation will impact on jobs in District Councils and

Ministries• Recommendations– Coordination of devolution– Strengthen District Councils and LASCOM before devolution – Overall functional review and job regarding

GOVERNANCE IN THE DECENTRALISED FRAMEWORK

Governance in decentralisation• Governance is a key concern in decentralisation• District - wide structures• Health specific governance structures

Issues in functionality of District wide structures

• Impact of 2010 amendments, and role of MoLGRD• Understanding roles and responsibilities• Calibre of elected officials• Support staff vs elected officials• Role relationships among elected officialsRecommendations• Clarification of roles and responsibilities• Development of specific skills• Facilities

Some broad observations

• Mandates need to be reviewed in the light of decentralisation• Improved communication and coordination would improve

effectiveness• More emphasis needed on advocacy• Capacity development required across the board• Lack of resources is impacting functionality and effectiveness• There are CSO networks that can be harnessed to improve

functionality

Recommendations

• MoH should develop guidelines for health specific structures (collaborate with District Councils) as a legacy to the decentralisation process

• Intensive, prolonged and coordinated capacity building is required to improve functionality and effectiveness

END