The impact of devolution on local health systems: Evidence from Greater Manchester, England

Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach. We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents. Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (-110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed. Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region.

'Border Country': health law in a devolved UK

How are we to understand and research health law under devolution in the UK? Building on work in law and geography, we argue that the figure of the border is key to the production and implementation of devolved health law and the variety of forms that this takes. The utility of border thinking in this context is shown through a review of thematic areas, including infectious disease control, access to health care, and abortion, each instantiating a distinct bordering process. In each, we consider recent developments in policy and legislation, framed with reference to constitutional change, and the politics of devolution in the UK. Taking Wales as an exemplary site, we argue that health law produces borders in traditional and non-traditional places. It creates and blurs territories. It is equally constituted by pluralistic bordering practices. On the basis of this theoretically informed review, we conclude by proposing a cross-disciplinary legal, ethical, and socio-legal research agenda for future research.

Evaluating whole system reforms: A structured approach for selecting multiple outcomes

Whole-system reforms, including devolution and integration of health and social care services, have the potential to impact multiple dimensions of health system performance. Most evaluations focus on a single or narrow subsets of outcomes amenable to change. This approach may not: (i) capture the overall effect of the reform, (ii) identify the mechanisms through which system-wide changes may have occurred, (iii) prevent post-hoc selection of outcomes based on significant results; and (iv) facilitate comparisons across settings. We propose a structured approach for selecting multiple quantitative outcome measures, which we apply for evaluating health and social care devolution in Greater Manchester, England. The approach consists of five-steps: (i) defining outcome domains based on a framework, in our case the World Health Organisation's Health System Performance Assessment Framework; (ii) reviewing performance metrics from national monitoring frameworks; (iii) excluding similar and condition specific outcomes; (iv) excluding outcomes with insufficient data; and (v) mapping implemented policies to identify a subset of targeted outcomes. We identified 99 outcomes, of which 57 were targeted. The proposed approach is detail and time-intensive, but useful for both researchers and policymakers to promote transparency in evaluations and facilitate the interpretation of findings and cross-settings comparisons.

The impact of devolution on experienced health and well-being

Devolution of health systems from national to local levels is a common focus of policymakers across the world. The overarching aim is to improve population health by better meeting the specific needs of local citizens. We examine the case of a coordinated devolution across several public service sectors in Greater Manchester, England, in 2016. We estimate the impact on experienced health and well-being using Short-Form 12 scores from 13,938 adult respondents to the UK Household Longitudinal Survey between 2012 and 2020. We use difference-in-differences and lagged-dependent variable regressions to compare Greater Manchester to the rest of England. We find no statistically significant changes in experienced health and well-being over the four years following the start of devolution. Our findings suggest that devolving population health management alone without budgetary powers and local accountability mechanisms may not be effective in improving experienced health and well-being in the relatively short-term.

The equity implications of an expanded health and wellbeing role for housing associations

Objectives

in light of the acknowledged relationship between housing circumstances and health outcomes, the research explored the implications of the diversifying role of housing associations, considering the extent and form of engagement with the health sector and the potential repercussions for inequalities.

Study design

the research was based on a single case study of the Manchester city-region, chosen to provide a way of considering the role of recently agreed devolved governance and funding arrangements in respect of housing and health.

Methods

primary qualitative data were assembled via a programme of semi-structured interviews with housing and health policy actors and direct observation of six quarterly meetings of a housing-health steering group established as part of new devolved governance arrangements.

Results

the findings reveal a perception among housing managers that the reorientation of housing association services to offset the rationalisation of mainstream provision risks exacerbating inequalities. Interview and observational data suggest that the diversification of housing association activity may have begun to erode the sector's ability and willingness to provide affordable housing on a universal basis to those in need.

Conclusions

The growing non-landlord functions of some housing associations can act as a deterrent to the allocation of housing to applicants with complex (and expensive) needs. This reinforces the increased selectivity in housing association stock allocations, linked to marketization and the increasingly commercial outlook of some providers. Further inequalities may be engendered because while tenants can benefit from the extended housing associations services, others continue to depend on a weakened statutory sector.

Devolution of forest management to local communities and its impacts on livelihoods and deforestation in Berau, Indonesia

Law 11/2020 on job creation has changed a partial forest business license to a multi-purpose forest business and devolved some authorities in forest management to local communities. Studies on common-pool resources demonstrate that devolution of common property is one of the most important factors for sustainability. This study aims to analyze the factors that influence reducing deforestation and focuses on two different village forest organizations in East Kalimantan: first, village forests under the management of the Forest Management Unit of Berau Barat -forests managed by a provincial government (Long Duhung and Merapun village forests), and second, devolution of village forest managed by a local village institution (Merabu village forest). Recent evidence from these study sites indicates that the devolution of forest management associated with village forests has not consistently reduced forest cover loss. There was a complex interaction between the passage of robustness of the institutional settings and economic preferences linked to deforestation. The forest governance systems, including rules that determine property rights, can promote forest conservation when people's interests are served by forest land use. Conversely, economic preferences also control deforestation. This study confirms that the institutional robustness of forest governance systems and actors' economic preferences play an important role in controlling deforestation. This study suggests the devolution of rights for forest management and incentivizing economic alternatives for using forest resources to reduce deforestation.

Americans' Attitudes Toward Federalism

Contemporary and historical political debates often revolve around principles of federalism, in which governing authority is divided across levels of government. Despite the prominence of these debates, existing scholarship provides relatively limited evidence about the nature and structure of Americans' preferences for decentralization. We develop a new survey-based measure to characterize attitudes toward subnational power and evaluate it with a national sample of more than 2000 American adults. We find that preferences for devolution vary considerably both across and within states, and reflect individuals' ideological orientations and evaluations of government performance. Overall, our battery produces a reliable survey instrument for evaluating preferences for federalism and provides new evidence that attitudes toward institutional arrangements are structured less by short-term political interests than by core preferences for the distribution of state authority.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11109-022-09820-3.

The status and future of emergency care in the Republic of Kenya

Kenya is a rapidly developing country with a growing economy and evolving health care system. In the decade since the last publication on the state of emergency care in Kenya, significant developments have occurred in the country's approach to emergency care. Importantly, the country decentralized most health care functions to county governments in 2013. Despite the triple burden of traumatic, communicable, and non-communicable diseases, the structure of the health care system in the Republic of Kenya is evolving to adapt to the important role for the care of emergent medical conditions. This report provides a ten-year interval update on the current state of the development of emergency medical care and training in Kenya, and looks ahead towards areas for growth and development. Of particular focus is the role emergency care plays in Universal Health Coverage, and adapting to challenges from the devolution of health care.

Level and determinants of county health system technical efficiency in Kenya: two stage data envelopment analysis

BACKGROUND

Improving health system efficiency is a key strategy to increase health system performance and accelerate progress towards Universal Health Coverage. In 2013, Kenya transitioned into a devolved system of government granting county governments autonomy over budgets and priorities. We assessed the level and determinants of technical efficiency of the 47 county health systems in Kenya.

METHODS

We carried out a two-stage data envelopment analysis (DEA) using Simar and Wilson's double bootstrap method using data from all the 47 counties in Kenya. In the first stage, we derived the bootstrapped DEA scores using an output orientation. We used three input variables (Public county health expenditure, Private county health expenditure, number of healthcare facilities), and one outcome variable (Disability Adjusted Life Years) using 2018 data. In the second stage, the bias corrected technical inefficiency scores were regressed against 14 exogenous factors using a bootstrapped truncated regression.

RESULTS

The mean bias-corrected technical efficiency score of the 47 counties was 69.72% (95% CI 66.41-73.01%), indicating that on average, county health systems could increase their outputs by 30.28% at the same level of inputs. County technical efficiency scores ranged from 42.69% (95% CI 38.11-45.26%) to 91.99% (95% CI 83.78-98.95%). Higher HIV prevalence was associated with greater technical inefficiency of county health systems, while higher population density, county absorption of development budgets, and quality of care provided by healthcare facilities were associated with lower county health system inefficiency.

CONCLUSIONS

The findings from this analysis highlight the need for county health departments to consider ways to improve the efficiency of county health systems. Approaches could include prioritizing resources to interventions that will reduce high chronic disease burden, filling structural quality gaps, implementing interventions to improve process quality, identifying the challenges to absorption rates and reforming public finance management systems to enhance their efficiency.

Examining health facility financing in Kenya in the context of devolution

Background

How health facilities are financed affects their performance and health system goals. We examined how health facilities in the public sector are financed in Kenya, within the context of a devolved health system.

Methods

We carried out a cross-sectional study in five purposely selected counties in Kenya, using a mixed methods approach. We collected data using document reviews and in-depth interviews (no = 20). In each county, we interviewed county department of health managers and health facility managers from two and one purposely selected public hospitals and health center respectively. We analyzed qualitive data using thematic analysis and conducted descriptive analysis of quantitative data.

Results

Planning and budgeting: Planning and budgeting processes by hospitals and health centers were not standardized across counties. Budgets were not transparent and credible, but rather were regarded as “wish lists” since they did not translate to actual resources. Sources of funds: Public hospitals relied on user fees, while health centers relied on donor funds as their main sources of funding. Funding flows: Hospitals in four of the five study counties had no financial autonomy. Health centers in all study counties had financial autonomy. Flow of funds to hospitals and health centers in all study counties was characterized by unpredictability of amounts and timing. Health facility expenditure: Staff salaries accounted for over 80% of health facility expenditure. This crowded out other expenditure and led to frequent stock outs of essential health commodities.

Conclusion

The national and county government should consider improving health facility financing in Kenya by 1) standardizing budgeting and planning processes, 2) transitioning public facility financing away from a reliance on user fees and donor funding 3) reforming public finance management laws and carry out political engagement to facilitate direct facility financing and financial autonomy of public hospitals, and 4) assess health facility resource needs to guide appropriate levels resource allocation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07123-7.

Managers' Perspectives on the Devolved Health System Response to the Public Health Needs of Internally Displaced Persons in Pakistan: A Qualitative Study

Population displacement has been embedded in Pakistan's history since its inception in 1947. The displacement of more than 3 million people from the tribal areas of the Khyber Pakhtunkhwa Province of Pakistan and their settlement in recipient areas have posed challenges to governance, service delivery, financial management, and integration of internally displaced persons (IDPs) into existing devolved district health systems. Evidence is lacking on the management of devolved health systems to respond to the public health needs of IDPs. The authors adapted qualitative methods to explore challenges faced by managers of health departments in Khyber Pakhtunkhwa Province in responding to the public health needs of IDPs and to explore policy recommendations for a devolved health system. Study findings revealed that the lack of a skilled workforce, lack of political will, financial limitations, and poor intersectoral collaboration had an impact on the humanitarian crisis response in the province. These findings suggest a dire need for overarching binding international laws and local national policies for complete protection of IDPs, particularly in regard to their health, shelter, and social security.

Perceived consequences of healthcare service decentralization on access, affordability and quality of care in Khartoum locality, Sudan

BACKGROUND

Decentralization of healthcare services has been widely utilized, especially in developing countries, to improve the performance of healthcare systems by increasing the access and efficiency of service delivery. Experiences have been variable secondary to disparities in financial and human resources, system capacity and community engagement. Sudan is no exception and understanding the perceived effect of decentralization on access, affordability, and quality of care among stakeholders is crucial.

METHODS

This was a mixed method, cross-sectional, explorative study that involved 418 household members among catchment areas and 40 healthcare providers of Ibrahim Malik Hospital (IBMH) and Khartoum Teaching Hospital (KTH). Data was collected through a structured survey and in-depth interviews from July-December 2015.

RESULTS

Access, affordability and quality of healthcare services were all perceived as worse, compared to before decentralization was implemented. Reported affordability was found to be 53 and 55% before decentralization compared to 24 to 16% after decentralization, within KTH and IBMH catchment areas respectively, (p = 0.01). The quality of healthcare services was reported to have declined from 47 and 38% before decentralization to 38 and 28% after, in KTH and IBMH respectively (p = 0.02). Accessibility was found to be more limited, with services being accessible before decentralization approximately 59 and 52% of the time, compared to 41 and 30% after, in KTH and IBMH catchment areas respectively, (p = 0.01). Accessibility to healthcare was reported to have decreased secondary to facility closures, reverse transference of services, and low capacity of devolved facilities. Lastly, privatized services were reported as strengthened in response to this decentralization of healthcare.

CONCLUSIONS

The deterioration of access, affordability and quality of health services was experienced as the predominant perception among stakeholders after decentralization implementation. Our study results suggest there is an urgent need for a review of the current healthcare policies, structure and management within Sudan in order to provide evidence and insights regarding the impact of decentralization.

Decentralization and Regionalization of Surgical Care as a Critical Scale-up Strategy in Low- and Middle-Income Countries Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries"

As global attention to improve the quality, safety and access to surgical care in low- and middle-income countries (LMICs) increases, the need for evidence-based strategies to reliably scale-up the quality and quantity of surgical services becomes ever more pertinent. Iversen et al discuss the optimal distribution of surgical services, whether through decentralization or regionalization, and propose a strategy that utilizes the dimensions of acuity, complexity and prevalence of surgical conditions to inform national priorities. Proposed expansion of this strategy to encompass levels of scale-up prioritization is discussed in this commentary. The decentralization of emergency obstetric services in LMICs shows promising results and should be further explored. The dearth of evidence of regionalization in LMICs, on the other hand, limits extrapolation of lessons learned. Nevertheless, principles from the successful regionalization of certain services such as trauma care in high-income countries (HICs) can be adapted to LMIC settings and can provide the backbone for innovation in service delivery and safety.

Can Scotland achieve its aim of narrowing health inequalities in a post-pandemic world?

In this commentary we explore the potential for the devolved Scottish Government to achieve its stated aim of narrowing health - and broader societal (including economic) - inequalities within both the restrictions of limited devolved powers, and in the context of post-pandemic uncertainty. We do so by focussing on two questions: first, where were we with regards to inequalities policy in Scotland before the pandemic? And second, what are the likely implications of the pandemic for inequalities, and inequalities policymaking, in the country?

Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya

Background

Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi’s equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya.

Methods

We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach.

Results

Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date.

Conclusions

If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.

Applying an intersectionality lens to examine health for vulnerable individuals following devolution in Kenya

BACKGROUND

Power imbalances are a key driver of avoidable, unfair and unjust differences in health. Devolution shifts the balance of power in health systems. Intersectionality approaches can provide a 'lens' for analysing how power relations contribute to complex and multiple forms of health advantage and disadvantage. These approaches have not to date been widely used to analyse health systems reforms. While the stated objectives of devolution often include improved equity, efficiency and community participation, past evidence demonstrates that that there is a need to create space and capacity for people to transform existing power relations these within specific contexts.

METHODS

We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from across the health system in ten counties, 14 focus group discussions with community members in two of these counties and photovoice participatory research with nine young people. We adopted an intersectionality lens to reveal how power relations intersect to produce vulnerabilities for specific groups in specific contexts, and to identify examples of the tacit knowledge about these vulnerabilities held by priority-setting stakeholders, in the wake of the introduction of devolution reforms in Kenya.

RESULTS

Our study identified a range of ways in which longstanding social forces and discriminations limit the power and agency individuals can exercise, but are mediated by their unique circumstances at a given point in their life. These are the social determinants of health, influencing an individual's exposure to risk of ill health from their living environment, their work, or their social context, including social norms relating to their gender, age, geographical residence or socio-economic status. While a range of policy measures have been introduced to encourage participation by typically 'unheard voices', devolution processes have yet to adequately challenge the social norms, and intersecting power relations which contribute to discrimination and marginalisation.

CONCLUSIONS

If key actors in devolved decision-making structures are to ensure progress towards universal health coverage, there is need for intersectoral policy action to address social determinants, promote equity and identify ways to challenge and shift power imbalances in priority-setting processes.

Devolving healthcare services redesign to local clinical leaders: does it work in practice?

PURPOSE

The purpose of this paper is to present the findings arising from a three year research project which investigated a major system-wide change in the design of the NHS in England. The radical policy change was enshrined in statute in 2012 and it dismantled existing health authorities in favour of new local commissioning groups built around GP Practices. The idea was that local clinical leaders would "step-up" to the challenge and opportunity to transform health services through exercising local leadership. This was the most radical change in the NHS since its inception in 1948.

DESIGN/METHODOLOGY/APPROACH

The research methods included two national postal surveys to all members of the boards of the local groups supplemented with 15 scoping case studies followed by six in-depth case studies. These case studies focused on close examination of instances where significant changes to service design had been attempted.

FINDINGS

The authors found that many local groups struggled to bring about any significant changes in the design of care systems. But the authors also found interesting examples of situations where pioneering clinical leaders were able to collaborate in order to design and deliver new models of care bridging both primary and secondary settings. The potential to use competition and market forces by fully utilising the new commissioning powers was more rarely pursued.

PRACTICAL IMPLICATIONS

The findings carry practical implications stemming from positive lessons about securing change even under difficult circumstances.

ORIGINALITY/VALUE

The paper offers novel insights into the processes required to introduce new systems of care in contexts where existing institutions tend to revert to the status quo. The national survey allows accurate assessment of the generalisability of the findings about the nature and scale of change.

"Sometimes it is difficult for us to stand up and change this": an analysis of power within priority-setting for health following devolution in Kenya

BACKGROUND

Practices of power lie at the heart of policy processes. In both devolution and priority-setting, actors seek to exert power through influence and control over material, human, intellectual and financial resources. Priority-setting arises as a consequence of the needs and demand exceeding the resources available, requiring some means of choosing between competing demands. This paper examines the use of power within priority-setting processes for healthcare resources at sub-national level, following devolution in Kenya.

METHODS

We interviewed 14 national level key informants and 255 purposively selected respondents from across the health system in ten counties. These qualitative data were supplemented by 14 focus group discussions (FGD) involving 146 community members in two counties. We conducted a power analysis using Gaventa's power cube and Veneklasen's expressions of power to interpret our findings.

RESULTS

We found Kenya's transition towards devolution is transforming the former centralised balance of power, leading to greater ability for influence at the county level, reduced power at national and sub-county (district) levels, and limited change at community level. Within these changing power structures, politicians are felt to play a greater role in priority-setting for health. The interfaces and tensions between politicians, health service providers and the community has at times been felt to undermine health related technical priorities. Underlying social structures and discriminatory practices generally continue unchanged, leading to the continued exclusion of the most vulnerable from priority-setting processes.

CONCLUSIONS

Power analysis of priority-setting at county level after devolution in Kenya highlights the need for stronger institutional structures, processes and norms to reduce the power imbalances between decision-making actors and to enable community participation.

Effects of undocumented immigrants exclusion from health care coverage in Spain

BACKGROUND

In 2012 the Spanish government passed Royal Decree-Law 16/2012 (RDL) aimed at containing public expenditure in response to the economic crisis. This RDL redefined just who would be entitled to public health care. As a result, a large proportion of undocumented immigrants in Spain were excluded from basic publicly financed health care with access only being granted under particular circumstances (emergency care, maternal care, children under 18, asylum seekers and victims of human trafficking).

AIM

The aims of this paper are to identify the specific traits of this policy, review its impact on health and health care access, and to evaluate its economic impact.

RESULTS

Most political parties and health professional groups opposed the RDL, and a large number of Spanish regions either declined to apply it or opted to apply it partially. To date, the RDL has had a considerable impact on the access of undocumented immigrants to public health care, with evidence suggesting that approximately 870,000 people have been excluded. A slight increase in infectious diseases has been reported, albeit not as high as originally predicted, and recent evidence points to an increase in mortality among this population subgroup.

CONCLUSIONS

Regional legislation favouring the coverage of undocumented immigrants might have acted as a counterweight and thus contained the negative health effects in this population subgroup. But the Constitutional Court invalidated all regional arrangements obliging regions to comply with the RDL.

Systems, supplies, and staff: a mixed-methods study of health care workers' experiences and health facility preparedness during a large national cholera outbreak, Kenya 2015

Background

From December 2014 to September 2016, a cholera outbreak in Kenya, the largest since 2010, caused 16,840 reported cases and 256 deaths. The outbreak affected 30 of Kenya’s 47 counties and occurred shortly after the decentralization of many healthcare services to the county level. This mixed-methods study, conducted June–July 2015, assessed cholera preparedness in Homa Bay, Nairobi, and Mombasa counties and explored clinic- and community-based health care workers’ (HCW) experiences during outbreak response.

Methods

Counties were selected based on cumulative cholera burden and geographic characteristics. We conducted 44 health facility cholera preparedness checklists (according to national guidelines) and 8 focus group discussions (FGDs). Frequencies from preparedness checklists were generated. To determine key themes from FGDs, inductive and deductive codes were applied; MAX software for qualitative data analysis (MAXQDA) was used to identify patterns.

Results

Some facilities lacked key materials for treating cholera patients, diagnosing cases, and maintaining infection control. Overall, 82% (36/44) of health facilities had oral rehydration salts, 65% (28/43) had IV fluids, 27% (12/44) had rectal swabs, 11% (5/44) had Cary-Blair transport media, and 86% (38/44) had gloves. A considerable number of facilities lacked disease reporting forms (34%, 14/41) and cholera treatment guidelines (37%, 16/43). In FDGs, HCWs described confusion regarding roles and reporting during the outbreak, which highlighted issues in coordination and management structures within the health system. Similar to checklist findings, FGD participants described supply challenges affecting laboratory preparedness and infection prevention and control. Perceived successes included community engagement, health education, strong collaboration between clinic and community HCWs, and HCWs’ personal passion to help others.

Conclusions

The confusion over roles, reporting, and management found in this evaluation highlights a need to adapt, implement, and communicate health strategies at the county level, in order to inform and train HCWs during health system transformations. International, national, and county stakeholders could strengthen preparedness and response for cholera and other public health emergencies in Kenya, and thereby strengthen global health security, through further investment in the existing Integrated Disease Surveillance and Response structure and national cholera prevention and control plan, and the adoption of county-specific cholera control plans.

How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya

Background

A common challenge for health sector planning and budgeting has been the misalignment between policies, technical planning and budgetary allocation; and inadequate community involvement in priority setting. Health system decentralisation has often been promoted to address health sector planning and budgeting challenges through promoting community participation, accountability, and technical efficiency in resource management. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, and a substantial transfer of responsibility for healthcare from the central government to these counties.

Methods

This study analysed the effects of this major political decentralization on health sector planning, budgeting and overall financial management at county level. We used a qualitative, case study design focusing on Kilifi County, and were guided by a conceptual framework which drew on decentralisation and policy analysis theories. Qualitative data were collected through document reviews, key informant interviews, and participant and non-participant observations conducted over an eighteen months’ period.

Results

We found that the implementation of devolution created an opportunity for local level prioritisation and community involvement in health sector planning and budgeting hence increasing opportunities for equity in local level resource allocation. However, this opportunity was not harnessed due to accelerated transfer of functions to counties before county level capacity had been established to undertake the decentralised functions. We also observed some indication of re-centralisation of financial management from health facility to county level.

Conclusion

We conclude by arguing that, to enhance the benefits of decentralised health systems, resource allocation, priority setting and financial management functions between central and decentralised units are guided by considerations around decision space, organisational structure and capacity, and accountability. In acknowledging the political nature of decentralisation polices, we recommend that health sector policy actors develop a broad understanding of the countries’ political context when designing and implementing technical strategies for health sector decentralisation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-017-0649-0) contains supplementary material, which is available to authorized users.

Devolution and its effects on health workforce and commodities management - early implementation experiences in Kilifi County, Kenya

BACKGROUND

Decentralisation is argued to promote community participation, accountability, technical efficiency, and equity in the management of resources, and has been a recurring theme in health system reforms for several decades. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments, with substantial transfer of responsibility for health service delivery from the central government to these counties. Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, we analysed the early implementation experiences of this major governance reform at county level.

METHODS

We employed a qualitative case study design, focusing on Kilifi County, and adapted the decision space framework developed by Bossert et al., to guide our inquiry and analysis. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014.

RESULTS

As with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. For HRH, this led to major disruptions in staff salary payments, political interference with HRH management functions and confusion over HRH management roles. There was also lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level. Subsequently health worker strikes and mass resignations were witnessed. With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution.

CONCLUSION

The devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies.

"We are toothless and hanging, but optimistic": sub county managers' experiences of rapid devolution in coastal Kenya

BACKGROUND

In March 2013, Kenya transitioned from a centralized to a devolved system of governance. Within the health sector, this entailed the transfer of service provision functions to 47 newly formed semi-autonomous counties, while policy and regulatory functions were retained at the national level. The devolution process was rapid rather than progressive.

METHODS

We conducted qualitative research within one county to examine the early experiences of devolution in the health sector. We specifically focused on the experience of change from the perspective of sub-county managers, who form the link between county level managers and health facility managers. We collected data by observing a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, conducting informal interviews wherever we could. Informal observations and interviews were supplemented by fifteen tape recorded in depth interviews with purposively selected sub-county managers from three sub-counties.

RESULTS

We found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources in addition to confused lines of accountability within the health system. However, they harnessed individual, team and stakeholder resources to maintain their jobs, and continued to play a central role in supporting peripheral facility managers to cope with change.

CONCLUSIONS

Our study illustrates the importance in accelerated devolution contexts for: 1) mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; 2) clear lines of communication during reforms to these actors and 3) anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, we show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained software capacity building within the health system.

Constitutional Reforms In Pakistan: Turning Around The Picture Of Health Sector In Punjab Province

consequences of 2011 reforms on the future roles demarcation between the federation and provinces for steering the health sector. The objective of this assessment study was to conduct an institutional appraisal of the provincial health department in Punjab to mark the achievements, problem areas and issues, as well as to formulate the recommendations in the post-devolution scenario. It was an in-depth literature review comprising papers found on PubMed/Medline, Google Scholar, reports published by the government departments, independent research works, academic papers, and documents produced by the development agencies in Pakistan, covering 18th constitutional amendment and its implications on health sector. Following 18th amendment, the Punjab Government formulated health sector strategy (2012-2017) which is being implemented in a phased approach. All districts have developed their three years rolling out plans. An integrated strategic and operational plan of MNCH, Nutrition and Family Planning is under review for approval. Punjab Health Care Commission has been established and is functional to regulate the health sector. Development agencies have in principle committed to support health sector strategy till 2017. Fair investments in improving governance, service delivery structure, human resource, health information, and medical products are expected more than ever in the post 18th amendment scenario. This is the chance for the health system of Punjab to serve the vulnerable people of the provinces, saving them from health shocks.

Envisioning the Third Sector's Welfare Role: Critical Discourse Analysis of 'Post-Devolution' Public Policy in the UK 1998-2012

Welfare state theory has struggled to come to terms with the role of the third sector. It has often categorized welfare states in terms of the pattern of interplay between state social policies and the structure of the labour market. Moreover, it has frequently offered an exclusive focus on state policy - thereby failing to substantially recognize the role of the formally organized third sector. This study offers a corrective view. Against the backdrop of the international shift to multi-level governance, it analyses the policy discourse of third sector involvement in welfare governance following devolution in the UK. It reveals the changing and contrasting ways in which post-devolution territorial politics envisions the sector's role as a welfare provider. The mixed methods analysis compares policy framing and the structural narratives associated with the development of the third sector across the four constituent polities of the UK since 1998. The findings reveal how devolution has introduced a new spatial policy dynamic. Whilst there are elements of continuity between polities - such as the increasing salience of the third sector in welfare provision - policy narratives also provide evidence of the territorialization of third sector policy. From a methodological standpoint, this underlines the distinctive and complementary role discourse-based analysis can play in understanding contemporary patterns and processes shaping welfare governance.

A Modified Actor-Power-Accountability Framework (MAPAF) for analyzing decentralized forest governance: case study from Ethiopia

This paper posits a Modified Actor-Power-Accountability Framework (MAPAF) that makes three major improvements on the Actor-Power-Accountability Framework (APAF) developed by Agrawal and Ribot (1999). These improvements emphasize the nature of decentralized property rights, linking the outputs of decentralization with its outcomes and the inclusion of contextual factors. Applying MAPAF to analyze outputs and outcomes from two major decentralized forest policies in Ethiopia, i.e., delegation and devolution, has demonstrated the following strengths of the framework. First, by incorporating vital bundles of property rights into APAF, MAPAF creates a common ground for exploring and comparing the extent of democratization achieved by different decentralizing reforms. Second, the inclusion of social and environmental outcomes in MAPAF makes it possible to link the output of decentralization with local level outcomes. Finally, the addition of contextual factors enhances MAPAF's explanatory power by providing room for investigating exogenous factors other than democratization that contribute to the outcomes of decentralization reforms.