Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines

Abstract

BackgroundSeveral studies on decentralisation have used the ‘decision space’ approach to assess the breadth of space made available to decision-makers at lower levels of the health system. However, in order to better understand how decentralisation becomes effective for the health sector, analysis should go beyond assessing decision space and include the dimensions of capacity and accountability. Building on Bossert’s earlier work on the synergy of these dimensions, we analysed decision-making in the Philippines where governmental health services have been devolved to local governments since 1992.MethodsUsing a qualitative research design, we interviewed 27 key decision-makers at different levels of the Philippine health system and representing various local settings. We explored their perspectives on decision space, capacities and accountability in the health sector functions of planning, financing and budget allocation, programme implementation and service delivery, management of facilities, equipment and supplies, health workforce management, and data monitoring and utilisation. Analysis followed the Framework Method.ResultsAcross all functions, decision space for local decision-makers was assessed to be moderate or narrow despite 25 years of devolution. To improve decision-making in these functions, adjustments in local capacities should include, at the individual level, skills for strategic planning, management, priority-setting, evidence-informed policy-making and innovation in service delivery. At institutional levels, these desired capacities should include having a multi-stakeholder approach, generating revenues from local sources, partnering with the private sector and facilitating cooperation between local health facilities. On the other hand, adjustments in accountability should focus on the various mechanisms that can be enforced by the central level, not only to build the desired capacities and augment the inadequacies at local levels, but also to incentivise success and regulate failure by the local governments in performing the functions transferred to them.ConclusionTo optimise decentralisation for the health sector, widening decision spaces for local decision-makers must be accompanied by the corresponding adjustments in capacities and accountability for promoting good decision-making at lower levels in the decentralised functions. Analysing the health system through the lens of this synergy is useful for exploring concrete policy adjustments in the Philippines as well as in other settings.Electronic supplementary materialThe online version of this article (10.1186/s12961-018-0402-1) contains supplementary material, which is available to authorized users.

Connecting communities to primary care: a qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines

“…Meaningful participation of BHWs in decision making represents yet another means of integrating and embedding them further into the local health system [2,40]. In the decentralised Philippine context, this could be readily achieved, for example, through the inclusion of BHWs as 'local' health experts in multi-stakeholder consultations administered by local governments on the planning, financing, implementation, management and monitoring of community health services [42]. With the ongoing implementation of the Universal Health Care Act in the Philippines [43], and the renewed commitment to strengthen primary health care [44], a formidable cadre of BHWs stand ready to dedicate their time, energy and expertise to help realise these goals for the nation.…”

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

“…We performed the in-depth interviews face-to-face with up to 27 decision-makers in 2017 who were purposivelyselected to represent different levels of decision-making, institutional affiliations, and geographical settings in the Philippine health system. The profiles of these 27 decision-makers [18] and a selection of quotes from our interviews with them [24] were published elsewhere. It was at the 27th interview when saturation [25] was judged to have been achieved, or the point when new information was no longer emerging.…”

“…All relevant data are provided in the manuscript, in the online supplementary files (Additional files 1 and 2), and in two other publications which have been referenced [18,24].…”

Should Employers Invest in Employability? Examining Employability as a Mediator in the HRM – Commitment Relationship

“…This theory has often been applied from the perspective of tangible rewards (e.g., financial incentives or promised promotions) yet we argue that there is also a “social career exchange” in which reciprocity is activated because of long-term gains for both parties. Second, our study contributes to filling the so-called “black box” of HRM (Becker and Huselid, 2006) by studying whether employability might be a mechanism through which HR practices can bring about enhanced workplace commitment. As a third contribution, we study the relationship between HR practices and employability, which is an important but understudied area (Van Harten et al, 2017).…”