Surviving decentralisation?

Kristiansen, Stein; Santoso, Purwo

doi:10.1016/j.healthpol.2005.07.013

Cited by 80 publications

(51 citation statements)

References 15 publications

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“…Previous studies suggest a number of contributing factors explaining the failure of decentralisation to improve health system performance. These include limited local capacity for planning (Friedman et Linkages between decentralisation and neonatal health inequalities 15 responsibilities at different levels of government (Habsjah, 2009;Lieberman et al, 2005;World Bank, 2008) and a complicated funding mechanism, with delays in disbursement of central funds, and limited discretion over resource allocation at the local level (Heywood & Harahap, 2009b;Kristiansen & Santoso, 2006;Kruse, Pradhan, & Sparrow, 2009). Moreover, remnants of the old system continue to be influential, with centralised control over human resources and a reliance on topdown health programmes.…”

Section: Discussionmentioning

confidence: 99%

Linkages between Decentralisation and Inequalities in Neonatal Health: Evidence from Indonesia

Hodge

Firth

Jimenez-Soto

et al. 2015

The Journal of Development Studies

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This study uses five waves of the Indonesian Demographic Health Surveys to analyse decentralisation and geographical inequality in health services delivery. Accounting for unobserved community-level heterogeneity with random effects and correlated random effects models, we link facility-based birth delivery to the period of decentralisation and Indonesia's major island groups using a pooled sample of 71,815 children. We also generate direct estimates of neonatal mortality from 1990 to 2007. The results show that the implementation of decentralisation has accorded with a marked expansion in both health service and outcome inequalities in Indonesia, at least with respect to neonates. Systemic funding failures for health and decision-space issues resulting from decentralisation are likely to have greater impact in disadvantaged regions where local capacity is weakest. The need to address these fundamental issues to reduce inequalities and improve general health outcomes appears supportable.

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Section: Discussionmentioning

confidence: 99%

Linkages between Decentralisation and Inequalities in Neonatal Health: Evidence from Indonesia

Hodge

Firth

Jimenez-Soto

et al. 2015

The Journal of Development Studies

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“…In health, decentralisation was seen as a way of improving local authorities' ability to address local problems and, accompanied by a substantial increase in public spending on health, was expected to improve health system performance. Available evidence suggests that this has not been the case [36], [37]. A combination of limited local capacity [2], [36]–[38], confusion of responsibilities for different levels of government [9], [39], [40] and a complicated funding mechanism with delays in disbursement and limited discretion over resource allocation at the local level [37], [41], [42] may have contributed.…”

Section: Discussionmentioning

confidence: 99%

“…Available evidence suggests that this has not been the case [36], [37]. A combination of limited local capacity [2], [36]–[38], confusion of responsibilities for different levels of government [9], [39], [40] and a complicated funding mechanism with delays in disbursement and limited discretion over resource allocation at the local level [37], [41], [42] may have contributed. Moreover, the ‘Big Bang fashion’ of implementing decentralisation in Indonesia (i.e.…”

Section: Discussionmentioning

confidence: 99%

Location Matters: Trends in Inequalities in Child Mortality in Indonesia. Evidence from Repeated Cross-Sectional Surveys

et al. 2014

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BackgroundConsiderable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography.MethodologyUsing data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under-five and neonatal mortality rates were generated for 1980–2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth.FindingsDeclines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened.ConclusionIndonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997–98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised.

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“…That is, social exposures such as education, income level and rural residence are the best predictors of health service access and health outcomes for populations. Across Asia, evaluations from China, [2] India,[3] Indonesia, [4,5] Cambodia,[6] Vietnam [7] and Bangladesh [8] emphasize persisting health inequities in access to care and in poorer health outcomes for the socially disadvantaged. Additional studies highlight the multi-dimensional nature of poverty and ill health in urban slums including the heterogeneity of social structure, [9] and recommend a range of responses.…”

Section: Introductionmentioning

confidence: 99%

Taking action on the social determinants of health: improving health access for the urban poor in Mongolia

Lhamsuren¹,

Choijiljav²,

Budbazar

et al. 2012

Int J Equity Health

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IntroductionIn recent years, the country of Mongolia (population 2.8 million) has experienced rapid social changes associated with economic growth, persisting socio-economic inequities and internal migration. In order to improve health access for the urban poor, the Ministry of Health developed a "Reaching Every District" strategy (RED strategy) to deliver an integrated package of key health and social services. The aim of this article is to present findings of an assessment of the implementation of the RED strategy, and, on the basis of this assessment, articulate lessons learned for equitable urban health planning.MethodsPrincipal methods for data collection and analysis included literature review, barrier analysis of health access and in-depth interviews and group discussions with health managers and providers.FindingsThe main barriers to health access for the urban poor relate to interacting effects of poverty, unhealthy daily living environments, social vulnerability and isolation. Implementation of the RED strategy has resulted in increased health access for the urban poor, as demonstrated by health staff having reached new clients with immunization, family planning and ante-natal care services, and increased civil registrations which enable social service provision. Organizational effects have included improved partnerships for health and increased motivation of the health workforce. Important lessons learned from the early implementation of the RED strategy include the need to form strong partnerships among stakeholders at each level of the health system and in the community, as well as the need to develop a specific financing strategy to address the needs of the very poor. The diverse social context for health in an urban poor setting calls for a decentralized planning and partnership strategy, but with central level commitment towards policy guidance and financing of pro-poor urban health strategies.ConclusionsLessons from Mongolia mirror other international studies which point to the need to measure and take action on the social determinants of health at the local area level in order to adequately reduce persistent inequities in health care access for the urban poor.

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Surviving decentralisation?

Cited by 80 publications

References 15 publications

Linkages between Decentralisation and Inequalities in Neonatal Health: Evidence from Indonesia

Linkages between Decentralisation and Inequalities in Neonatal Health: Evidence from Indonesia

Location Matters: Trends in Inequalities in Child Mortality in Indonesia. Evidence from Repeated Cross-Sectional Surveys

Taking action on the social determinants of health: improving health access for the urban poor in Mongolia

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