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

Abstract

Background: The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers' perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. Methods: We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. Results: We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support.

Management of human resources for health in health districts in Uganda: A decision space analysis

“…The DHMTs also reported that the districts suffer from insufficient skills and capacity of some staff in health facilities, for example, the reported cases of the lack of nutritional assessment and false positive testing of TB cases by some staff, but the DHMTs tried to overcome this by conducting on‐site mentorship to build capacities among staff. This goes in accordance with recommendations from the literature that the available decision space to managers is better used when it is accompanied by capacity building and better accountability 9,17,18 …”

“…In order to be more adaptive and responsive to their local health system needs, DHMTs need a wider decision space and strengthened capacity to use this decision space. Clarifying the role of the central government and the relationship dynamics with the local level would also help eliminate political interference and support the DHMT to better use their available decision space 18 …”

“…This goes in accordance with recommendations from the literature that the available decision space to managers is better used when it is accompanied by capacity building and better accountability. 9,17,18 Politics and bureaucracy also play a role in limiting the decision-making powers transferred to the DHMTs. 3 On one hand, politics hinder the implementation of some policies for example, sanctioning, especially where some staff members are 'untouchable' as reported by one DHMT.…”

“…level would also help eliminate political interference and support the DHMT to better use their available decision space. 18…”

“…Some authors argue that UHC cannot be achieved without strong local (e.g., district) health systems 16 . However, the transfer of management authority to the local levels should be accompanied by adequate decision‐making and management capacities for the health managers to perform better and improve health services 17,18 …”