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Public Health Service Delivery in a Decentralized Global Journal of Medical Research: K Interdisciplinary Volume 19 Issue 2 Version 1.0 Year 2019 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Online ISSN: 2249-4618 & Print ISSN: 0975-5888 Public Health Service Delivery in a Decentralized System: A Qualitative Study of the Perception of Health Providers and Community Members in Gida Ayana Woreda, Western Ethiopia By Habtamu Tolera, Tegegne Gebre-Egziabher & Helmut Kloos Addis Ababa University Abstract- Some policy-makers believe a decentralized health system enhances service delivery by improving authority, autonomy, accountability, and community participation at the local level. Evidence on the extent to which these benefits have been realized and whether there are gaps in service delivery is essential for policy designs and system reinforcing strategies. The study gathered data through 29 interviews with service providers and policy-makers and eight FGDs with residents and analyzed it for themes. The results showed several benefits of the decentralization system program that includes increased autonomy over staff planning, budgeting, appointments; increased participation in service boards, in cash and kinds. The findings also revealed several challenges that hinder the effective functioning of decentralization including lack of authority to recruit staff, interference in the appointment, transfer of cases, procurement; limited decision making power over local revenue resources; lack of community responsibility in service planning and monitoring. Keywords: decentralized health service, Ethiopia, authority, autonomy, effects of decentralization. GJMR-K Classification: NLMC Code: W 84 PublicHealthServiceDeliveryinaDecentralizedSystemAQualitativeStudyofthePerceptionofHealthProvidersandCommunityMembersinGidaAyanaWoredaWesternEthiopia Strictly as per the compliance and regulations of: © 2019. Habtamu Tolera, Tegegne Gebre-Egziabher & Helmut Kloos. This is a research paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http://creativecommons.org/licenses/by-nc/3.0/), permitting all non commercial use, distribution, and reproduction inany medium, provided the original work is properly cited. Public Health Service Delivery in a Decentralized System: A Qualitative Study of the Perception of Health Providers and Community Members in Gida Ayana Woreda, Western Ethiopia α σ ρ Habtamu Tolera , Tegegne Gebre-Egziabher & Helmut Kloos Abstract- Some policy-makers believe a decentralized health described decentralization as a process of offering 2019 system enhances service delivery by improving authority, routine managerial authority to semi-autonomous health autonomy, accountability, and community participation at the facility boards reporting to politicians and Year local level. Evidence on the extent to which these benefits decentralization is the move of power and structures for 23 have been realized and whether there are gaps in service health from the central government to the local delivery is essential for policy designs and system reinforcing strategies. The study gathered data through 29 interviews with government answerable to electorates (Smith, 1997) service providers and policy-makers and eight FGDs with and according to Hutchinson (1999) it is a shift of public residents and analyzed it for themes. The results showed health to private providers. several benefits of the decentralization system program that Local authority and autonomy overcome the includes increased autonomy over staff planning, budgeting, disadvantages of centralized institutional and spatially appointments; increased participation in service boards, in distant bureaucracies; minimize costs, increase cash and kinds. The findings also revealed several challenges responsiveness to local needs; improve community that hinder the effective functioning of decentralization involvement; and ensure accountability of local including lack of authority to recruit staff, interference in the appointment, transfer of cases, procurement; limited politicians, health managers, planners, and decision decision making power over local revenue resources; lack of makers (Tang & Bloom, 2000; Rifkin, 2014). Several community responsibility in service planning and monitoring. health sector reforms recommend citizen participation Although the designing of decentralized health program was to ensure local accountability of health program Volume XIX Issue II Version I appropriate in earnest, critical elements for attaining adequate management for granting adequate service delivery, ) D D DD K decentralization are still lacking. The region has still played the monitoring the allocation and utilization of monies ( biggest role in staff recruitment, resource transfer, planning/ for health services, and developing and monitoring programming. These deficiencies have resulted in inadequate programs that permit them to voice their rights information, nominal service monitoring, and low quality (Molina, 2017). of services outcomes. Better quality of service delivery Some of studies have emphasized the need for necessitates financial independence and significant service Research monitoring. local institutional authority, autonomy, participation, Keywords: decentralized health service, Ethiopia, and accountability for effective implementation and authority, autonomy, effects of decentralization. improvements of health services outcomes (Mill,1990; Medical Murthy & Klugman, 2004; Menon, 2006). However, I. Background evidence drawn from 10 countries indicates that alls for health system decentralization dated back decentralization of public systems, including health to the Alma Ata Declaration (Beard & Redmond, systems, has increased only slightly in Africa recently, 1979) and became more urgent during the with few achievements in the areas of autonomy, C accountability, and capacity in service delivery (Wunsch, 1990s (Mehrotra, 2006). Conceptually, decentralization in the context of health services entails the transfer 2014) . Many healthcare professionals have raised that Global Journal of of administrative authority to lower offices accoun- only a few of the policy designs and systems, in table to the centre (Rondinelli et al., 1989). Mills (1990) practice, reinforce strategies for health that use authority, autonomy, participation, and accountability as Correspondence Author α: Department of Geography and Environ- basic guidelines for effective health policy programs mental Studies, Wollega University, P.O. Box 395, Nekemte, Ethiopia. (Mill,1990; Murthy & Klugman, 2004). Some studies also e-mail: [email protected] report a lack of effort to systematically examine this Author σ: Department of Geography and Environmental Studies, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia. situation even though these aspects are essential for the e-mail: [email protected] implementation of decentralized public health services Author ρ: Department of Epidemiology and Biostatistics, University of (Kassa & Shawel, 2013; Kwamie et al., 2015). California, P. O. Box 0560, San Francisco, USA. e-mail: [email protected] ©2019 Global Journals Public Health Service Delivery in a Decentralized System: A Qualitative Study of the Perception of Health Providers and Community Members in Gida Ayana Woreda, Western Ethiopia Before 1991, Ethiopia was a centralized country Lastly, the results of this study call for policy-makers to with a unitary form of authoritarian government. revisit decentralized health programs to ensure that The government made decisions at the center in woreda government structures have adequate authority, the absence of formally established sub-national autonomy, resources, accountability, and popular governments accountable to the needs of local participation in the implementation, management and communities (Gebre-Egzhiabher, 2014). The unitary provision of quality health care services. government channeled decisions on production and distribution of public health services from the capital, II. Methods Addis Ababa, without actual authority, autonomy, a) Study approach accountability, or participation at the lower levels (Kloos, This qualitative research used a naturalist 1998; Fiseha, 2007). approach, which tries to understand phenomena in With the introduction of decentralization context-specific settings and gives insights of following the downfall of the authoritarian military regime participants’ experiences of the world (Frumence et al., in 1991, the sub-national governments gained status in 2019 2013; Tong et al., 2018). The qualitative approach was the country (Gebre-Egzhiabher, 2014). As a result, the considered suitable because it can elucidate the Year reform transferred power to the regions and woredas experiences of those who are directly dealing with the (district) as part of a broader process of political and 24 planning and implementation of healthcare reforms as economic reform in two waves (Dickovick & Gebre- well of community users (Kwamie et al., 2015; Abayneh Egziabher, 2014). In the early 1990s, the country et al., 2017). Our study focuses on intermediate implemented the first wave, or regional decentralization. outcomes of decentralization, such as local authority, The program divided Ethiopia into nine regional state autonomy, accountability, and participation, in a case structures (The Federal Democratic Republic of study of Gida Ayana Woreda. Ethiopia, 1995). This considerably devolved power, authority, functions,
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