PSCII10 - Local governance and decentralization in health

"Governance" means: the process of decision-making and the process by which decisions are implemented (or not implemented). Governance can be used in several contexts such as corporate governance, international governance, national governance and local governance.

Good governance has 8 major characteristics. It is participatory, consensus oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive and follows the rule of law. It assures that corruption is minimized, the views of minorities are taken into account and that the voices of the most vulnerable in society are heard in decision-making. It is also responsive to the present and future needs of society.

• Participation - Participation by both men and women is a key cornerstone of good governance. Participation could be either direct or through legitimate intermediate institutions or representatives. It is important to point out that representative democracy does not
• necessarily mean that the concerns of the most vulnerable in society would be taken into consideration in decision making. Participation needs to be informed and organized. This means freedom of association and expression on the one hand and an organized civil society on the other hand.

Rule of law - Good governance requires fair legal frameworks that are enforced impartially. It also requires full protection of human rights, particularly those of minorities. Impartial enforcement of laws requires an independent judiciary and an impartial and incorruptible police force.

• Transparency - Transparency means that decisions taken and their enforcement are done in a manner that follows rules and regulations. It also means that information is freely available and directly accessible to those who will be affected by such decisions and their
• enforcement. It also means that enough information is provided and that it is provided in easily understandable forms and media.

Responsiveness - Good governance requires that institutions and processes try to serve all stakeholders within a reasonable timeframe.

Consensus oriented - There are several actors and as many view points in a given society. Good governance requires mediation of the different interests in society to reach a broad consensus in society on what is in the best interest of the whole community and how this can be achieved. It also requires a broad and long-term perspective on what is needed for sustainable human development and how to achieve the goals of such development. This can only result from an understanding of the historical, cultural and social contexts of a given society or community.

Equity and inclusiveness - A society’s well being depends on ensuring that all its members feel that they have a stake in it and do not feel excluded from the mainstream of society. This requires all groups, but particularly the most vulnerable, have opportunities to improve or maintain their well being.

Effectiveness and efficiency - Good governance means that processes and institutions produce results that meet the needs of society while making the best use of resources at their disposal. The concept of efficiency in the context of good governance also covers the sustainable use of natural resources and the protection of the environment.

• Accountability - Accountability is a key requirement of good governance. Not only governmental institutions but also the private sector and civil society organizations must be accountable to the public and to their institutional stakeholders. Who is
• accountable to whom varies depending on whether decisions or actions taken are internal or external to an organization or
• institution. In general an organization or an institution is accountable to those who will be affected by its decisions or actions. Accountability cannot be enforced without transparency and the rule of law.

Decentralization can be described, in general terms, as the ‘socio-political process’ of ‘power-sharing arrangements’ between central government and local authorities in planning, management and decision-making. This process is often triggered by a desire to bring politicians and policy-makers closer to citizens and also partly to make public services efficient and effective.

Decentralization has been acknowledged as a means of improving public services in both developed and developing world and has increased the potential to more effectively address poverty, gender inequality and overall improvement in health care systems.24 However, decentralization may also bring some disadvantages: lack of control over local bodies, a widening gap between and among regions whereby progressive regions could develop their economy, leading to regional imbalance, and intensifying regional sentiments at the expense of national unity.

The decentralization now a worldwide phenomenon. Both developed and developing countries are pursuing it. Developed countries use it as an effective tool for the reorganization of the government to provide the public goods and services efficiently. Developing countries use it to free from ineffective and inefficient governance.

• - Promote local democracy
• - Mobilization of people’s participation politically
• - From Administrative view points, it improves administrative efficiency
• - Make government quickly respond to the needs and aspirations of the peoples
• - Enhance the quantity and quality of services, government provides to the people
• - From development view point, it lead better decision-making and greater efficiency and effectiveness on locally specific plans, inter-organizational coordination, motivation of field level workers
• - It is possible to produce locally financed and provided services at lower cost because of time saving, local
• resources use and exercising of responsibility and oversight
• - Co-ordination at the local level is easier.

• • Diverse understanding among different agencies/actors on decentralization and inadequate commitment of central level
• government institutions
• • Safeguarding interest of local governance vis-àvis federal restructuring
• • Ambiguous and overlapping tasks and expenditure assignments
•  Revenue assignment, grants and revenue sharing not clearly linked with Expenditure Assignments
•  Weak linkage between District Periodic Plan (DPP) and annual District Development Plan (DDP)
•  High cost of local infrastructures due to dispersed settlements
•  Distortion in users committee mobilization
•  Issue of over exploitation and mismanagement of natural resources of stones, boulders and sand
•  Poor accountability of local staff deployed from the central government agencies
•  Weak discipline among the LB staffs in absence of elected officials and transfer provision
•  Structure and number of Local Bodies specially VDCs not viable
•  Weak capacities of the centre to regulate, facilitate and monitor the decentralized governance
•  Weak market decentralization by the Local bodies
•  Expansion of citizen awareness centres to cover disadvantaged groups in larger VDCs
•  Quality standards not defined
•  More budget allocation by LBs on smaller projects
•  Poor vertical and horizontal coordination
•  Many of small local infrastructure projects still implemented by line ministries
• Weak Management Information and Reporting System
•  Non-implementation of judicial power

• 1. Lack of clear-cut policy -
• Although the process of handing over Health facilities (HFs) started in 2000, the roles and responsibilities are not yet clear. Within the MoHP, the exact roles of different divisions and centers are unclear. Other key partners and stakeholders such as the Ministry of Local Development (MoLD), DDCs, DPHOs, HFs, VDCs and supporting partners, are also in a state of confusion with regards to their respective roles and authority.

2. Lack of coordination among different sectors: To manage the HFs that have been handed-over properly, there is an urgent need for coordination between the Ministries and intra-ministerial divisions at MoHP, DoHS, the centre and districts. Coordination among these stakeholders- at both vertical and horizontal levels- has remained weak. In many cases, disputes have occurred due to a lack of understanding and coordination among various stakeholders.

• 3. Handover process not conducted properly
• Orientation sessions are needed to better prepare and sensitize not just the community, but all concerned actors, about the handover process.

• 4. Lack of coherence on capacity building of local bodies:
• Since handover and orientation was not properly or adequately carried out, member’s level of knowledge and skills on health facility management was poor. Most members were not aware of their roles and responsibilities. A complete capacity building package is needed, where the training component is only one element among many. Therefore until and unless there is capacity within local bodies to bear the devolved authorities and responsibilities, backed by consolidated and effective capacity building measures, health sector decentralization won’t achieve its desired objectives.

• 5. Federalism and state restructuring process in Nepal
• As a result of recent political development, Nepal has become a Federal Democratic Republic and the country is in the process of political restructuring. Due to this development, there is confusion on how the decentralization process is to move ahead, including its relevance when such structural changes happen.

• 6. Health sector financing, human resource policy and capacity issues
• The budget process was more of an input-based (facilities and beds rather than e.g. disease burden). Poor financial performance caused by rigid financial procedures and lack of timely disbursements of budget in the public sector has created an imbalance between allocation and expenditure. Lack of a decentralized human resource policy is one of the critical issues in the overall management of human resources in Nepal’s public health system.

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