Health System Decentralization as A Critical Driver for Better Care Delivery

By Odette Kibu, Health Policy Analyst (PDF Version)

1. An Overview on Health System Decentralization in Cameroon

I ntegrated health services encompass the management and delivery of quality and safe health services. This will result to a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health system, and according to their needs throughout the life ⁽¹⁾ course. In recent years, many countries, both developed and developing, have engaged in a process of decentralization of health service delivery and other functions of the health care system. The concept of decentralization involves the transfer of political, economic, and administrative power from higher to lower levels of an organization or a system. This usually involves four stages: delegation, de-concentration, devolution, and privatization ⁽²⁾. In most cases, decentralization has been adopted to improve accountability to the local population, efficiency in service provision, equity in access and resource distribution, or to increase resource mobilization ^{(3) (4)}. The paramount importance of decentralization is to optimize efficiency of organizations using small scale management units which are believed to be more flexible and responsive, well structured, as well as more accountable compared to a larger bureaucracy⁽²⁾. The potential gains in decentralization improve health care delivery ⁽⁵⁾. Scrutiny of decentralization has predominantly focused on structural changes, extent of decision space provided or performance in terms of better equity, efficiency and accountability^{(6) (7)}.

The Cameroonian healthcare system is divided into three levels; Central (strategic), intermediary (technical) and peripheral (operational) levels. The creation of health districts (peripheral level) in 1996 (almost 20 years ago) in Cameroon were created to become autonomous managerial entities that would implement primary health care policies. This policy was implemented as the country moved towards decentralization as a national administrative framework. This came as a result of the early 90s civil unrests, political bargains and constitutional reforms that followed ⁽⁸⁾. Despite the fast pace with which health districts were created, none of them has reached an autonomous state either in respect to technical, institutional, or economic autonomy (Ministry of Public Health, 2009).

The reasons for Cameroonian health districts remaining merely at a stage of delegation or de-concentration could be classified based on institutional, technical, and economic reasons. Among institutional reasons, the very slow pace of the national decentralization process has resulted in the limitation of the power of local and regional authorities. Also, district management teams still have very little power in terms of human resource management that, unfortunately, remains highly centralized. In addition, health districts still have total dependence on the central level for funding, and this regulatory authority does not have an equitable tool for resource allocation to health districts. The result is a system where resource allocation respects neither territorial size, population size, nor the performance of the health district. This financial dependency contributes to further erosion of the decision-making power of district management teams, leading directly to the provision of substandard health care in these localities.

In addition to the highly centralized health system, Cameroon is one of many African countries experiencing a crisis in human resources for health. Poor human resource management has been shown to be a hindrance to a decentralized health care system⁽⁹⁾. Approximately 80% and 90% of health structures are located in urban areas and the quality of health care is relatively acceptable in urban areas which tend to have more qualified staff ⁽¹⁰⁾. Such is not the case in rural areas mainly because of under-qualified staff ⁽¹⁰⁾. There is approximately 1 physician that is available for every 10,000 of the population ⁽¹¹⁾.  This is far below the standard from the World Health Organization (WHO) which recommends 10 physicians for every 10,000 of the population. In addition, most of the physicians reside in urban areas, further compounding the problem.  Primary health care (PHC) is provided in line with the health district framework proposed by the WHO Regional Office for Africa, which entails a nurse-based, doctor-supported infrastructure of State-owned, denominational and private integrated health centers. It is supported by a diverse, though a fragmented, system of community health workers recruited by priority public health vertical programs. The 2016 evaluation of this sectoral strategy found that 7% of the 189 health districts were equipped well enough to provide services⁽¹²⁾. PHC performance in Cameroon is below expectations when compared to the current health expenditure, mostly because of the weak regulatory system and lack of accountability.

The Ministry of Public Health in 1995 revealed that even though an average of 70% of the population had access to health care within a 5-km radius, less than 30% used its services⁽¹⁰⁾. Due to the centralized location of health care facilities, long distances hinder access to health care services. In rural areas, health care facilities operate within a range of 12 to 54 km depending on the regions. For many women, these distances are the major obstacle to access care and vaccination thus reducing the efficiency of health care delivery. The pace of the process of decentralization in a given context unavoidably depends on the degree to which exists a favorable legal environment in addition to the dynamism of stakeholders (especially of local entities, the state, development cooperation partners and civil society)⁽¹³⁾.

2. Importance of decentralization in health care delivery

Decentralization is a key instrument for improving service delivery across an economy. In the health sector, issues regarding decentralization are of increasing importance, with the objective of involving the local government more actively in the development process.  The enabling conditions for successful decentralization have not been well implemented in Cameroon^{(14) (15)} which directly affects the strategy and operational plan. Indeed, many ministries tend to view the decentralization process more as a threat to their control over resources and influence⁽¹⁶⁾. This is the reason why financial resources, human resources and equipment are disproportionately located in the urban areas. This has affected health service delivery indicators in Cameroon which lags behind those of countries at similar income levels, including indicators of child mortality and life expectancy at birth. A centralized system has exacerbated poverty levels in rural areas, with poorer health outcomes. Poverty is usually associated with socioeconomic or political factors and the local population in a community usually have a better mastery of the problems they face. Therefore, a decentralized health care system is important in delivering quality health care services because it involves the local population who have a better knowledge of their environmental and socio-economic problems.

A centralized government has not been beneficial to the Cameroonian health sector. The poor public expenditure of state funds has handicapped the financing of health (only 4.29% of the state budget spent on health) ⁽¹⁸⁾. If Cameroon fully embraces health care decentralization policy, it will reap the promise to increase efficiency in service delivery and cost-effectiveness in service provision.

3. Policy recommendations for a decentralized health system

The central government should reduce its role in the delivery of direct health care and rather transfer resources to local governments and communities who are better positioned to properly respond to their health needs. This will enable the health sector to be more effective and efficient. A health system decentralization framework is greatly needed, and would further clarify and detail the responsibilities and functions of each government level and agency. Decentralization requires a strong central entity to regulate, to provide an overall framework to manage the re-allocation of responsibilities and resources in a predictable and transparent way and to assist local governments build their capacity in the early stages.  The solution to pitfalls of decentralization is the empowerment of people through broader local participation, transparent governmental procedures, and protection of minority rights.  A strategic approach could be to develop a detailed plan for phased implementation of decentralization, in which local government with a stronger capacity receive technical assistance and support as needed to effectively implement the first group of decentralized local government in health⁽⁴⁾. Learning from these experiences would then allow fine-tuning and correcting implementing strategies for the second round of districts to implement health decentralization.

In addition, decentralization can become a reality if opportunities are created for the private sector to unleash their potentials and penetrate the health care sector. This will de-concentrate activities and responsibilities at the central level.  Eventually, this will help create jobs and reduce poverty level in Cameroon ⁽¹⁹⁾.

To sum up, an often-expressed hope is that decentralization will reduce overload and congestion in the channels of administration and communication thus, paving the way for better health care delivery. This method of governance in the health care sectors has the potential to pave the way for private sectors to improve on health care delivery and encourage competition thus, in return better health care services are delivered.

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Odette Kibu is a Health Policy Analyst at the Nkafu Policy Institute, an independent think tank at the Denis & Lenora Foretia Foundation. She can be reached at [email protected]