The following four country vignettes provide examples of successes and challenges in the HRH arena that decentralization has brought for local health managers, health workers and national leaders.
South Africa
The post-apartheid government in South Africa inherited a centralized, highly fragmented and inequitable health system. The government seeks to increase equity, efficiency, and community involvement by creating a unified, decentralized national health system, which is based on a district health system model. The development of such a decentralized district health system continues to face considerable human resource challenges.
One of the most daunting tasks has been the integration of health workers into a single district staff establishment. Doctors and nurses who now work in one district health system were previous employees of national, provincial, municipal or homeland governments. Their remuneration packages and service conditions varied widely, as did the legislations governing their work, and the organizational cultures and management styles under which they worked. Substantial differences have also become evident in the skill levels of health workers coming from such divergent backgrounds.
Other important decentralization-related human resource problems include:
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Lack of accurate and timely human resource information and functioning HR management systems at district and provincial levels (e.g. job descriptions, performance evaluation systems, etc.)
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Lack of authority of local managers to reallocate staff, create new posts or change the existing ones
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Mismatch between HR standards, set at the national or provincial levels, and the ability of disadvantaged districts to attract and retain staff to meet such standards
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Inequities in salary levels, terms of employment and continuing education opportunities, rising disparities in financial capacity and local budget allocations
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Pressure on local governments to award salary levels that they cannot afford, as a result of local labor negotiations in which unions compare salary awards of different local governments
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Poor morale and lowered performance due to staff concerns about the security of their employment and limitations to their career development
Positive experiences include some managers' creative use of their decentralized powers, such as the decision to freeze salaries of health workers who took an extended, unauthorized absence, which achieved a dramatic improvement in staff discipline. Other encouraging examples include the improvement of skill levels through an innovative two-year District Management and Leadership Course in Eastern Cape Province. The course is organized through in-service, but awards the graduates an academic qualification. In the same province, supervision improved through the development and application of a supervisory manual that establishes the expected standards of work. The use of the manual assures an objective supervision based on positive reinforcement, and ensures that the obligations of the supervisee and the supervisor are documented in writing.
[Based on personal communication with Ms. Nomathemba Mazaleni and Dr. Jon Rohde, Equity project, Eastern Cape province, South Africa, and information in Martineau et al. 2003 [See [32]].]
Ghana
The Ghana Strengthening District Health Systems Initiative (SDHS) aimed to improve management at the decentralized levels. It prepared the ground for a successful and stable health sector reform process in Ghana. The approaches used, i.e. problem analysis and solving, team based training focusing on self-identified needs, and regular facilitated progress reviews and feedback, were critical for making districts better planners and advocates for their specific needs. As district capacity increased, regional and national supervisory levels began to demand more training for themselves in order to be better equipped to support the newly identified district needs.
An encouraging example of how innovative local decision-making can have a national impact comes from the Nkwanta District in the remote Northern Volta Region. The Nkwanta District team attended district health systems training at the Navrongo Health Research Center, exposing them to methods of research that had achieved health gains. Navrongo had had good results from using community health nurses, who lived within the communities they served, to deliver primary health care and family planning services. The Nkwanta District Director and his team decided to implement a similar scheme in their district, and the high level of decentralized decision making in Ghana allowed the Director to place community health nurses in particularly deprived sections of the Nkwanta district. This decision had such good results that it eventually became the basis for national policy. The methodology that emerged, Community Health Planning and Services (CHPS), now aims to increase access to health care in the whole country.
(Based on personal communication with Dr. Delanyo Dovlo, previously Director of Human Resources Development in the Ministry of Health, Ghana.)
Indonesia
Law 22/1999 on regional governments in Indonesia initiated a radical decentralization of powers over a large number of government functions. Central government civil servants who worked in a region were now brought together with local government personnel in a regional government structure. In the health sector, over a quarter of a million health personnel were transferred to regional governments. They included medical officers who had for many years been seconded to regional health offices, as well as hospital staff who were only now being transferred.
Almost 2.4 million civil servants in total were reassigned from the central to local governments. No other decentralizing country has undertaken such a massive transfer of staff. Its successful completion was one of the greatest achievements of Indonesia's transition to regional autonomy. The transfer did not involve a physical relocation for most staff, but was mainly a bureaucratic process. In fact, observers have commented that the fact that staff transfers were a routine task of the Civil Service Board was one of the main reasons for the success. While the scale of the transfers was enormous, the work required was not new, and the Civil Service Board was appropriately structured to undertake it.
The transition was not without huge challenges. Developing a staff list for each regional office took much longer than expected. Substantial differences initially existed between the lists of the central government and those in the local offices. Each staff member required a decree ordering his or her transfer. Each region, in turn, needed records of individual entitlements, such as leave and family allowances. The capacity of some regional offices of the Civil Service Board was grossly inadequate for a task of this magnitude. They had to await additional funding and the purchase of needed computer equipment.
Matters were complicated further in May 2000, when the central government approved a program to rationalize the pay of civil servants. This included a pay rise which the regions had not budgeted for, since they were unaware that it was coming. Late payment of the increases created labor disturbances that exposed flaws in the prepared staff lists. In a number of regencies, hundreds of health workers, for example, were found to be still on the provincial payroll.
Regions now have the power to hire, appoint, transfer and fire personnel. It is alleged that they tend to favor staff who originate from the same region. While no systematic research exists on the distribution of civil servants, available data from the Civil Service Board reveals a highly unequal distribution of health staff. Authority for training is also now with the regions. It is not clear what training regions are planning or undertaking, nor whether sufficient funds have been allocated for such training. What role the central government will play in human resource development is also yet to be determined. In the meantime, decentralized staff remain concerned about their removal from the career paths and opportunities that their prior employment status with the national government made possible.
[Based on Turner and Podger [33].]
Mexico
Mexico decentralized considerable powers over the health sector from the federal to the state governments. The aim was to increase health care accessibility and coverage, and some 116,000 health workers were transferred from federal to state employment. Three main strategies have been used to strengthen human resources, and develop the staff required to implement decentralized service delivery. First, federal initiatives, aimed at increasing service demand, are linked with considerations about the availability of appropriate staff at the state level. Second, staff qualifications are improved through training. Third, adjustments are sought in the legal framework governing labor matters.
Most health workers are reluctant to accept rural postings because the working conditions and quality of life compare unfavorably with what they are accustomed to in the urban areas. In order to meet the needs of underserved rural areas, the Ministry of Health provides scholarships to recent graduates in nursing, medicine and social work who agree to do their Social Service time in such areas. These efforts have, however, failed because of the shortage of both federal and state staff positions and funding. State governments have chosen to concentrate the available personnel in the state capitals. Federal employees tend also to be concentrated in state capitals directing federally funded health programs, rather than working at the municipal level. Municipalities therefore claim that decentralization has resulted in a new centralization at the state level.
Staff with qualifications appropriate to the positions they hold continue to be concentrated in the major urban centers because of constraints in training capacity and competition for posts in the preferred urban locations. While 90 % of transferred physicians do meet the requirements for the posts they hold, 16%-31% of all medical, paramedical and administrative staff have not yet completed their studies to gain an appropriate qualification. Without such a qualification, they cannot be confirmed in their positions. It is the fully qualified health personnel, who obtain the positions in the major urban centers [34]. In response to the increased need for public health managers at state and municipal levels, state governments have attempted, but failed to persuade local universities and health institutes to provide post-graduate training and continuing education for these key personnel. Public health and management training remain centralized in the principal academic centers, located in the center of the country.
One of the most damaging results of decentralization is the fragmentation in labor policy. Most states hire personnel through (at least) two different mechanisms, i.e. 'federal' and 'state' contracts. These contracts result in quite different labor benefits and working conditions for personnel, with the consequence that two health workers who hold the same type of post and perform similar tasks may have very different earnings. The fragmented labor policy is a very divisive factor for labor relations at both the federal and state levels. Finding a solution remains one of Mexico's most important human resource challenges [35, 36].
[Based on information provided by Dr. Armando Arredondo and Mr. Emanuel Orozco, Health Systems Research Center, National Institute of Public Health, Cuernavaca, Mexico, including the referenced documents they cite.]