Resource Allocation and Budgetary Mechanisms for Decentralized Health Systems: Experiences from Balochistan, Pakistan
Green, Andrew, Ali, B., Naeem, A., Ross, D., Bulletin of the World Health Organization
Voir page 1033 le resume en francais. En la pagina 1034 figura un resumen en espanol.
Health sector reform is now a main focus of attention for the ministries of health in many developing countries. Policy discussions often focus on the development of a more efficient service through initiatives such as distinguishing between the functions of "purchasing" and "provision", the development of the public/private mix, greater autonomy for hospitals, and the development of district-based systems. Critical to the last of these is the development of appropriate systems for allocating resources from central to lower administrative levels. For many countries, the existing system of allocating resources, particularly financial resources, to lower levels in the health service is inconsistent with decentralization policies and the pursuit of equity. However, less attention has been paid to the development of resource allocation processes.
This article analyses issues involved in the development of such resource allocation and budgetary systems, drawing on the experience of work conducted under the Balochistan Health Systems Strengthening Component (BHSSC) of the Second Family Health Project (FH2P). The BHSSC seeks to develop institutional capacity to support a more decentralized and effectively functioning district health system. These objectives are directly linked into the wider Government of Balochistan's Social Action Programme (SAP), which places priority on primary care services and decentralization from the provincial level towards district-based management.
The decentralization strategy being developed and implemented within the project is based primarily around the strengthening of district management and planning capacity brought about by increasing management skills, improving management systems and developing more decentralized organizational structures. This is combined with a strengthening of provincial planning systems to provide strategic policy guidance to districts and builds upon earlier work carried out to establish a provincial health planning system (1). Within such a decentralization process, one necessary precondition for achieving equity is the development of systems for allocating resources to districts in line with health needs. The objective is to develop an approach that allows for central resource planning and local health care programming (2). The present article is limited to a consideration of resource allocation within the government health sector and does not consider the overall levels of sectoral funding or resource flows to nongovernmental elements. The resource allocation and budgeting system in Balochistan is primarily incrementalism. There are various weaknesses, including, most importantly, mismatches between the population health needs, the requirements of existing facilities, and the budgets set. The strategy adopted by the project to initiate a more appropriate resource allocation system has involved the following: analysis of previous resource allocation patterns; development of proposals for modifying resource allocation systems; and development of necessary support systems and organizational structures for linking the resource allocation process into the provincial and district planning and budgeting systems. Despite these technical developments, the project has been unable to produce significant changes in the allocation processes. This is largely the result of failing to gain sufficient support in key areas of government, at both the political and bureaucratic level.
The objectives of this article are as shown below.
* First, we explore the more technical issues involved in resource allocation in developing health systems, an area in which little has been published.
* Second, through an analysis of the Balochistan public health sector, we illustrate that technical solutions alone, in the absence of wider political ownership, will not lead to change. …