Conn C P, Jenkins P, Touray S O
Institute of Development Studies, Brighton, UK.
Health Policy Plan. 1996 Mar;11(1):64-71. doi: 10.1093/heapol/11.1.64.
The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level.
地区级卫生团队缺乏基本管理技能，这常被视为发展中国家实施初级卫生保健的主要制约因素。为改善冈比亚的地区级管理，在三个卫生区域中的两个实施了一个“加强管理”项目。在卫生部门权力下放政策的背景下，该项目有两个主要目标：提高卫生团队的管理技能，并在经过专门培训的管理人员领导下改善资源管理。该项目采用了解决问题和参与式的策略来规划和实施活动。该项目使地区级卫生服务管理有了一些改进，特别是在团队规划与协调质量以及有限可用资源的管理方面。然而，该项目表明，尽管卫生团队具备了更好的管理技能和系统，但其成效往往受到国家层面政府和捐助机构的政策及做法的限制。特别是，在人员配备、预算编制和规划问题上决策集中的程度，以及国家层面管理人员在管理变革方面缺乏技能和积极性的程度，都对其产生了限制。此外，捐助方支持的项目仍基于标准化模式，无法适应地区层面多样且复杂的环境，这也对其造成了限制。尽管越来越多的人主张将决策权更多地下放给地方，但这些都是常见问题。
