KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, P.O. Box 230-80108, Kilifi, Kenya.
Global Health Department, Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine, London, UK.
Int J Equity Health. 2017 Sep 15;16(1):151. doi: 10.1186/s12939-017-0649-0.
A common challenge for health sector planning and budgeting has been the misalignment between policies, technical planning and budgetary allocation; and inadequate community involvement in priority setting. Health system decentralisation has often been promoted to address health sector planning and budgeting challenges through promoting community participation, accountability, and technical efficiency in resource management. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous devolved county governments, and a substantial transfer of responsibility for healthcare from the central government to these counties.
This study analysed the effects of this major political decentralization on health sector planning, budgeting and overall financial management at county level. We used a qualitative, case study design focusing on Kilifi County, and were guided by a conceptual framework which drew on decentralisation and policy analysis theories. Qualitative data were collected through document reviews, key informant interviews, and participant and non-participant observations conducted over an eighteen months' period.
We found that the implementation of devolution created an opportunity for local level prioritisation and community involvement in health sector planning and budgeting hence increasing opportunities for equity in local level resource allocation. However, this opportunity was not harnessed due to accelerated transfer of functions to counties before county level capacity had been established to undertake the decentralised functions. We also observed some indication of re-centralisation of financial management from health facility to county level.
We conclude by arguing that, to enhance the benefits of decentralised health systems, resource allocation, priority setting and financial management functions between central and decentralised units are guided by considerations around decision space, organisational structure and capacity, and accountability. In acknowledging the political nature of decentralisation polices, we recommend that health sector policy actors develop a broad understanding of the countries' political context when designing and implementing technical strategies for health sector decentralisation.
卫生部门规划和预算编制的一个常见挑战是政策、技术规划和预算分配之间的错位；以及社区在确定优先事项方面的参与不足。卫生系统权力下放通常被用来解决卫生部门规划和预算编制方面的挑战，方法是促进社区参与、问责制以及资源管理方面的技术效率。2010 年，肯尼亚通过了一项新宪法，该宪法引入了 47 个半自治的权力下放县，将医疗保健的大量责任从中央政府转移到这些县。
本研究分析了这一重大政治权力下放对县级卫生部门规划、预算编制和整体财务管理的影响。我们采用了一种定性的案例研究设计，重点是基利菲县，并以权力下放和政策分析理论为指导的概念框架为指导。通过文件审查、关键知情者访谈以及在 18 个月期间进行的参与者和非参与者观察，收集了定性数据。
我们发现权力下放的实施为地方一级的优先事项和社区参与卫生部门规划和预算编制创造了机会，从而增加了地方一级资源分配公平的机会。然而，由于在县级能力建立之前，职能加速向县转移，以承担权力下放的职能，因此没有利用这一机会。我们还观察到一些迹象表明，财务管理从卫生机构重新集中到县一级。
我们的结论是，为了加强分权卫生系统的效益，中央和分权单位之间的资源分配、优先事项设定和财务管理职能应考虑决策空间、组织结构和能力以及问责制。在承认权力下放政策的政治性的同时，我们建议卫生部门政策行为者在设计和实施卫生部门权力下放的技术战略时，对国家的政治背景有一个广泛的了解。
