Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
Independent Consultant, Khartoum, Sudan.
Front Public Health. 2024 Nov 8;12:1439219. doi: 10.3389/fpubh.2024.1439219. eCollection 2024.
Health system reform initiatives have increasingly embraced decentralization as a key trend. The implementation process and its outcomes are influenced by a myriad of factors, including economic forces, political dynamics, and ideological factors. Comprehending and carefully examining the implementation phase of decentralization and its consequences to achieve desired outcomes is crucial. Notably, this phase is often considered the weakest aspect of policy reforms, especially in developing countries. Therefore, this study aimed to explore and analyze the implementation phase of decentralization and its implications as essentials for achieving intended goals. The study objectives evolved around examining the entire decentralization as a multifaceted social and political process in Khartoum State, Sudan, from its early stages of decision-making, policy formulation, and implementation process and the influencing contextual factors.
This study was an exploratory qualitative study that employed in-depth interviews to gather perspectives of healthcare providers and policymakers, semi-structured observations, and thematic analysis. The study utilized Grindle's framework for analysis.
This study revealed a political nature of decision-making, with a top-down approach to the implementation, which also lacked stakeholder involvement. It showed a lack of transparency, official documentation, and proper handover procedures from the Ministry of Health to the devolved hospitals during the implementation process. A conflict of interest between the federal and the state level was also reported. It is important to note that this process occurred within the context of structural adjustment program (SAP) schemes, which had already empowered the private sector in Sudan.
This study documented the implementation process of decentralization of health services and its influencing factors. The study recommended reforming the decentralization policy through consultative stakeholder involvement and by implementing a concurrent responsibility paradigm that divides authority between the federal and state levels.
健康系统改革举措越来越倾向于将权力下放作为一个关键趋势。实施过程及其结果受到众多因素的影响，包括经济力量、政治动态和意识形态因素。理解和仔细检查权力下放的实施阶段及其结果对于实现预期目标至关重要。值得注意的是，这一阶段通常被认为是政策改革中最薄弱的环节，尤其是在发展中国家。因此，本研究旨在探索和分析权力下放的实施阶段及其对实现预期目标的影响，以此作为实现目标的关键要素。研究目标围绕着考察苏丹喀土穆州权力下放作为一个多方面的社会和政治进程，从其决策、政策制定和实施过程的早期阶段，以及影响的背景因素进行研究。
本研究是一项探索性的定性研究，采用深入访谈来收集医疗服务提供者和政策制定者的观点、半结构化观察和主题分析。研究利用了 Grindle 的分析框架。
本研究揭示了决策的政治性，实施过程采用自上而下的方法，也缺乏利益相关者的参与。研究表明，在实施过程中，卫生部向分权医院移交过程中缺乏透明度、正式文件和适当的交接程序。还报告了联邦和州一级之间存在利益冲突。值得注意的是，这一过程发生在结构调整计划（SAP）方案的背景下，该方案已经在苏丹赋予了私营部门权力。
本研究记录了卫生服务权力下放的实施过程及其影响因素。研究建议通过利益相关者的协商参与和实施联邦和州级之间权力划分的并行责任模式来改革权力下放政策。
