Decentralization and public services: the case of immunization
Introduction
Decentralization has become an increasingly familiar theme in development theory and practice over the past two decades. Yet the literature on decentralization has concentrated on case studies and theoretical discussions rather than empirical analysis, and few studies have explored the practical consequences of decentralization policies in a quantitative way. The purpose of the present study is to empirically test the impact of decentralization on an essential public service provided in all countries—childhood immunization—and to see if the various benefits proposed for decentralization are, in practice, seen. Given the continued interest in decentralization in developing countries, the findings are expected to be of interest to those in the development community as well as to health specialists concerned specifically with immunization.
Examining the impact of decentralization on immunization services has several objectives. First, examining the decentralization-immunization relationship can help planners and policymakers to predict the likely consequences of decentralizing processes—most of which originate as political decisions outside the health sector—on immunization and other preventive and public health services within the health sector. Decentralization has featured prominently in health sector reform efforts in many countries, and there has been considerable discussion of its potential to negatively affect health services such as immunization and family planning (Kolehmainen-Aitken & Newbrander, 1997; Melgaard, 1998; WHO, 1999; Feilden and Nielson, 2001; POLICY Project, 2001). Published studies of national immunization and family planning programs have also given prominence to the effect of decentralization on these services (Msambichaka, 1998; Feilden et al., 1999; POLICY Project, 2001). As a rule, these studies have used case studies, qualitative methods and managerial indicators to examine the impact of decentralization. The aim of the present study is to complement these works by using a quantitative approach to measure the approximate extent to which decentralization affects the delivery of immunization services, as well as to explore some of the channels through which it works.
Second, if immunization is accepted as a proxy for other (similar) public services, the analysis can illuminate the broader effects of decentralization on public service provision as a whole. Immunization has a number of unique characteristics, so its use as a proxy for all public services is not without shortcomings. But given the ready availability of data on immunization coverage, and the reasonable quality and comparability of these data across time and space, they nevertheless provide a useful lens through which to examine the impact of decentralization policies in a quantitative way (Gauri & Khaleghian, 2002). Caution is required when generalizing such findings, except perhaps to similar services such as malaria control or aspects of maternal and child health: but the exercise can nonetheless provide helpful insights into the effects of decentralization and a platform for testing some of the theoretical benefits proposed for it. This study therefore contributes to the small but emerging literature that uses quantitative analysis to examine the impact of decentralization on public services, examples of which include Bird, Ebel, and Wallich (1995), West and Wong (1995), Isham and Kähkönen (1999), Akin, Hutchinson, & Strumpf (2001) and Faguet (2001).
Section snippets
Definitions
For the purposes of this paper decentralization is defined as the presence of taxing, spending or regulatory authority on the part of subnational authorities such as state, provincial, district or municipal governments. Deconcentration of the health sector (also known as administrative or ministerial decentralization) is not included, since our primary question is about the implications of political decentralization rather than of organizational arrangements within a given sector;1
Decentralization and public services
Many of the proposed benefits of decentralization are based on the premise that it brings local decision makers closer to the constituencies they serve. Implicit in this are assumptions about the nature of information available to local decision makers, the presence of effective channels for the public to express wants and preferences, and the incentive environment motivating decision makers to respond. Each of these assumptions leads to specific conclusions regarding the benefits of
Decentralization and the health sector
Experience in the health sector has confirmed many of the problems summarized above. Community participation has seldom materialized as expected, capacity constraints have prevented decentralized managers from carrying out their new functions or adopting innovative approaches, accountability has failed to emerge, and failures of institutional design have left both central and local authorities confused about their responsibilities and relationships. Case studies have illustrated these issues in
Decentralization and immunization
The impact of decentralization on immunization is a matter of special concern for three reasons. First, immunization is among the cheapest and most effective health interventions available and is a core element of public health programs in all countries. Properly carried out, immunization programs can have a dramatic impact on childhood morbidity and mortality from communicable diseases, especially in developing countries and especially among the poor (Jamison, Mosley, Measham, & Bobadilla, 1993
Data and variables
To examine this question, we use a cross-sectional time-series of data on low- and middle-income countries from 1980 to 1997. Data on immunization coverage were obtained from WHO and UNICEF. Data were obtained on coverage rates for two vaccines: measles vaccine, a single vaccine usually administered at around 9 months of age, and DPT3 vaccine, the third of a three-vaccine series against diphtheria, pertussis (whooping cough) and tetanus that is usually administered at around 10–16 weeks of age.
Methods
Our empirical analysis has two objectives: first, to characterize differences in immunization coverage between decentralized and non-decentralized countries, controlling for other determinants such as national income and contact with donors; and second, to examine how these effects are modified in the presence of factors such as democracy, illiteracy, institutional quality and ethnic heterogeneity. To do this, we model immunization coverage rates using the general form
Decentralization is associated with higher immunization coverage rates in low-income countries, but lower coverage rates in middle-income countries
The parameter estimate for the decentralization variable is large and statistically significant in both low- and middle-income countries. Surprisingly, however, the sign of the coefficient is different for each: it is positive in low-income countries, indicating higher coverage rates in decentralized countries than centralized ones, and negative in middle-income countries, indicating the reverse (Table 3, Table 4). Other things being equal, decentralization is associated with an 8.8 percent
Conclusions
Decentralization is not without benefits. While empirical support may be limited, there are numerous theoretical and common sense reasons to expect a positive relationship between decentralization and various aspects of government performance. One thing is clear, however: decentralization, for all its benefits, is not a panacea. Given proper design and the right environment, decentralization can be an effective reform that meets many of its theoretical expectations. Absent these conditions,
Acknowledgements
The author gratefully acknowledges the comments and assistance of Timothy Baker, William Reinke, Laura Morlock, Carl Taylor, Larry Moulton, Manning Feinleib, Varun Gauri, Ruth Levine, Paul Fife, Imran Hafiz and Hedy Sladovich. The findings, conclusions and interpretations expressed in this paper are those of the author and do not necessarily reflect those of the World Bank, its Executive Directors or the countries they represent.
The word “processed” describes informally reproduced works that
References (91)
- et al.
Going down to the localIncorporating social organisation and political culture into assessments of decentralized health care
Social Science & Medicine
(2000) Analyzing the decentralization of health systems in developing countriesDecision space, innovation and performance
Social Science & Medicine
(1998)Democratic governance and sectoral policy reformTracing linkages and exploring synergies
World Development
(2000)- et al.
Decentralization of health services in Western Highlands Province, Papua New GuineaAn attempt to administer health service at the subdistrict level
Social Science & Medicine
(1995) - et al.
Decentralising the health sectorIssues in Brazil
Health Policy
(2000) - et al.
Fiscal decentralization and economic growthA cross-country study
Journal of Urban Economics
(1998) Malaria control in NicaraguaSocial and political influences on disease transmission and control activities
Lancet
(1999)- et al.
Health sector reforms in sub-Saharan AfricaLessons of the last 10 years
Health Policy
(1995) - et al.
Geographically decentralized planning and management in health careSome informational issues and their implications for efficiency
Social Science & Medicine
(1995) - et al.
Trust in a rent-seeking worldHealth and government transformed in Northeast Brazil
World Development
(1994)
Knowledge, attitude and practice survey on immunization service delivery in Guangxi and Gansu, China
Social Science & Medicine
The reforms of the Chinese health care system: county level changesThe Jiangxi study
Social Science & Medicine
Attempts to decentralize in recent Brazilian health policyIssues and problems, 1988–1994
International Journal of Health Services
Decentralization, governance and public servicesThe impact of institutional arrangements
Conditions for effective decentralized governanceA synthesis of research findings
What to do (and not to do) with time-series cross-section Data
American Political Science Review
Decentralization of the socialist stateIntergovernmental finance in transition economies
To decentralize or not to decentralize, is that the question? Nicraguan health policy under structural adjustment in the 1990s
International Journal of Health Services
Decentralization of health systems in Latin America
Pan American Journal of Public Health
‘Bottom-up’ planning in IndonesiaDecentralization in the ministry of health
Health Policy and Planning
Routes to low mortality in poor countries
Population and Development Review
The social component of mortality declineAn investigation in South India employing alternative methodologies
Population Studies
Decentralization of health service in Papua New Guinea
Health Policy and Planning
Decentralization and the need for political and critical analysis
Health Policy and Planning
Decentralization and primary health careSome negative implications in developing countries
International Journal of Health Services
Measuring Income InequalityA new data base
World Bank Economic Review
Decentralization and its implications for urban service delivery
Local government decentralization and the health sector in Tanzania
Public Administration and Development
Health services decentralization in MexicoFormulation, implementation and results of policy
Health Policy and Planning
Cited by (75)
Examining decentralization and managerial decision making for child immunization program performance in India
2023, Social Science and MedicineCitation Excerpt :Studies of decentralization's impact on childhood immunization highlight key features of the decision space framework and their critical roles in health services delivery. In his study examining the impact of political decentralization on childhood immunization across 138 countries, Khaleghian found that decentralized middle-income countries have lower coverage rates than centralized middle-income countries (Khaleghian, 2004). One explanation offered for these findings was that, without sufficient central direction to make immunization a health priority, local authorities may face a greater diversity of demands from the local community, driving negative impacts on immunization coverage.
The effect of devolution on health: a generalised synthetic control analysis of Greater Manchester, England
2022, The Lancet Public HealthBuilding and sustaining public and political commitment to the value of vaccination: Recommendations for the Immunization Agenda 2030 (Strategic Priority Area 2)
2022, VaccineCitation Excerpt :While national governments typically oversee immunization program decision-making and strategic planning, all levels of planning and implementation must work in concert. In decentralized systems, strong commitment, leadership and management capacity, and coordination are often even more critical to ensure efficient, effective, equitable program implementation [26,27]. Immunization programs have traditionally focused on delivery—ensuring the right vaccine, in the right condition and right quantities, reaches the right place at the right time.
Decentralization of health care systems and health outcomes: Evidence from a natural experiment
2017, Social Science and MedicineCitation Excerpt :In fact, there is some recent research suggesting that decentralization funded primarily through grants is likely to lead to a high local government size, while decentralization funded through own taxes (especially when there is a tax separation scheme) favours the containment of local public expenditure (Liberati and Sacchi, 2013). Potential gains to be realised from decentralization are also conditional on the existence of decentralization of political decision-making authority, and in particular, effective channels for the individuals to express their preferences, and incentives for the policymakers to respond to those preferences (Khaleghian, 2004; Bossert and Mitchell, 2011). The potential benefits of decentralization have to be balanced against the presence of spillover effects and public good characteristics, diseconomies of scale, and heterogeneity of preferences (Besley and Coate, 2003).
Exploring the Interrelationships between Public Health, Fiscal Decentralization, and Local Government Debt in China
2023, Healthcare (Switzerland)