Improving Health System Performance in a Decentralized Health System: Capacity Building in Pakistan

What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines

“…A semi-structured questionnaire ( S1 File ) was developed by drawing from the decision space approach and the concept of health sector functions [ 13 ], as well as from two studies in Pakistan that analyzed the synergies between decision space, capacity, and accountability [ 18 , 19 ]. The questionnaire provided latitude in exploring participants’ insights and probed their perspectives on and personal experiences in implementing devolution.…”

“…We examined their flexibility in making decisions within selected health sector functions. These functions were broad categories of tasks where decision-makers make choices for the health sector as previously reported in the studies by Bossert [ 13 , 14 , 18 , 19 ]. Drawing from these studies, we initially identified these functions as: 1) planning; 2) health budgeting and financing; 3) human resources for health management; and 4) service delivery.…”

“…wide, moderate, or narrow) transferred from higher to lower levels, the decisions made at local levels within this granted “space,” and the effects that these decisions have on the health system. Previously, decision space has been reported as mostly wide in the Philippines [ 14 ], mostly narrow in Ghana [ 14 ] and India [ 15 ], almost none in Fiji [ 16 ], and moderate or varying in Zambia [ 14 ], Uganda [ 14 , 17 ], and Pakistan [ 18 , 19 ]. The studies in Pakistan have suggested that a wide decision space at local levels may not be enough to improve service delivery unless it is accompanied by building the capacity of decision-makers who assume the new tasks and by ensuring accountability for the decisions they make.…”

Managerial capacity among district health managers and its association with district performance: A comparative descriptive study of six districts in the Eastern Region of Ghana

“…state, regional, district, sub-district), is frequently perceived as a way to improve health system performance as local authorities are better able to make informed decisions regarding local conditions [1][2][3]. However, in order to improve performance, individual capacity among local health managers are needed [1,[4][5][6]. Moreover institutional capacities, such as functional support systems and enabling work environments, including an appropriate level of autonomy for the managers', must be in place [7].…”

Decision Space and Capacities in the Decentralization of Health Services in FijiComment on "Decentralisation of Health Services in Fiji: A Decision Space Analysis"

“…In the Pakistan study, we identified some process indicators of health system performance and found some relationships suggesting that the combination of higher capacity and more use of decision space led to some improvements in these process indicators. 6 The Fiji study does not examine the relationship between decision space and performance but that should be the subject of future research.…”