Making Sense of the Complexity of Decentralised Governance; Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis"

Abstract

The article by Rotulo and colleagues suggests that health sector fiscal decentralisation has been bad for Italy. But given the complexity of fiscal decentralisation, this interpretation is not necessarily so. Their analysis was based on assumptions about causality that are better suited for simple interventions. Assumptions of simplicity show up as misleading artefacts in the conclusion of evaluations of complex interventions. Complex interventions work by triggering mechanisms – e.g., reasoning and learning processes – that manifest differently across the units of a decentralised system, contingent on context, evolving over time. Evaluation findings can only be partial and provisional; neither summarily good nor bad. The goal of evaluating a complex intervention – like decentralised governance – should be to understand how, under what circumstances and for whom they are good or bad – at a point in time.

Finagle’s laws of information: lessons learnt evaluating a complex health intervention in Nigeria

“… 1 12 Therefore, evaluators need to embrace the broader range of approaches from evaluation sciences and social sciences and accept that evaluations may at best provide ‘partial and provisional’ results. 12 Alternative approaches include theory-based evaluations that rely mostly on qualitative research methods and focus on interventions’ processes, providing information regarding how, why, where and for whom interventions work . As such, their focus is generally less on attribution (direct causal links) and more on contribution to change (recognising that multiple contributing factors produce results).…”

“…It has been argued that evaluations of complex interventions can at best provide 'partial and provisional' results given that human behaviour and context are ever-changing. 12 GRID3 is an example of a complex intervention. It started with the aim of supporting health sector microplanning and service delivery by providing high resolution demographic estimates and geographical settlement patterns.…”

“… 10 Others have proposed that complex interventions are highly dependent on human agency and context 11 and that they work by triggering context-specific and continuously evolving mechanisms. 12 A variety of qualitative and quantitative methodological approaches are often required to build a complete and comprehensive understanding a complex intervention. The focus is generally less on attribution (direct causal links) and more on contribution to change (recognising that multiple contributing factors produce results).…”

“…It has been argued that evaluations of complex interventions can at best provide ‘partial and provisional’ results given that human behaviour and context are ever-changing. 12 …”

The Dangers of Fiscal Decentralisation in Healthcare: A Response to the Recent Commentaries

“… 3 Under this type of decentralisation, providers and regional authorities can compete against each other, in an open market environment, on the offer of different bundles of public services for a certain taxation level. 4 In the academic and policy debate the terms “decentralisation” and “fiscal decentralisation” are often used interchangeably, 3 a fact that inhibits mutual understanding and adds further ambiguity in the relevant policy discussion.…”