U-Form vs. M-Form: How to Understand Decision Autonomy Under Healthcare Decentralization? Comment on "Decentralisation of Health Services in Fiji: A Decision Space Analysis"

Abstract

For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization.

Decentralisation; The Question of Management Capacity: A Response to Recent Commentaries

“…10,19 The decision space analysis of Fiji’s decentralisation initiative supports this view, revealing a system that remains centrally controlled. The Fijian health system reflects a U Form organisation 2 whereby health services are delivered through a network of government owned facilities, controlled by divisional managers who liaise with subdivisions to ensure that a minimum standardised package of health services is delivered. While this has the benefit of realising economies of scale, there is growing evidence that countries could better benefit from a mix of centralisation and decentralisation strategies, taking advantage of efficiencies gained from centralisation of certain functions and decentralisation of others.…”