Decentralization, Co-Management and FBOs by Franklin Baer Baertracks

1)What are UFOs? 2)Where do they come from? 3)What do they want? 4)What should we do about them? UFOs U nprecedented F BO O pportunities UFUFOOUFUFOOO

FBO Network Opportunities in Africa African CHAs Lesotho – CHAL Zimbabwe – ZACH Zambia – CHAZ Malawi – CHAM Tanzania – CSSC Kenya – CHAK & KEC Uganda – UPMB, UCMB Sudan - CHAS Nigeria - CHAN Ghana – CHAG Liberia – CHAL Sierra Leone - CHASL

Unprecedented FBO Opportunities in Decentralization & Co-Management  Public vs. Private  Decentralization  Co-Management

Lesson Learned # 1 The country-specific historical context FBO shapes FBO & MOH collaboration (or lack of collaboration.

Lesson Learned # 2 FBO-managed health facilities are more of a public sector than private sector resource (and should be recognized as such).

Health System Providers Public Private

Decentralization Decentralization: The shifting of decision-making powers from a central to a peripheral level for one or more management functions:  Planning  Budgeting  Training/Supervision  Personnel

Types of Decentralization 1.Deconcentration: Power shifted to periphery within the MOH, e.g. regional/district offices 2.Devolution: Power transferred to local gov’t, i.e., no longer under MOH direct control. 3.Delegation: Transfer of responsibility to parastatal organizations, e.g., NGOs or FBOs 4.Privatization: Transfer of responsibility to private-for-profit sector, e.g., private clinics.

Lesson Learned # 3 The process of decentralization needs to be decentralized in order to better empower the peripheral levels. Centralized Decentralization: is a top-down imposed decentralization to keep power at the central level.

Lesson Learned # 4 Poor communication and transportation systems can sometimes facilitate decentralization.

Lesson Learned # 5 Deconcentration with delegation is a hybrid form of decentralization particularly appropriate for collaboration with FBOs. This involves deconcentrattion within the MOH and some delegation of functions to FBOs or NGOs. Delegated Deconcentration Deconcentrated Delegation Co-Management

Lesson Learned # 6 Health system co-management with FBOs (Deconcentration+ Delegation) requires more geographic flexibility than traditional decentralization.

Three Dimensions of a Health System

Model for a Comprehensive Health System

Levels of FBO-MOH Collaboration Levels Community Health Center Hospital Medical School Other institutions Collaboration ? –Parallel –Integrated –Co-Managed

Three Types of Collaboration 1)Parallel: Separate independent (and competing ?) systems with little exchange of technical support or information. 2)Integrated: Coordinated system with a common technical support and system, e.g., health district. 3)Co-Managed: Coordinated system with FBOs having geographically defined areas of responsibility, e.g., co-managed health zones.

Parallel Collaboration

Integrated Collaboration

Co-Management Collaboration

Lesson Learned # 7 FBOs can help establish decentralization and management precedents for national health system development.

The Hospitals of DR Congo (c. 1960)

Pilot Health Zones ( )

Health Zones (1982)

Health Zones (1984) before delimitation of Health Zones

Health Zones (1984) after delimitation of Health Zones

DR Congo FBOs co-manage 1/3 of the 515 Health Zones

Lesson Learned # 8 The comprehensive infrastructure of FBOs can help accelerate health systems building. Having good schools for the children of health workers can be an important retention factor in rural areas.

Lesson Learned # 9 FBO networks and umbrella groups can be effective project-of-projects managers, including projects that involve decentralization. The SANRU I Basic Rural Health project was designed as a Project of 50 Health Zone projects.

Lesson Learned # 10 FBOs are a permanent resource that can contribute significantly to sustainability of health systems even (and especially) in times of crisis.

Korten’s FBO/NGO Development Strategies From David Korten’s “Generations” of NGO Development Strategies

Ten Lessons Learned about Decentralization and Co-management 1)Historical context shapes FBO & MOH collaboration 2)FBOs more public than private sector 3)Decentralization needs to be decentralized 4)Poor communication can facilitate decentralization. 5)Deconcentration + Delegation = Co-Management 6)Co-management with FBOs requires geographic flexibility 7)FBOs help establish management precedents 8)FBO infrastructure accelerates health systems building 9)FBOs can be effective project-of-projects managers 10)FBOs are a permanent resource, esp. in times of crisis

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