Keywords

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After Reading This Chapter, You Will Be Able to

  • Understand the concept of decentralization and decentralization in health services.

  • Explore the nature and typology of decentralization.

  • Examine some opportunities and challenging aspects of decentralization.

Introduction

Currently, health systems worldwide are facing a serious challenge, not only because they have not addressed the people’s health-care needs and demands appropriately but also because the systems have consistently failed to accommodate wider health-care determinants and principles of universality, equality, opportunity and responsibility in health and well-being (WHO 2004; National School of Government 2007). Health sectors are complex structured relationships between the people and the institutions, where institutions will offer an organised social response to the people’s need (Londono and Frenk 1997). Since the 1990s, decentralization, a form of reform mechanism, has been initiated in many transitional nations (Dzakula 2005). This is a process of transfer or dispersal of central authority and power to local authorities or sub-national bodies in making public services more responsive to meeting people’s needs (Saltman and Figueras 1997; Saltman et al. 2007). The World Bank report highlights that ‘out of 75 developing and transitional countries with populations greater than 5 million, all but 12 claim to be embarked on some form of transfer of political power to local units of government’ (Dillinger 1994, p.8). It is therefore a general consensus that reforming of public services in the form of new models of health delivery is inevitable in response ‘to a variety of economic and political pressures as well as to the population’s longstanding health-care problems’ through delivering more inclusive and equitable services (Figueras et al. 2005; World Bank 1993; World Bank 2004; WHO 2008a).

Why Decentralization

Decentralization concerns how government should be structured and where power, authority and responsibilities should be located (SOAS 2009). This involves bringing ‘local governments closer to the people to be able to address local needs appropriately’ (Smith 1985, pp. 8–9; Work 2002, p. 4). Hadenius (2003) argues that when decentralization brings government closer to people, this would enable the local community to ‘participate and exert influence’ as the reason given was that ‘when power is brought closer to citizens, the political process becomes more tangible and transparent and more people can become involved’ (p. 1).

There are several justifications given for transferring or devolving central authorities and responsibilities to local authorities, but one promising reason was to make public services more responsive towards people’s needs through correcting central government’s top-down ‘bureaucratic’ mentality (Bienen et al. 1990). This will also develop some degree of efficient and harmonious relationship between the central and local authorities (UNDP 1999). In the light of these notions, Hutton (cited in National School of Government 2007) argues that we need to develop a model of delivery which ‘fundamentally rejects the old model of top-down monolithic public services, run from the centre, in favour of greater devolution, diversity and choice; that shifts the focus into meeting the individual needs of those who use these services, and onto the quality and not just the quantity of public service provision’ (p. 12).

In a similar vein, WHO (2007) notes that reform should be an essential step for undertaking changes in health performance.

‘A directed change approach from the centre need to be rejected in decentralised health system instead needs a wider decision space at the locality. A wide choices of economic and non-economic incentives scheme, both for individual and institutional, need to be tested and established to rectify current issues of human resources retention at the local level’ (WHO 2007, p.2).

Another important reason to advocate decentralising health systems is that many health services are rated as being of poor quality and they are delivered by poorly motivated staff and outdated clinical practices, and as a result, the current health-care services have not been appropriately responsive to address the people’s health-care needs (Figueras et al. 2004). In Cassels’ (1995) view, reforms should relate to defining and refining service priorities and reforming institutions which formulate and then implement appropriate policies in the light of these priorities in practice. Collins (1996) views decentralization as a mechanism or approach to reform the institutional paradigm. Traditionally the concept of decentralization has emerged from the field of public administration focusing on how a state or national political structure operates in terms of distributing its authorities, responsibilities and accountabilities (Bossert 1996). The notion of decentralization in the health sector has not been well researched, and even the available literature has failed to link decentralization and health at appropriate levels.

Decentralization is a sociopolitical process of moving or redistributing central authorities and responsibilities to the local or peripheral governments, with some level of negotiation, in the hope that locals are ‘champions’ to assess and address local people’s interests and needs (Mills et al. 1990; Regmi et al. 2009). In this respect, decentralization is a mechanism in health system reform – but clearly one of many forms linking to political devolution, administrative changes, increased autonomy for practitioners and local systems (Peckham et al. 2005; 2008). There are various models and approaches to employ in public sector—including health service—reform, but which to use, if any, and how such model(s) would work in practice are other challenges (National School of Government 2007). This will have different relevance in different systems (e.g. centrally funded and controlled within a strong democratic framework (UK), federal systems (Spain, Canada, USA), provincial, countries with weak institutional structures). The UK government approach to the reform of public services, for example, is directed at:

‘Citizen-centred and response; universal, accessible to all (in the case of core services like health and education) free at the point of use; efficient and effective, offering value for money to the taxpayer; equitable, helping to reduce social exclusion and improve the life chances of the disadvantaged; excellent quality; and empowering and involving citizens in shaping public policies’ (National School of Government 2007, p. 12).

Motives for Decentralization

  • In Latin America—it has been considered as an essential process of democratisation by installing elected governments over central autocratic regimes.

  • In Africa—the advent of multiparty political systems can make public services responsive to the needs of people while at the same time empowering local people in planning and decision-making.

  • Ethiopia—as a response to minimising inequalities and ethnic disparities, groups thereby provide opportunities to participate in the political process.

  • Mozambique and Uganda—an attempt to keep the country together as an outcome of long civil wars—‘asymmetrical federations’.

  • Former socialist states (e.g. the Czech Republic, Baltic states and Poland)—to collapse old central autocratic-hierarchical regimes.

  • Russia, Bosnia—to minimise some ethnic tensions.

  • Eastern Europe and former Soviet Union—transition from a command to a market economy.

  • East Asia—to improve planning and delivery of public services on a larger scale.

  • South Asia—to overcome challenges of ethnic and geographical disparities.

  • In many nations across the world—decentralization acts as a means to providing public services through establishing good governance systems, often cross-cutting themes of the broader processes of political and economic reform—political development, institutional capacity, corruption, governance, equity and poverty reduction.

Source: Litvack et al. (1998), World Bank (1997), World Bank (n.d.).

Decentralization in Health

Decentralization policies in the health sector have been gaining popularity in most developed and developing nations since 1990, as it has been considered as a powerful driving force to improve the effectiveness and standard of national health systems and to promote empowerment and equity by reducing the unmet demands of the community (Collins et al. 2003a, b; WHO 2008a; Costa-Font 2012). The World Bank (2004) highlights tripartite dynamics of decentralization between service users (clients), citizens (people) and institutional systems to be able to make services responsive to the needs of people by making government closer to citizens and closer to services.

Decentralization is in fact a catch-all description rather than a definitive reform mechanism in health, as it is not one concept in itself but is highly contested. It is therefore important to focus on what type of decentralization is being addressed and how it affects health system design and functioning. It is, however, interesting to point out that the most appropriate level of decentralization in the health system is an important unresolved policy debate (Robalino et al. 2001; Peckham et al. 2005; Kurk and Freeman 2008; Siddiqi et al. 2009). In addition, several authors have also noted that very ‘little attention has been paid to the measurement of decentralization in health services, as opposed to the relatively greater amount of literature available about the effects of decentralization on government size, economic growth’, equity and performance (Smith 1997; Jimenez and Smith 2005, p. 3; Peckham et al. 2005).

The notion of the decentralization policies is, however, to develop a new type of health-care organisation that would allocate some degree of ‘spaces’ to local authorities or local governments to assess, analyse and then plan and deliver (action) appropriate health-care services, keeping people at the centre of their policies (Bossert 1996; Peckham et al. 2005), i.e. nothing about us without us (Werner 1998). The World Bank (n.d., p.x.) states that for two important reasons we failed to measure the effects of decentralization on health sector outcomes: first, ‘how these benefits can be realised’, if any, and in what context and, second, ‘specific impact of different health system reforms are not well understood’. Similarly, Wollmann (2008) also argues two important ‘deficits’ to make the decentralization reform inevitable: (a) democratic deficit (poor accountability and transparency prevails in decision-making at the local levels) and (b) performance deficit (local authorities have consistently failed to address wider determinants (socio-economic, political and environmental)).

Analysis of decentralization policies in many developing parts of the world may draw on similar principles and theoretical frameworks as decentralization in the UK or USA, but they are different due to their different socio-economic and political landscapes. In the USA, for example, Medicaid (health insurance) is one of the programmes for which important elements of federal authority have been devolved to the states; in the UK, the English National Health Service (NHS) is one of the basic responsibilities of the new Scottish and Welsh parliaments; and in Spain and Italy, legislative powers have been combined with an augmented fiscal autonomy in health care (Jiménez and Smith 2004, p. 2). In many parts of the world, the motives of decentralization of health services by different funding agencies, such as the World Bank and UNDP, vary, and they influence recipient’s spending patterns and budgetary process (Atkinson et al. 2000; Rubio and Smith 2004; WHO 2008b). The World Bank (2004), for example, noted some donors interfere directly with the design and deliver of public services:

‘First, donors may support only capital spending (construction) and expect the government to supply complementary inputs (staff, maintenance). Governments often fail to finance the complementary inputs. Second, donors may fund projects that governments are not interested in. This contradicts ownership. Third, donors may set targets for the share of spending in particular sectors as conditions for flow. Fourth, donors may give aid to a priority sector and assume that government spending from its own resources remain unchanged’ (p. 204).

Decentralization is fundamentally ‘politically motivated, and consequently much of the literature has stressed the advantages—service access and responsiveness and limitations of the sub-national (district/sub-district) provision of health services’ (Jimenez and Smith 2005, p.3; Rubio 2006). There is not much strong evidence prevailing, for example, ‘countries with a more decentralised health system experience better health outcomes’ (Conyers 1986; Manor 1997a, b; Shah et al. 2004; Jimenez and Smith 2005, p.13; Prieto and Saez 2006; Rubio 2006; Kurk and Freedman 2008). Therefore the ‘means and ends’ of decentralization are different both rhetorically and in practice. In the case of health care, it is often pursued with the motive of political, technical and financial purposes—sometimes technical means of improving the effectiveness of management and service delivery (WHO 2008a); politically, seeking community participation, power and autonomy (WHO 2008a, p.1; WHO 2008b); and fiscally as a means of cost-effectiveness and cost-efficiency (Saltman et al. 1997, 2003; Agrawal et al. 1999; WHO 2004, 2007; World Bank 2004a, b). It is, therefore, important to set out the nature of decentralization—focusing more on the elements of what is often parcelled up as decentralization. This includes institutional reform, political change, autonomy and accountability.

Activity 1

What are the organisational polices and professional opportunities and barriers to implementing decentralization in health services?

Typology of Decentralization

Decentralization is a complex term to define as it not only brings different paradigms and perspectives into place but also takes many forms and dimensions including labelling and labels (Fig. 1.1). This is complex in nature—as Omar (2002, pp. 25–26) argues ‘no country conforms to any single category of decentralization, but manifests multiple elements of the different forms of decentralization at the same time’—within countries and even within sectors; second, there is clearly some overlap between/among their concepts and interpretations.

Fig. 1.1
figure 1

Typology of decentralization [Source: Saltman et al. (2007), Cohen and Peterson (1999)]

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Different authors review decentralization in different forms and levels. Treisman (2002, p.14), for example, views decentralization in six dimensions: vertical decentralization (based on the number of tiers), decision-making decentralization (space provided to make political decisions at the local level), appointment decentralization (whether local authorities have the right to make any executive appointments), electoral decentralization (nature of local authorities/officials are elected), fiscal decentralization (sharing/generating revenues and taxes) and personal decentralization (roles of local employees in total government). Meanwhile Rondinelli (1981, 1989), a renowned author and internationally established subject expert, offers three types of decentralization, i.e. political decentralization (devolution), administrative decentralization (deconcentration and delegation) and fiscal decentralization.

  1. 1.

    Political Form of Decentralization (Devolution)

    Decentralised systems bring more accessibility to political movements and minority groups in their attempts to influence politics—this is particularly important to the national and international contexts where there are ethnically divided societies, and political exclusion can have serious polarising effects (Hadenius 2003, p.1; also see World Bank 1997; Grindle 2000). Inman and Rubinfeld (1997) argue that political decentralization would help to map local people’s needs and interests while making decisions at policy levels.

    Political decentralization is often called devolution, where central government transfers authority and responsibility to local authorities (quasi-autonomous units of local government) for decision-making, finance and management. This approach is also called an extensive form of decentralization, as this often transfers responsibilities to that unit (municipalities or districts, provinces or villages) who are elected from their community, can raise their own revenues and have a great amount of decision space at the local discretion. In Rondinelli’s (1989) view, local government will have established legal boundaries to exercise their power and authority to deliver public services. The aim of political decentralization is to promote people’s participation in local planning and decision-making. This approach is often called an institutionalised form of strengthening democratic decentralization (see Ribot 2002; Kassibo 2002; Cohen and Peterson 1999).

    Characteristics

    • Radical form of restructuring/reforming health services.

    • There is little or no direct control by the central government—local government or local authorities are autonomous and independent.

    • Normally there are clear legal and geographical boundaries of local bodies (LBs), within which they perform their functions and exercise devolved authority.

    • The local governments to which the power and responsibilities have been devolved are perceived as government units.

    • Granted few revenue-raising powers.

    • On the basis of the concept of reciprocity, a coordinated relationship between the central and local government takes place for their mutual benefit.

    • Decision-makers are elected representatives accountable to voters who participate in other ways in the political life of local communities or regions.

    • Effectiveness will often be determined by four sets of supportive conditions: political and administrative, organisational and institutional, behavioural and psychological and the availability of resources.

    Source: Cheema and Rondinelli 1983; Smith 1985, p.11; Mills et al. 1990.

    It is, therefore, important to acknowledge that to make a successful ‘transition’ of transferring authority and responsibility between the different levels/tiers of government, three important components should interplay—political, fiscal and economic aspects.

  2. 2.

    Administrative Form of Decentralization (Deconcentration and Delegation)

    Administrative decentralization relates to the process of how defined political institutions would make collective decisions to bring distributive outcomes utilising both fiscal and regulatory mechanisms. As Litvack et al. (1998) argue, political decisions aim ‘to devolve powers from central government, for example, can only get translated into actual powers being shifted if supranational governments have the fiscal, political, and administrative capacity to manage this responsibility’ (p.6).

    Deconcentration—a form of administrative decentralization where central government disperse responsibilities of certain services to their own regional/local branches. This however does not involve transfer of authority and responsibility to the local government and is unlikely to lead to the potential benefits or pitfalls (Regmi et al. 2009). Though there may be some ‘downward’ accountability (to service users, etc.) built into their functions, their primary responsibilities are to represent the central government and to deliver public services on its behalf (World Bank & United Cites and Local Governments, 2008, p.306). Indeed, much of the developing world—East Asia and Eastern Europe—adopt this approach as a form of decentralization, as in many government systems there is no legally separate identity of local independent government and regional/local branches which are used to make services effective and efficient. Litvack et al. (1998) suggest deconcentration is sometimes used to deliver certain functions in federal countries when there are certain strong government systems.

    Delegation—the extent to which central government transfers authority and responsibility to local governments or semi-autonomous institutions, often called ‘parastatal organisations’, for making public services more effective. One argument is that this form of decentralization applies when local governments or semi-autonomous institutions are not solely dependent on the control or command of central government—that means local governments have some degree of space to make decisions independently. As Bossert (1998) suggests, such a form of decentralization could also be viewed as a ‘principal (central government)—agent (local governments/semi-auto institutions)’ approach.

    Characteristics

    • Deconcentration entails the redistribution or ‘handing over’ of some administrative responsibilities to lower units of central government without transferring any authority to make independent decisions (Kassibo, 2002).

    • Involves the transfer of administrative rather than political responsibility, and it has been the form of decentralization most frequently used in developing nations (Mills et al. 1990).

    • It is usually regarded as a weaker form of decentralization because downward accountability is not well established, unlike in the democratic or political forms. In certain cases of delegation, certain responsibilities are transferred to organisations which are outside the bureaucratic structure and are indirectly controlled by the central government (Cohen and Peterson 1999).

  3. 3.

    Fiscal Form of Decentralization

    The process of making appropriate decisions through the defined nature and form of taxes and approaches. Several studies have noted that decentralization with local and central regions able to decide about financial matters as per the nation’s own requirements brings about better health outcomes (Litvack et al. 1998). In addition, it is important to note that there should be a strong local network of professionals who offer support with their skills and capacities to assess, identify and analyse appropriate problems and concerns (Kocia 2008).

    Characteristics

    • Fiscal decentralization aims to bring about the ‘transfer of the resources necessary for the exercise of the transferred powers and responsibilities’ (World Bank & United Cites and Local Governments 2008, p. 306).

    In some literatures, privatisation, deregulation and divestment are presented as forms of market decentralization. Privatisation entails the ‘transfers of functions to the private sectors including planning and administration, previously held by public institutions’ (World Bank & United Cites and Local Governments 2008, p.306), but usually they are excluded from decentralization typologies, as Ribot (2002) notes that privatised markets mostly operate for profit motives rather than public accountability, and most importantly, a greater amount of authority and responsibility would remain in the centre (also see Bossert 1996; Green and Matthias 1997). However, several authors (Litvac et al. 1998; Litvac and Jessica 2005; Mills et al. 1990) equally argue that decentralization is not necessarily confined only to the public sector—it may happen with the voluntary sectors whose motive may not be profit-seeking, for example, non-governmental organisations, trade unions and professional bodies. Green and Matthias (1997) view this group as defined as ‘formal organisations, which have corporate objectives concerned with humanitarian aims concerning groups outside the direct control of government’ (p. 7). Nevertheless, both devolution and deconcentration are taken as means of pushing forward the angel of privatisation (Slater 1989).

Activity 2

Can you identify any factors which help or hinder the translation of decentralization of health sector policy into practice?

Opportunities and Challenges of Decentralization

As the nature of decentralization is complex, thereby its opportunities and significance to practice are complex too. Litvack et al. (1998) discuss three important implications: First, decentralization is a process of negotiation between central and local tiers of governments through mobilisation and allocation of resources, which as a result might have positive effects from service delivery to poverty reduction. Second, understanding of institutional content (knowledge), context and process of decentralization is paramount. There is a need to understand the driving forces and the stakeholders involved. Third, there is still limited information—either non-existent or conflicting—on how and in what context, if any, decentralization does or does not work. Similarly, Crook and Manor (1998) also note that the ‘outcomes of a decentralization policy will depend not just on the relative weights of devolution and deconcentration in the institutional and fiscal structures, but also on their combination with two other important elements: the kind of legitimation and accountability adopted (e.g. participatory, electoral) and the principles according to which the areas (and hence size and character) of a decentralised authority are determined’ (p. 2).

Health sector decentralization advocates point out its various perceived benefits (Mills et al. 1990; Conn et al. 1996). Since the 1990s, management of health services has shifted from the costly curative model, to become more promotive and preventive, where community or service users are actively involved in planning and management, including sharing benefits through restructuring of power between the central and local authorities (Mills et al. 1990; Mills 1994; Chambers 1983, 1995, 1997; WHO 2008b).

Mills et al. (1990, p.142), however, highlight key promises of decentralization in health care:

  • Organise a more rational and unified health service on the basis of geographical and administrative areas that will be able to address local people’s health-care preferences.

  • Involve local communities in the management of their own health.

  • Reduce duplication of services, particularly at the secondary and tertiary levels of health care, by relating responsibilities to defined catchment populations.

  • Reduce inequalities between regions and between rural and urban areas.

  • Integrate service activities of government and non-governmental and private health organisations.

  • Reduce centralised control over local administrative matters.

  • Encourage greater community financing and control over primary health-care facilities and staff.

  • Inter-sectoral coordination between the health sector and other sectors, particularly at the local levels.

Success Factors of Decentralization

Decentralization is a complex phenomenon, and it does embed with different socio-economic, political and institutional factors as well as countries’ own health systems and infrastructure. Therefore there is more than one factor to determine the success of any decentralization reform. Some of the important points as enablers or drivers to make decentralization in health services successful are:

  • A strong and sustained political will and commitment to delegate authority and stop encroaching on authority already delegated.

  • Improved capacity of local authorities needs to be appraised and necessary training and support provided so that all their executions are based on informed decisions.

  • Redefine the new and strategic role of various levels of central authorities, and restructure them accordingly so as to avoid ambiguities in discharging functions.

  • Strengthen the process development—development of strategies, standards, norms and performance indicators.

  • Strengthen local—district—or provisional health systems management.

  • Develop appropriate analytical frameworks to study the achievements attained through the assessment of the performance-based health outcomes.

  • Systems of accountability to be able to measure the effectiveness of local government functions on people using an appropriate and responsive legal and institutional framework.

  • Establish a high-level task force involving all stakeholders engaging in the process of monitoring utility-based research on local health systems, introducing new innovative choices for better health performance in local authorities.

  • Widen the decision space for the local bodies not only to exercise power and authority but also to execute functions tailored to local needs and demands.

    Source: WHO (2007, p.2)

Challenges

Though there are some promising outcomes of the effect of decentralization in health services, (re)distribution of authorities, responsibilities and resources are never exempt from controversy (Costa-Font 2012, p.252). Several studies warn that decentralization may result in the inequitable distribution of resources or bring challenges related to insufficient human resource capacity (Kolehmainen-Aitken 1999; Lubben et al. 2002). Several authors (Standing 1997; Kaufman and Jing 2002) rather reveal negative outcomes between the association of health sector reforms, privatisation and health outcomes. Similarly, a review of the literature on decentralization in Asia noted that decentralization of health systems had a negative impact on health, though the existing evidences are insufficient to support this assertion (Collins et al. 2003a, b) and a number of challenges have been noted—limited authority and autonomy, poor institutional mechanisms and a weak level of trust among actors. It is clear from a review of pertinent literatures on the impact of decentralization that a number of tensions still exist among researchers. Some assume that decentralization is ‘good in itself’ without explaining why it is desirable (Bossert and Beauvais 2002; Collins et al. 2003a, b). Others see ‘decentralization as a means (or process) of achieving specific objectives rather than an end (or outcome)’ in itself (Peckham et al. 2005, p.38).

Therefore, it can be argued that decentralization is one of the most widely debated topics among politicians, bureaucrats and donor communities (Saltman et al. 2007). WHO (2007) adds that though decentralization may create more power and space for the local authorities, arguably this process might equally create some monopolisation of power by certain elites—often the consequences of centralised political and administrative structures (Hadenius 2003). Costa-Font (2012) discussed several myths about the effects of decentralization on health services, i.e. regional inequalities, privatisation, inefficacity and lower productivity which might be emerged from the assumptions and speculations rather than the empirical evidences. It is therefore important to acknowledge two important facts: first, it has been consistently noted that inappropriate design of decentralization would have negative impacts on health service delivery (Gilson et al. 1994; Kolehmainen-Aitken and Newbrander 1997); second, a lack of reliable analytical frameworks brings some challenges to effectively measuring the effects of decentralization in health at appropriate levels (Bossert 1997).

Activity 3

To what extent has decentralization contributed to making health services effective, efficient, equal and accessible? What other factors were involved?’

Conclusion

This chapter discussed the concept of decentralization as a process within policy and political options rather than a truly ‘dependent or independent’ variable or product (Bossert 1998; Peckham et al. 2005). Though decentralization offers inspiring vision, it is often challenging to translate its forms and mechanisms into practice as it embeds a number of assumptions, speculations, contradictions, tensions and challenges. This also highlights that success of decentralization in public services—health determines not only the degree and the extent of fiscal, political and administrative choices and how best they interplay but also institutional development, better information systems and strengthening better capacities and capabilities of both central and local peoples including civil societies to bring sectoral performance and a wide range of outcomes. In addition, health reforms should link to better planning of human resource and stewardship by governments and should provide technical capacity and appropriate information systems. Though the participation of the private sector in health has not been a well-researched theme, it is equally important to investigate its wider role to increase the efficiency, quality and effectiveness of the health sector. Most importantly, government should have a strong political will to reform the health sector, as many nations across the world would have still frequent changes of government; political instability and poor citizen empowerment are the major pitfalls of a successful decentralization.

Activity 4

In what ways can decentralization be described as ‘means’? In what ways can it be described as ‘ends’?

Further Discussion

  • Which form(s) or type(s) of decentralization would you favour in your specialised field and why?

  • To what extent do you agree with this statement? ‘All services do not need to be decentralised in the same way or to the same degree.’ Discuss.

  • Whether decentralised systems devolution would be the best option to bring services closer to the public while making services effective and efficient or whether centralised government would still equally impact positively if resources and capacity at the local level were raised and improved. Discuss.

Recommended Reading

Burns, D., Hambleton, R., & Hoggett, P. (1994). The politics of decentralization: Revitalising local democracy. Basingstoke: McMillan.

Useful textbook, which focuses mostly on market and competition into public services from the neighbourhood perspective.

Cohen, J. M., & Peterson, S. B. (1999). Administrative decentralization: Strategies for developing countries. Oakwood: Kumari Press.

Readable textbook, which has been recommended for some PG management courses in some universities, both in developed and developing countries. This book highlights the ‘administrative’ aspect of decentralization, and draws experiences mostly from developing countries.

Saltman, R. B., Bankauskaite, V., & Vrangbaek, K. (2007). Decentralization in health care. London: OUP.

Popular reading resource on ‘decentralization and healthcare’ from the experience of EU contexts.

Bardhan, P., & Mookherjee, D. (2006). Decentralization and local governance in developing countries: A comparative perspective. London: MIT Press.

Useful textbook, which mostly draws on experience from the economic viewpoint of decentralization. This book may be beneficial at strengthening the capacity, through education and training, and capability of the workforce to contribute to public services reform and development.