DECENTRALIZATION AND COMMUNITY HEALTH

Decentralization is the process of redistributing administrative authority, and sometimes resources, to local communities for planning, program management, and evaluation. Since the early 1960s in the United States and the mid-1970s in Canada, there have been notable efforts to shift decisionmaking authority away from central governments to the local level in the area of community health.

Decentralization of public health and health planning is intended to facilitate public participation; provide greater local and personal control over the determinants of health; and spur cooperative, intersectoral action among coalitions of stakeholders at the local level. Demands for less involvement of "big government" in local issues and a desire for self-determination fueled the decentralization movement. By bringing decision making closer to home and involving local people, decentralized approaches were expected to result in more appropriate decisions about public health and health planning within local communities. Decentralization was also intended to enhance democratic principles and community empowerment, and to boost local people's autonomy and capacity to take control over the determinants of their own health.

By increasing the decision-making power of local communities, decentralized public health and health-planning systems place greater fiscal responsibility for health on local governments and agencies. In the United States and Canada, decentralization of responsibility was achieved while leaving intact most of the highly centralized national, state, and provincial taxation and corporate-financing mechanisms. Since the establishment of block grants in the United States in the mid-1980s and revenue sharing in Canada in the early 1990s, federal control has declined in both countries, resulting in less central control. The amount of money available to transfer from federal to state or provincial coffers, however, did not always match the devolution of responsibility. Therefore, many local health initiatives collapsed because the pressure of greater responsibility was combined with fewer resources for program managers.

Managing increased responsibility within the context of scarce resources was not the only problem that arose from efforts to decentralize authority in health matters. Local public health and health-planning goals often conflict with each other and with the rights of individuals pursuing their own well-being and happiness. The social fabric of many communities can be badly torn when local people engage in a decision-making process where there can be only one winner. For example, local communities across the United States and Canada facing decisions about whether to close or maintain hospitals often experience bitter and emotional debates that may generate a sense of disempowerment for many local groups and individuals.

Successful decentralization of public health and health planning depends on the provision of adequate and appropriate assistance to local communities. Providing resources, including both expertise and time, is a critical ingredient for successfully decentralizing responsibility. Many communities lack the local resources to resolve the complex problems they face and have limited control over outside influences. As a result, they have become increasingly beholden to external sources of support.

The issues of ownership and goals becomes problematic when the central funding source requires a health-specific commitment, but the local population wishes to focus on a different problem that is not a priority for the central funding bodies. For example, a community group may receive funding from a research-oriented agency to examine health issues related to cardiovascular disease, while the community's priorities may be focused on creating jobs and stimulating the local economy or dealing with a teenage drug problem.

Similarly, locally funded organizations may not have enough expertise to provide the monitoring most central funding mechanisms require for accountability. These circumstances typically prompt a rush of technical assistance from central to local organizations, welcomed or not. Outside experts often do not know enough about local circumstances to be as helpful as their substantive expertise might make them in more familiar territory, or they are held at arm's length from intruding on local prerogatives.

Will public health and health-planning systems continue to pursue decentralized decisionmaking? Economic recoveries in many countries have renewed hopes at the local level for increased revenue sharing to support public health and health-planning initiatives. Financial resources represent one part of the solution, but it remains to be seen whether communities can develop sufficient capacity to take control over the determinants of their own health. To date, the evidence has been inconsistent regarding the effectiveness of local planning initiatives in achieving health objectives at affordable costs.

Jean A. Shoveller

Lawrence W. Green

(see also: Citizens Advisory Boards; Coalitions, Consortia, and Partnerships; Community Health; Community Organization; Health Goals; Healthy Communities; Participation in Community Health Planning; Regional Health Planning )

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