Nations are doing it, provinces and states are doing it, and, heaven preserve us, even organizations like MSH are doing it. It has become the "in" thing to do, it has become ubiquitous, but it is confusing and many of us wish it would go away!
There are clearly many benefits to be gained from decentralizing services, although for the majority of people actively involved in a process of decentralization these benefits can be very hard to perceive. It would seem clear that the much-touted benefits of decentralization may be more ephemeral than anticipated, and in many cases, may not even exist. In fact, heretical as it may be, it should be said that in some cases, decentralization has made things much worse!
Decentralization takes place for many different reasons, but it is usually (if not always) a politically driven process, and as such it usually poses a unique problem for the health planner:
How to plan for something that is being initiated for reasons quite remote from those stated, and usually unrelated to any potential benefits to either the health status of the population being served, or to the improvement of the quality of health services being delivered?
Many health planners give up the struggle. They determine that it is too difficult, or the goals of decentralization are just too vague, or too unrealistic. What they are doing when they throw up their hands in despair however, is forgetting that decentralization is not the goal, and that it will never be "done." Decentralization is a political process that leads to changes in local governance, and as such it offers a set of opportunities to the health planner, which if he or she is "on the ball," can be used to greatly improve the functioning of a health service.
In answer to my own question: "Is it possible to plan for decentralization?" I would answer, "Yes it is!" However, the planning that is realistically possible, is not at the level of saying, "Here is a laudable goal in improving the delivery of health services that I must plan for." Rather it is to say, "Here is something that I must live through and with. How can I take the best elements of it and turn them to my advantage and how can I ensure that negative effects on service delivery and health status are minimized?"
When it comes to decentralization, the health planner's role becomes far more critical than during the status quo, but it also becomes much more complicated. In looking at three different models of decentralization, in Haiti, the Philippines, and the Province of Saskatchewan, in Canada, it is clear that no matter how varied the approach, the issues, problems and challenges remain remarkably similar for the health planner
