Health care based on priorities is lost in decentralisation

doi:10.1136/bmj.331.7510.235

BMJ 2005;331:235 (23 July), doi:10.1136/bmj.331.7510.235

Letter

Health care based on priorities is lost in decentralisation

EDITOR—Decentralisation of the health system was appliedin all transition countries in the 1990s.^1-3 In most countriesit was encouraged by the necessity to reform the inherited modelof health organisation and to achieve the final goal—anefficient and fair health system. Croatia has special experiencein decentralisation, primarily because of its geographical,political, and administrative circumstances but also becauseof its decentralised health system during the socialist regimein the 1980s.

Firstly, Croatia is a country with extreme differences betweenits regions. The income per head in the richest region is 10times that in the poorest region.

Secondly, decentralisation reforms were not based on analysesof the problems and assessment of resources but on maintainingthe framework within which they were implemented. Such implementationof the changes resulted in a complete change of the essenceof the local health system, whereas the given framework imposedlimitations on the development and changes, instead of fosteringthem.

Thirdly, decentralisation was implemented without having organiseda local network of professionals that would work on the locallevel and would be able to manage local health needs.

Decentralisation is always a challenge in any health systemand is mostly looked at as a series of political and organisationalmeasures. Unfortunately, the expectation that decentralisationwill ensure successful professional activities is often overlookedin the analyses. Furthermore, the measures and the purpose ofdecentralisation are often not recognised as important elementsof political culture. The primary purpose of decentralisation—healthcare based on the real priorities and resources—thereforeremains marginal.

Aleksandar Dzakula, research fellow

Andrija Stampar School of Public Health, Rockefellerova 4, Zagreb, Croatia adzakula{at}snz.hr

Competing interests: None declared.

References

McKee M, Fister K. Post-communist transition and health in Europe. BMJ 2004;329: 1355-6.[Free Full Text]
Fuenzalida-Puelma HL. Health care reform in Central and Eastern Europe and the Former Soviet Union. Budapest: OSI (Local Government and Public Services Reform Initiative), 2002: 81-8.
Horvath MT, ed. Decentralization: experiments and reforms. Budapest: OSI (Local Government and Public Services Reform Initiative), 2000: 15-8.