Decentralization~ 2) Pros & Cons!

.......السلام عليكم ورحمة الله وبركاته

The general decentralization process has had many impacts on the health system, even though it was not designed specifically with the health sector in mind. Under decentralization, responsibility for health care provision is largely in the hands of regional governments.

i) Human Resources	The human resource situation in health has major deficiencies in numbers and quality of the health workforce. Decentralization is one of many factors exacerbating long-standing problems with mal distribution and reportedly low productivity and quality of health workers. Limited number of health workers affected health service in Indonesia. In 2006, ratio of general practitioners was 19.9 per 100,000 populations while ratio of midwife per 100,000 populations was 35.4.
ii) Health Information System	Decentralization resulted in a partial breakdown of health information systems and led to an unclear division of reporting responsibilities. As a result, no comprehensive data exist that cover the entire nation. The disruption of the information flow makes it difficult to develop strategies and monitor health programmes in provinces and districts. Exceptions do exist in some vertical programmes (tuberculosis, malaria or HIV-AIDS) where the Central Government retains the responsibility as the principal recipient of GFATM grants to the country
iii) Health Financing	Indonesia spends relatively little on health services. Estimated total expenditure on health (per capita, in 2003) was $ 33. The overall health financing situation in Indonesia is complex and incompletely documented. In 2003, around 34% of total health expenditure is undertaken by public sector agencies, while 66% is private. By far the largest single source of private expenditure is direct out-of-pocket payments by households, accounting for nearly half of the total expenditure. Privately provided services are largely financed by out-of-pocket payments, with some insurance and employer-financed expenditure benefiting a minority of formal sector employees. Publicly provided services are financed by a mix of public budgets and user fees, in turn financed by a combination of households, employers and insurers. Until the advent of the new social insurance scheme for the poor, insurance coverage of the population was low, at well under 10%.
iv) Health Services	At primary health care level, Indonesia is generally regarded as having relatively adequate levels of provision, one public health centre for every 30 000 people on average. In addition to public facilities, private practices are operated by doctors, nurses and midwives, in many cases by the same personnel as are employed in public facilities. At the hospital level, Indonesia has low levels of bed provision at 62, 5 beds per 100,000 populations. Paradoxically, the utilization is also low, with bed occupancy rates in the vicinity of 56.2 % in both public and private facilities. The private sector is increasingly important in the provision of health care in Indonesia, especially in big cities, with wide variations in quality of care. Furthermore, since there is no regulation of pricing or quality of service in place, users are vulnerable to excessive treatment and expenses. The role of non-governmental organizations (NGOs) in Indonesia has been growing during the last two decades but the exact number of NGOs providing health care services remains unknown. Despite the presence of a strong Drug Regulatory Authority, responsible for the registration of medicines as well as quality control and inspection, counterfeit drugs remain a big problem. At the same time, the use of traditional medicines (such as ‘jamu’) is popular and widespread in Indonesia. Yet procedures for quality control of traditional medicines are limited in scope, and difficult to implement, also because large numbers of small-scale manufacturers exist.

When it comes to decentralization, many people see it negatively. It is true that decentralization has negative impacts, but do not forget that it also bring some good. Decentralization can be beneficial in the fact that it:

• allows for experts to take control of specific functions of an organization
• easily convey information back and forth
• allows for direct contact and relationships with managers
• allows managers to participate in planning.
  

Unfortunately, there are disadvantages of decentralization as well. For example:

1. Some managers will find that they have too much work to do and other will have too little.
2. It will also become difficult to have managers take on different tasks or projects if needed because of overspecialization.
3. Also, if one manager leaves, there will not be anyone to pick up his place with quite the same knowledge and expertise.

Centralization is another method which has its pros and cons. A positive aspect is the fact that the corporate decision maker has full control over the organization and the decisions that the organization must follow. The organization may also benefit from the fact that all information is reported to the corporate decision maker; he or she listens to all comments and concerns and is able to infer from all information received.

There are disadvantages to centralization as well. The larger an organization becomes, the more information that one manager has to comprehend and consider; eventually he/she will need help. Tasks will have to be divided or else the organization will become disorganized and at times, seem chaotic. What happens if the manager is away for whatever reason? Timely corporate decisions are impossible when no one is around to make them.

Whether an organization chooses centralization or decentralization is completely a matter of choice. One system may work better than the other depending on the situation or the type of organization. It is an important choice and should be carefully and wisely considered.