The impact of decentralization on health workforce development in Papua New Guinea
| Date | 01 May 1992 |
| DOI | http://doi.org/10.1002/pad.4230120205 |
| Published date | 01 May 1992 |
| Author | Kolehmainen‐Aitken, Riitta‐Liisa |
PUBLIC ADMINISTRATION AND DEVELOPMENT, VOL.
12,175191 (1992)
The impact
of
decentralization on health workforce
development in Papua New Guinea
RIITTA-LIISA KOLEHMAINEN-AITKEN
Harvard
School
of
Public
Health
SUMMARY
Papua New Guinea decentralized a wide range of health functions to provincial governments
between 1977 and 1983. The national Department of Health
(DOH)
was given no role in
provincial budget and stafting decisions, and the national health budget was fragmented into
the health components of provincial budgets. The impact of decentralization on health work-
force development was particularly severe and largely unforeseen. Many difficulties were inher-
ent in the manner in which decentralization regulations structured power relationships. Others
arose
as
a result of the administrative confusion and inflamed relationships that accompanied
the forceful transfer of power from a very reluctant national DOH to the provinces. Even
though policy formulation and planning were retained as national functions, decentralization
hampered their effective execution. Human resource data bases deteriorated, responsibility
for planning became confused, and the ability of the DOH to implement its planning decisions
was compromised. In reality, health workforce planning was carried out by the Departments
of Finance and Planning, and Personnel Management through the annual budgetary process
of provincial financial limits and staff ceilings, without any attempt to assess health service
needs, either in the country as a whole or between the provinces. Decentralization brought
a need for new management skills, and it complicated administrative relationships between
training institutions and the provinces. The Papua New Guinea experience has shown that
in a decentralized health service, there is a great potential for conflict between national goals
and the aspirations of individual provinces. To achieve an equitable, appropriate and effective
staffing of services, standards must be formulated
as
the basis for planning and conflict resolu-
tion. Effective linkages between central government departments and between the national
and provincial health authorities must be developed, and management and technical skills
of health managers improved.
INTRODUCTION
Decentralization,
a
recurrent theme in the literature
on
public administration
and
development, has increasingly been promoted in the health sector
as
a
key component
of the strategies aimed at reaching Health for
All
by the
Year
2000
(World Health
Organization,
1980).
The transfer of power
from
the central government to more
peripheral levels has been
seen
as a means for overcoming physical
and
administrative
constraints to development, improving the management of resources,
and
increasing
community participation (Vaughan
et
al.,
1984;
Mills
et
al.,
1990).
Diverse interpretations of what is meant by decentralization have confused the
debate over its merits. Rondinelli
et
al.
(1984),
in outlining the different types
of
decentralization-deconcentration,
delegation, devolution
and
privatization-
Dr. Kolehmainen-Aitken worked in the Planning Division of the Department
of
Health, Papua New
Guinea for five and a half years.
027
1-2075/92/020175-17%08.50
0
1992
by
John Wiley
&
Sons, Ltd.
176
R.-L.
Kolehmainen-Aitken
emphasized that they entail widely varying degrees of central government authority
and government responsibility. The general paucity of literature evaluating the results
of decentralization has been another considerable hindrance. Conyers
(
1984), in her
literature review on decentralization and development, referred to ‘the serious gaps
in the literature, including the lack of material on
.
.
.
monitoring and evaluation’.
Published studies documenting the impact of decentralization on the development
of a country’s health services are rare, especially for developing countries. Country
case-studies in the recent
WHO
publication on decentralization (Mills
et al.,
1990)
contain only general statements about achievements and weaknesses, concentrating
instead on detailed descriptions of the history and organization of decentralized
health systems. A notable exception to the descriptive literature on decentralization
is the analytic study conducted by Gonzales-Block and his colleagues (1989), which
demonstrated that in Mexico, decentralization accentuated, rather than diminished,
regional disparities in the distribution
of
health services.
The literature on health sector decentralization is particularly weak on analysing
the impact that the actual
devolution
of decision-making authority and financial
powers
to
peripheral levels has on central government functions. Little is known
of how either decentralization in general or devolution in particular influences a
country’s ability to formulate national health policies and plans, promote equity
in the allocation of financial and human resources, and ensure satisfactory national
standards of service provision.
Papua New Guinea (PNG) decentralized a wide range of functions to provincial
governments between 1977 and 1983. Full legislative and management responsibility
for many local functions was devolved to the provinces and, at the same time, con-
siderable responsibility was given to them for other functions that were deemed
‘concurrent’ local-national functions (Rondinelli
et
al.,
1984). Among the devolved
functions were most rural health services, while hospital services, malaria control
and extension services were designated concurrent functions.
As the country’s second 5-year national health plan was being formulated in the
mid-1980s (Papua New Guinea National Health Plan, 1986-1990), it became evident
that decentralization had several unintended and unexpected consequences for the
development of the country’s health sector. Many of the difficulties encountered
were inherent in the manner in which decentralization regulations structured power
relationships between the national level and the provinces on one hand and between
the national Department of Health (DOH) and other central government departments
on the other. Others arose as a result of the administrative confusion and inflamed
relationships that accompanied the forceful transfer
of
power from a very reluctant
national Department of Health to the provinces.
This paper focuses on the particularly severe impact that decentralization had
on the development of PNG’s human resources for health. It commences with a
brief introduction to the country, the nature of its decentralization process, its health
service structure and health workforce. The main body of the paper consists of
a detailed analysis of how decentralization influenced health workforce policy formu-
lation, planning, training and management. The paper concludes with a discussion
of the key decentralization issues that have had a notable effect on health workforce
development in PNG. An attempt is made to draw out lessons that would allow
other countries contemplating decentralization to avoid some of the pitfalls which
PNG experienced. In PNG, these issues demand urgent attention
if
the country’s
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