Tuberculosis (TB) kills two million people worldwide each year. The WHO recommended DOTS strategy for TB control is proving effective in many settings. But what is being done to avoid successful TB programmes being weakened by sector-wide health care reforms?

Health sector reforms typically include decentralisation. Unfortunately a recurring feature of these reforms has been a lack of consultation and dialogue between those responsible for health systems policy and those responsible for delivering specific programmes such as TB control.

In Nepal, reform of public services includes decentralisation that aims to bring more power to district level facilities. Although this devolution is not restricted to the health sector, there does not seem to be any dialogue between those responsible for cross-government decentralisation and those responsible for TB control activities.

Conscious of findings that indicate the importance of consultation to ensure ownership and informed decision-making, researchers at the UK's Nuffield Centre for International Health and Development conducted a study among TB control staff in Nepal. Group and one-to-one interviews were conducted at central government and district levels. Staff were asked for their views of the process of decentralisation, with the aim of uncovering those factors that influence:

• the extent to which decentralisation could be introduced
• how decentralisation could be introduced
• how that decentralisation could be made effective.

Respondents adopted a balanced approach, with careful consideration of the ‘pros’ and ‘cons’ of decentralisation. Potential advantages raised include:

• increased opportunities for social mobilisation
• improved management and problem solving
• better resource mobilisation
• improved engagement of private and non-governmental organisation (NGO) providers.

Potential problems included:

• decentralised units would not recognise TB as a priority
• problems with drug supplies
• local political bias
• inadequate supervision of patients
• loss of technical and management effectiveness
• a fall in staff training provision.

National level respondents believed a quite restricted range of responsibilities would be devolved to the districts, whilst at district level respondents focused on the role of the regional level in quality control.

There was also concern that districts may chose not to follow national guidelines; that they may not be able to regulate the private sector; and that they may integrate TB with other programmes, therefore failing to recognise the high level of training needed for TB control staff.

Implications for policy include:

• The implications of decentralisation for TB control have not been thought through.  Policy dialogue and analysis are required to inform decision-making and develop a sense of ownership for staff.
• Respondents' awareness of and willingness to recount the opportunities and threats posed by decentralisation suggests that consulting with health sector staff is crucial to effective policy-making.
• TB control managers should be proactive in seeking dialogue with those responsible for health systems policy, rather than passively waiting for policy to be declared and then dealing with its consequences.

A two-way process is needed to ensure both that decentralisation is adapted to the requirements of TB control, and that disease control specialists understand the broader picture of health and health systems.

Source(s):
‘Decentralisation and TB control in Nepal: understanding the views of TB control staff', Health Policy, by J.N. Newell et al, in press
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 9 May 2005

Further Information:
James N. Newell
Nuffield Centre for International Health and Development
University of Leeds
Leeds
UK

Contact the contributor: j.n.newell@leeds.ac.uk

Nuffield Centre for International Health and Development, University of Leeds, UK

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