Hospital nurses are counselling some flood victims at an evacuation centre in this filepic. Decentralisation could help with better coordination in cases of natural disasters like floods, as local healthcare providers would know best what is needed on the ground.
I recently visited Taiwan and took the opportunity to better understand their policy approach to an increasingly ageing society.
Taiwan’s proportion of their population aged 65 and above is projected to hit 28% by 2040.
As in Malaysia, there will be increasing need for long-term care services against a background of a decreasing working population, with a potential subsequent decline in labour availability and economic growth.
One thing that struck me was the degree of decentralisation within their healthcare service, i.e. the delegation of decision-making away from central authority.
Taiwan's National Health Insurance (NHI) system, which covers over 99% of the population, is managed by the federal government, but implemented locally.
The NHI is funded by premiums and government subsidies, and healthcare providers are paid on a fee-for-service basis.
Local health departments are responsible for managing healthcare delivery and ensuring that healthcare services are accessible to all residents, regardless of their location or income.
For long-term care, eligible individuals receive a care plan that is tailored to their specific needs, which may include home care, community-based care and institutional care.
The programme also provides support to family caregivers, including respite care services and training programmes.
Countries across the globe differ in their level of centralisation, depending on local need, as well as political ideology and policies.
In highly centralised systems, national governments tend to be in charge of providing funding, setting policies and managing healthcare services from the top down.
This approach can help ensure consistency in services and quality, but can also be cumbersome to manoeuvre and pivot with a lack of autonomy at the grassroots level.
In Germany, healthcare responsibilities are split between federal, state, and local governments.
Local governments have significant control over healthcare funding and provision, allowing for tailored healthcare services that reflect regional needs.
Canada has a publicly-funded, decentralised healthcare system where its provinces and territories are responsible for delivering and managing healthcare services within their own jurisdictions.
Decentralisation of the healthcare service can be advantageous in a number of ways; these include:
> Improved efficiency
A shorter chain of command with a faster response time can help reduce inefficiencies.
When decision-making is spread out among several smaller entities, a more effective response can be made that is tailored to local healthcare needs.
> Better coordination
Decentralisation can also help healthcare systems better coordinate their efforts at a local level.
For example, during a flood, local providers would be better placed in addressing the healthcare and public health issues faced in the affected area.
By working together, providers can share resources, knowledge and best practices, leading to better patient outcomes.
> Increased accessibility
This is particularly applicable for individuals in remote or underserved areas.
By placing healthcare services closer to the people who need them, patients can receive care more easily and quickly.
> Increased innovation
Decentralised healthcare systems can foster innovation by allowing smaller entities to experiment with new approaches to care delivery.
These may involve the use of new treatment or technologies, tweaking of guidelines and processes, or even decisions regarding public-private partnerships and outsourcing of services.
> Greater patient involvement
Decentralising can also empower patients and carers, especially if they are invited to take a more active role in local healthcare provision, either as volunteers or part of a non-governmental organisation (NGO).
This is particularly important as non-local policymakers may not always be aware of local issues, e.g. access to a particular clinic may be hampered because there are insufficient facilities for the disabled.
Decentralisation per se is not a panacea for the troubles ailing healthcare systems, but can resolve a number of issues if done properly.
This would include clear communication to relevant stakeholders regarding what exactly is being decentralised, alongside providing and developing capacity in order to ensure that authority is delegated to individuals who are capable of shouldering the responsibility.
If authority is delegated to more local authorities – e.g. hospital or state health directors – it must come with both sufficient authority on use of funds, as well as increased autonomy and accountability.
It is also worth highlighting that delegation does not equate to completely absolving the central authority of all functions, but is rather an effort to streamline processes.
After all, the process of decentralisation can potentially lead to adverse effects (e.g. inequality between regions, lack of standardised care, political interference in decision-making, etc).
These can be mitigated through thoughtful and thorough planning and implementation.
Ultimately, a governing system has to strike the right balance between central authority and the ability of local providers to serve stakeholders properly, safely and efficiently.
Dr Helmy Haja Mydin is a consultant respiratory specialist and a Special Advisor to the Health Minister. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
