Devolution of Power and Public Policy: The Potential of Local Governments to Address Population Issues Paper presented at the IUSSP 2017 International Population Conference, Cape Town, 30 October 2017; Session 1901—Population and policy changes in Africa AUTHORS Beth Fredrick 1,2 Celia Karp 1 AFFILIATIONS 1 Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 2 Bill and Melinda Gates Institute for Population and Reproductive Health, Baltimore, MD, USA CORRESPONDING AUTHOR Beth Fredrick Department of Population, Family and Reproductive Health Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe Street Baltimore, MD 21205 bethfred@jhu.edu
ABSTRACT Background: Devolved governance, the transition of power from national to subnational government units (SNGs), is nearly universal in sub-Saharan Africa. Devolution, sometimes referred to as decentralization, encompasses legal, political and fiscal control, administration, and service provision, which support local priority-setting, decision- making, and investments. Despite increased decentralization, little is known about how it has affected development and implementation of policies related to population issues at the subnational level. Understanding the parameters of subnational government decision- making and the evidence used to inform these decisions is critical to achieving health and development goals. Methods: A literature review was implemented to identify information on decentralization and data for decision-making in sub-Saharan Africa. Key informant interviews were conducted with public health practitioners at the international, national, and subnational levels to explore approaches to evidence-based subnational decision- making. Analysis was restricted to demographic and health information sources related to family planning in sub-Saharan Africa. Results: More than 40 articles were reviewed and 25 informants were interviewed. Limited data exist on the financial, political, and service provision authority of SNGs in Africa. Informants emphasized utility of five data systems within sub-Saharan Africa (DHS, DHIS2, HMIS, MICS, and PMA2020), stressing the limitations of these systems for subnational decision-making. Subnational reliance on antiquated data systems coupled with data literacy challenges among local leaders restrains the translation of data into practice. Discussion: The unique needs of SNGs for reliable and useful data to support national and global goals are not being met. Improved availability and use of data within decentralized countries could support SNGs to propose, enact or implement productive changes in policy and programs addressing population health needs. The responsibility is two-fold: SNGs should better inform data priorities, collection, and interpretation; researchers, analysts, and those supporting data collection and dissemination should investigate and anticipate needs for accessible and relevant subnational data within specific geographies. 1
INTRODUCTION Devolved governance, the transition of power from national to subnational government units (SNGs), is increasingly common worldwide and nearly universal in sub-Saharan Africa. 1 Devolution, sometimes referred to as decentralization, encompasses legal, political and fiscal control, administration, and service provision, all of which support local priority-setting, decision-making, and investments. 2 In conjunction with these authority changes, decentralization has diverse implications related to democratization, social, political, and economic development, information flow, and government transparency and accountability. At the core of decentralization is the concept that shifting decision-making closer to constituents themselves will result in improved policies and programs that reflect and respond to local priorities. 3 In the era of Sustainable Development Goals (SDGs) and the Family Planning 2020 (FP2020) partnership, national commitments to improved family planning (FP) access have positioned country governments with a need for data measurement at national and subnational levels. Exploring decentralization and the influence it has on where, how and when data is collected, analyzed and interpreted is equally important to development and the fulfillment of these national commitments. 4 Decentralization is directly relevant to the ability of countries to adapt to results-based financing mechanisms for reproductive, maternal, newborn, child and adolescent health (RMNCAH) such as the World Bank’s Global Financing Facility (GFF). The GFF “recognize[s] that countries themselves are the engines of progress and that the role of external assistance is to support countries both to get more results from the existing resources and to increase the total volume of financing”. 5 One of the core tenets of the GFF is the strengthening of systems to track progress, learn, course-correct, and help countries gain financial support for their own priorities. Kenya is just one example of a decentralized country that has already incorporated county governments in its GFF investment framework. 6 Other countries are likely to follow suit in the recent effort to engage and include subnational governments, if not in developing their investment case, then certainly in its implementation. 2
Despite rapid increase of decentralization since the 1990s and transfer of certain responsibilities to SNGs, little is known about how this process has affected development and implementation of financial and health policies related to population issues at the subnational level. 7 In part, this is a consequence of the diverse characteristics of decentralization and the variety of forms it takes in different country contexts, but it is also related to the ever-changing dynamics between central and subnational governance, priorities, and demands. 8 Regardless, subnational units are commonly responsible for planning, budgeting, and resource allocation and implementation of national policy. In order for subnational units (e.g., states, counties, provinces, districts, communes, municipalities) to fulfill these responsibilities and respond to local issues, they must first be equipped with the necessary tools to identify the issues in their own geographies and understand how to measure and monitor them. Beyond addressing the needs of their own constituents for contraceptive access, information, and quality services, understanding the parameters of SNG decision-making related to family planning and the evidence used to inform these decisions is critical to achieving global population health and development goals. The potential of subnational governments to contribute to global health goals and the constraints they face in effectively using data for decision-making are gaining prominence. In the words of Michael Bloomberg, United Nations (UN) Special Envoy for Cities and Climate Change and three-term New York City Mayor, a key mission of support for subnational policymakers is to “create ways to measure whether we’re actually meeting the goals, because if you can’t measure it, you can’t manage it. Government programs never want measurement because then you have to implement it, you have to pay for it—they don’t want to do that. And if you implement it poorly, they don’t want to be held accountable. 9 ” Conversely, as national and subnational leaders make financial decisions, design and manage programs, and monitor performance, effective collection and use of population data will drive innovation and economies of scale. As noted by experts convened by the 3
Sustainable Development Solutions Network in 2015, “encouraging new, reliable, and accessible government data, will provide governments the capacity to design better policies and programs. It will also enable citizens to hold leaders accountable for progress and improve their day-to-day decision-making”. 10 Yet, even with this recognition, little of the growing attention paid to improving data for decision-making at the global and national level has acknowledged or adequately incorporated the needs of subnational leaders. This paper focuses on the potential of decentralized governance for addressing population issues, emphasizing decisions related to delivery of contraceptive information, services, and supplies in sub-Saharan Africa. Research Questions and Focus 1. ¡ To what extent do SNGs in sub-Saharan Africa use data to inform their decision- making related to population, health, and development issues and what are the sources of those data? 2. ¡ How reliable, available, and useful are country-specific data systems for SNGs? 3. ¡ What ways are data limited or restrained in their capacity to inform subnational decision-making related to population, health, and development issues? 4. ¡ What is feasible and most urgently needed to improve the ability of SNGs use data effectively in meeting the needs of their communities and contribute to the achievement of national and global goals? To answer these questions, this research focuses on the following: 1) synthesis of related literature and contributions of public health practitioners at international, national, and subnational levels with diverse experience in data collection, analysis and application related to family planning and global compacts (i.e. the SDGs and FP2020) within sub- Saharan Africa; 2) identification of data deficits at subnational levels in sub-Saharan Africa for decision-making surrounding population, health, and development issues; 3) translation of results to inform recommendations for consideration by governments, donors, and researchers to address the SNG data needs. 4
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