George Larbi

Institutional constraints and capacity issues in decentralizing management in public services: the case of health in Ghana

Public health organization in Ghana has been a focus of reform in recent years. This paper examines the application of decentralized management as part of these reforms. It conceptualizes decentralized management as a component of the new public management. It assesses progress made in implementation, highlighting the institutional constraints encountered. The capacity issues raised by management decentralization, especially the trend towards autonomous hospitals and executive agencies, are outlined. The main lessons drawn are that reforms need to be sensitive to operational context and capacity and implementation needs to be planned and managed.

Contracting‐out in public health and water services in Ghana

This article examines contracting‐out in practice in public health and water services in Ghana. Drawing on in‐depth interviews and discussions with knowledgeable officials, complemented by documentary analysis and secondary sources, the article provides insights into some of the institutional constraints and capacity issues that policy‐makers and implementers need to be aware of in seeking to introduce and implement contracting‐out policies in a developing country context. Though contracting‐out in Ghana’s health and water sectors has so far been used in the provision of support services, attempts to broaden its application to include the direct provision of core services raise a number of capacity questions related to regulatory frameworks, enforcement and monitoring mechanisms, development of management information systems and skills for contract management. The capacity and willingness of the private sector to take on direct provision of public services are also crucial.

New public management as a template for reforms in low-income countries: Issues and lessons from ghana

This article presents findings and conclusions from a study of the application of “new public management” type reforms in a low-income country context, Ghana. Using case study data from the health and water sectors, including interviews and documentary analysis, it argues that reforms tend to put more emphasis on issues of what to implement and less on issues of how to implement. The evidence provided suggests that some progress has been made in downsizing, decentralizing, contracting-out, and performance contracting in the health and water sectors. In spite of this, the implementation of reforms has been patchy due to capacity constraints. Reforms are fragile and yet to be embedded

Changing Views of the Role of the Government

Over the last two decades there has been emphasis, particularly in the English-speaking advanced countries, on reducing the role of government and on reforming public management by adopting aspects of private sector practice. The research programme on which this study is based was concerned with the fact that similar practices were being introduced in developing and transitional countries, often in association with economic adjustment. There has been considerable research on the difficult process of adjustment but little on the process and outcomes of public management reform for improved service delivery.

Changing Approaches to Public Sector Management

Chapter 1 traced the changing perspectives on the role of government in development. It was noted that crisis in the welfare and developmental states in the 1970s and 1980s called into question the post-war consensus on the active role of the state in the economy and led to the ascendancy of neo-liberal economic policies from the 1980s. It was not just the welfare state that was called into question, but also the traditional Weberian model of bureaucracy came under attack as being slow, inefficient, ineffective and unresponsive to service users. The crisis in the welfare state and the weaknesses of state bureaucracy led to the search for alternative ways of organizing and managing public services and redefining the role of the state to give more prominence to markets and competition. The shift was in response to a combination of stimuli for change driven by both theoretical arguments and pragmatic rationales. This chapter first reviews the theoretical arguments that have influenced the new trends in public service reforms, including neo-classical and new institutional economic theories. Second, it describes the more pragmatic rationales for change in the management of public services.

The Experience of Contracting

This chapter explores evidence from the country cases studies about the experience of contracting across the service sectors.1 Table 7.1 classifies the forms of contractual arrangement examined in the text. Down the left-hand column, contractual types proceed from shorterterm and simpler forms to longer and more complex forms, as described in Chapter 6. It can be seen that the business sector is almost absent from the table because here privatization has been most complete. The private sector operates independently rather than under contract, and governments have removed themselves to a support role — as will be described in Chapter 8.

Working with Private Partners

The previous two chapters described reforms within public management. In some respects these have ‘imported’ market approaches and values into the public sector. In this chapter we examine the experience of ‘exporting’ functions to the private sector, and the impact this has on the functioning of public administration. Whether through the import of practices or the export of functions, these can be seen as different ways of addressing the principal-agent problem of public administration. That there is such a problem will be accepted for the purposes of this chapter, although it can well be counter-argued that this critique of public administration is less a description of reality and more a mobilizing device to generate impetus for reform (Salamon, 2002; Joshi and Moore, 2002).

The Experience of Charging for Public Services

This chapter examines the experience of financing public service delivery by charging users directly through user fees and tariffs and/or withdrawing government subsidies to the provision of services. As was noted in Chapter 2, charging for public services is part of the new approach to public management. Like other reforms examined in this book, charging raises a number of issues relating to the appropriateness of reforms to poor countries, the ‘new’ roles of government in implementing a policy of user charges, and the capacity implications for government and public agencies in managing the new roles associated with charging.

The Politics of Service Reform

This chapter asks whether citizens and politicians (the ‘principals’) in developing countries have been instrumental in demanding, designing and directing reforms in service delivery.1

Decentralizing Organizational Arrangements for Service Delivery

The key assumption that underlined the study was that organizational and management reforms in the four sectors studied were pushed by the new public management-type reform agenda reviewed in Chapter 2. These reforms tend to ignore the specificities of sectors and the institutional contexts of poor countries often characterized by state dominance, weak market institutions, fiscal crisis, poor incentives and political sensitivities. This chapter will examine the nature and the extent of ‘the new management’ organizational reforms for service delivery across the four sectors, using evidence from the case study countries (Ghana, Zimbabwe, India and Sri Lanka) and reference countries where possible. The focus in this chapter is on internal management reforms rather than externally oriented market-type reforms, which are analyzed in Chapters 6–8. To put the reforms in context, the first section briefly reviews the pre-reform organizational arrangements for service delivery. The second section then outlines the types of organizational arrangements, and the third section examines the nature and extent of reforms in organizational arrangements. The fourth section reviews the available evidence on the performance of reformed organizational arrangements.