PHN 1991 Sector Review 14 3.16 Many, if not most, developing countries view the decentralization of sector activities as a viable means of achieving greater effectiveness and efficiency in health sector activity and thus strive for greater decentralization. Realization of this objective, however, has been elusive. The Indonesia Provincial Health PCR notes a failure to decentralize health services effectively despite the government's stated objective and the project's Intention to support this effort At the end of the project, major decisionmaking, financial control, and other administrative responsibilities remained overly centralized.

3.17 More rigorous efforts should be made at the country and regional levels by Sector Operations Divisions (SODs) and Tbchnical Divisions (TDs), respectively, and eventually at the global level by PHRHN, to study and test both the means and the end of decentralization of decision-maldng and management authority to the provincial, district, and lower levels of government. This task may provide a good opportunity to implement the recommendation made in Chapter IV that PHN staff draw on the expertise of in-house management and institutional development staff working on publc sector management issues across sectors. Experience gained thus far strongly indicates that success requires clear delineation of responsibilities at each leveL mechanisms for communication and coordination among the various levels, sufficient management training to enable ful assumption of decentralized responsibilities, and a redefinition of the central government's role that would limit it to policymaking and coordination, regulation, flnancing (in part), and supel sion of sector activity. Useful insight on how to accomplish this is provided in the proceedings of an Economic Development Institute (EDI) policy seminar on Strengthening of Local Governments in Sub-Saharan Africa<sup>7</sup> A recent paper produced by the Poverty and Social Policy Division of the Africa lbchnical Department (AF1SP) on the poverty orientation of public expenditure<sup>6</sup> argues that efficiency gains in resource allocation can be realized from the decentralization of financial decisionmaking responsibilities to allow local and community groups a greater role in choosing, designing, and providing core services.

3.18 _OrgankationofServiceDeivery.Thedesirabili-_ ty of providing PHN services through a referral system based on a pyramid of services is well accepted in principle, but needs to be established in practice. Many developing countries continue to use expensive, higher-level facilities to provide primary ealth care, whether because of a shortage of lowerlevel facilides or because such facilities are inadequate or perceived to be so. And even when lowerlevel facilities are consulted, they do not always refer patients up the health services pyramid when they should because of inadequate training and guidelines, lack of equipment, such as ambulances and radios, and failure in the referral system itself--no coordination, communication, support, or follow-up between the various levels. A strengthening of the referral system improves resource use and makes health services more available and responsive, especia;ly to the needs of the poor and vulnerable groups. What is needed, among other things, is a clear definition of the pyramid of services, the range and sophistication of services to be provided at each level, and the roles and responsibilities of staff at each level with respect to referral and operational norms. Also important are staff training, mechanisms to facilitate communication among various service levels, adequate equipment, and a strengthening of basic health services. Sometimes different price structures are helpful in discouraging consultation at unnecessarily high levels of services. Any effort to strengthen or expand the pyramid of services should cover an service providers, public and private. A study prepared by the Population, Health and Nutrition Division of the Africa Tbchnical Department (AFTPN) on the Health Center in Sub-Saharan Africa, provides practical guidelines and insight on how to address these issues.<sup>9</sup> _3.19 Srengthening of Key Components of the Insiidonal Framework._ All institutions and actors that influence the PHN sector need to be well organized and effectively managed, with adequate legal frameworks, in order to maximize their contribution to sector activity. Any weak links in this institutional framework must be identified and strengthened through internal organization and management changes or a change in legal status. These efforts should focus on skills, functions, systems, and structure. PCRs on the Indonesia Provincial Health, Pakistan Population, and linisia Health and Population projects all conclude that early and rigorous assessments of the institutiuns involved in project