If a centralized system can’t do it, neither can a decentralized one

While not surprised, I am impressed with the results of the analyses in Leonard et al’s “Bypassing health centers in Tanzania.” It’s encouraging to read about the people’s careful and sophisticated thought process in deciding where to seek healthcare—a process that might not be much different from that of an average person in a developed country. Leonard’s research showed that when it is worth the expense and the long trip, the subjects willingly incurred the travel expenses and bypassed the closest health facility in an effort to reach a better-equipped, or more appropriate facility depending on their needs. This is indicative of the people’s advanced knowledge of the health system, the options available to them and the distinguishing factors.

But policy makers in Tanzania don’t normally consider the members of their population “active” patients who deliberate over the different options and their individual features, according to Leonard. And they don’t expect this level of sophistication in the people’s knowledge of the health system, or such willingness to spend money in order to bypass the nearest healthcare facility because it is inferior to another.

Although policy makers aren’t entirely aware of the people’s needs and the fact that they will do what it takes to get the care they’re looking for, Leonard’s recommendation to decentralize the system won’t be as effective as one might think. It’s natural to want to support decentralization since it seems unfair to give policy makers more leverage if they’re not even aware of the reality, but the fact is that healthcare facilities need the centralized government to maintain a certain level of quality and accessibility.

While a centralized system has not been effective enough in providing adequate funding and resources to all of its facilities in order to avoid the bypassing phenomenon and the expenses that come with it, a decentralized system might not be any more effective.

Currently, the centralized system isn’t working properly because the government isn’t functioning at its highest potential; no one really knows if it ever will. But what we do know is that the government works to serve the people, while the private sector works to make a profit. The system might become more centralized and specific to the people if the private sector were to take over, but it would no longer be as accessible since the governing body would be more interested in making a profit off of the patients than in making a difference to the best of their ability.

And if by “decentralized,” Leonard instead means that local governments, not the private sector, should take the control from the national government, then this would work better, but still might not be effective enough. If the local governments were to take over, each would work to develop its local health facilities and if one government were more successful than another, the bypassing phenomenon would continue to exist throughout the country…and we’re back at square one.


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