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PubMed2001

Effects of chronic cardiac decentralization on functional properties of canine intracardiac neurons in vitro.

Although intrinsic cardiac neurons display ongoing activity after chronic interruption of extrinsic autonomic inputs to the heart, the effects of decentralization on individual neurons remain unknown. The objective of this study was to determine the effects of chronic (3-4 wk) surgical decentralization on intracellular properties of, and neurotransmission among, neurons contained within the canine intrinsic right atrial ganglionated plexus in vitro. Properties of neurons from decentralized hearts were compared with those of neurons from sham-operated hearts (controls). Two populations of neurons were identified by their firing behavior in response to intracellular current injection. Fifty-nine percent of control neurons and 72% of decentralized neurons were phasic (discharged one action potential on excitation). Forty-one percent of control neurons and 27% of decentralized neurons were accommodating (multiple discharge with decrementing frequency). After chronic decentralization, input resistance of phasic neurons increased, whereas the duration of afterhyperpolarization of accommodating neurons decreased. Postsynaptic responses to interganglionic nerve stimulation were evoked in 89% of control neurons and 83% of decentralized neurons; the majority of these responses involved nicotinic receptors. These results show that, after chronic decentralization, intrinsic cardiac neurons 1) undergo changes in membrane properties that may lead to increased excitability while 2) maintaining synaptic neurotransmission within the intrinsic cardiac ganglionated plexus.

Action Potentials↗
PubMed2004

Decentralization's impact on the health workforce: Perspectives of managers, workers and national leaders.

Designers and implementers of decentralization and other reform measures have focused much attention on financial and structural reform measures, but ignored their human resource implications. Concern is mounting about the impact that the reallocation of roles and responsibilities has had on the health workforce and its management, but the experiences and lessons of different countries have not been widely shared. This paper examines evidence from published literature on decentralization's impact on the demand side of the human resource equation, as well as the factors that have contributed to the impact. The elements that make such an impact analysis exceptionally complex are identified. They include the mode of decentralization that a country is implementing, the level of responsibility for the salary budget and pay determination, and the civil service status of transferred health workers.The main body of the paper is devoted to examining decentralization's impact on human resource issues from three different perspectives: that of local health managers, health workers themselves, and national health leaders. These three groups have different concerns in the human resource realm, and consequently, have been differently affected by decentralization processes. The paper concludes with recommendations regarding three key concerns that national authorities and international agencies should give prompt attention to. They are (1) defining the essential human resource policy, planning and management skills for national human resource managers who work in decentralized countries, and developing training programs to equip them with such skills; (2) supporting research that focuses on improving the knowledge base of how different modes of decentralization impact on staffing equity; and (3) identifying factors that most critically influence health worker motivation and performance under decentralization, and documenting the most cost-effective best practices to improve them. Notable experiences from South Africa, Ghana, Indonesia and Mexico are shared in an annex.

Journal Article↗
PubMed1991

What supervisors want to know about decentralization.

Many organizations in various industries have tended to move away from strict centralization, yet some centralization is still vital to top management. With 19 of the 22 executives interviewed favoring or implementing some form of decentralization, it is probable that traditionally centralized organizations will follow the trend and begin to decentralize their organizational structures. The incentives and advantages of decentralization are too attractive to ignore. Decentralization provides responsibility, clear objectives, accountability for results, and more efficient and effective decision making. However, one must remember that decentralization can be overextended and that centralization is still viable in certain functions. Finding the correct balance between control and autonomy is a key to decentralization. Too much control and too much autonomy are the primary reasons for decentralization failures. In today's changing, competitive environment, structures must be continuously redefined, with the goal of finding an optimal balance between centralization and decentralization. Organizations are cautioned not to seek out and install a single philosopher-king to impose unified direction, but to unify leadership goals, participation, style, and control to develop improved methods of making all responsible leaders of one mind about the organization's needs and goals.

Administrative Personnel↗
PubMed2004

Attitudes and perceptions of stakeholders on decentralization of health services in Uganda: the case of Lira and Apac districts.

BACKGROUND: In Uganda, the decentralization of administrative functions, management, and responsibility for health care to districts, which began in 1994, resulted in fundamental changes in health care delivery. Since the introduction of the policy in Uganda, little information has been available on stakeholders' perceptions about the benefits of the policy and how decentralization affected health care delivery. OBJECTIVES: To identify the perceptions and beliefs of key stakeholders on the impact and process of decentralization and on the operations of health services in two districts in Uganda, and to report their suggestions to improve future implementation of similar policies. DESIGN: We used qualitative research methods that included focus group discussions with 90 stakeholders from both study districts. SETTING: The sample population comprised of 12 health workers from the two hospitals, 11 district health administrators, and 67 Local Council Leaders. MAIN OUTCOME MEASURES: Perceptions and concerns of stakeholders on the impact of decentralization on district health services. RESULTS: There was a general consensus that decentralization empowered local administrative and political decision-making. Among stakeholders, the policy was perceived to have created a sense of ownership and responsibility. Major problems that were said to be associated with decentralization included political harassment of civil servants, increased nepotism, inadequate financial resources, and mismanagement of resources. CONCLUSIONS: This study elicited perceptions about critical factors upon which successful implementation of the decentralization policy depended. These included: appreciation of the role of all stakeholders by district politicians; adequate availability and efficient utilization of resources; reasonably developed infrastructure prior to the policy change; appropriate sensitisation and training of those implementing policies; and the good will and active involvement of the local community. In the absence of these factors, implementation of decentralization of services to districts may not immediately make economic and administrative sense.

Attitude of Health Personnel↗
PubMed1998

Graft decentration in penetrating keratoplasty: nonmechanical trephination with the excimer laser (193 nm) versus the motor trephine.

BACKGROUND AND OBJECTIVE: Graft decentration is an obvious cause of postkeratoplasty astigmatism. The purpose of this study was to compare graft decentration after nonmechanical trephination with the excimer laser (193 nm) with that after mechanical motor-trephination in 50 consecutive patients with Fuchs' dystrophy and 50 patients with keratoconus. PATIENTS AND METHODS: To determine decentration in absolute values and clock hours, a postoperative slide was projected with a fixed magnification onto a pattern with circles corresponding to the trephination margin. Using a second transparent and movable pattern with concentric circles and ellipses, the authors measured the amount and direction of decentration relative to the limbus and to the pupil. In addition, the keratometric astigmatism and the refractive cylinder were assessed. In this prospective study, the patients were assigned randomly to either method of trephination. RESULTS: The decentration was significantly lower (P < .002) with excimer laser trephination (0.23 +/- 0.26 mm, relative to the limbus; 0.33 +/- 0.26 mm, relative to the pupil) than with mechanical trephination (0.58 +/- 0.23 mm, relative to the limbus [P < .01]; 0.64 +/- 0.24 mm, relative to the pupil [P < .005]). There was no significant difference between the results obtained in patients with Fuchs' dystrophy and those of patients with keratoconus. The preferred direction of decentration relative to the pupil was the lower quadrants. There was a mild correlation between net astigmatism and the absolute value of decentration. However, with sutures in place, there were no significant differences in the keratometric net astigmatism between mechanical and nonmechanical trephination (P = .16) or between Fuchs' dystrophy and keratoconus (P = .18). CONCLUSIONS: The results indicate that the amount of decentration can be reduced by specific techniques associated with nonmechanical trephination. This might have a favorable impact on the residual astigmatism after suture removal.

Adolescent↗
PubMed1999

Stimulant-induced exocytosis from neuronal somata, dendrites, and newly formed synaptic nerve terminals in chronically decentralized sympathetic ganglia of the rat.

Loss of preganglionic neurones underlies the autonomic failure of human multiple system atrophy. In rat sympathetic ganglia decentralization leads to new synapse formation. We explored whether these synapses are functional, and whether chronically decentralized neurones respond normally to activation, in terms of exocytosis. Potassium depolarization and cholinergic agonists were applied to freshly excised rat superior cervical sympathetic ganglia, preganglionically denervated with prevented reinnervation 5 months earlier. Ganglia were incubated and stimulated in the presence of tannic acid, which stabilizes released vesicle cores for subsequent electron microscopy. In denervated ganglia exocytosis was observed from newly formed synaptic nerve terminals, and from nonsynaptic surfaces of neurone somata and dendrites. The results demonstrated that the new intraganglionic synapses, which are mostly catecholaminergic, can function and that chronically decentralized sympathetic neurones remain capable of stimulant-induced exocytosis from somata and dendrites. The maximal release upon potassium depolarization did not differ significantly between denervated and contralateral ganglia. Relative to this, the exocytotic responses of decentralized somata and dendrites to nicotine resembled those of contralateral ganglia. Responses to muscarine were significantly less in denervated than in contralateral ganglia, indicating inhibition in dendrites. Responses to carbachol suggested interactions between nicotinic and excitatory muscarinic effects. Nerve terminals in denervated ganglia showed high basal release. Their responses to muscarine and carbachol resembled those of the decentralized neurones, from which most may originate. Their response to nicotine evidenced inhibition. Their actions, coupled with nonsynaptic effects of soma-dendritic exocytosis, might modulate responses of the decentralized neurone population to other surviving inputs. This modulation could be influential in disease-induced decentralization in man.

Animals↗
PubMed2002

A comparison of the changes in the non-neuronal cell populations of the superior cervical ganglia following decentralization and axotomy.

Transecting the axons of neurons in the adult superior cervical ganglion (SCG; axotomy) results in the survival of most postganglionic neurons, the influx of circulating monocytes, proliferation of satellite cells, and changes in neuronal gene expression. In contrast, transecting the afferent input to the SCG (decentralization) results in nerve terminal degeneration and elicits a different pattern of gene expression. We examined the effects of decentralization on macrophages in the SCG and compared the results to those previously obtained after axotomy. Monoclonal antibodies were used to identify infiltrating (ED1+) and resident (ED2+) macrophages, as well as macrophages expressing MHC class II molecules (OX6+). Normal ganglia contained ED2+ cells and OX6+ cells, but few infiltrating macrophages. After decentralization, the number of infiltrating ED1+ cells increased in the SCG to a density about twofold greater than that previously seen after axotomy. Both the densities of ED2+ and OX6+ cells were essentially unchanged after decentralization, though a large increase in OX6+ cells occurred after axotomy. Proliferation among the ganglion's total non-neuronal cell population was examined and found to increase about twofold after decentralization and about fourfold after axotomy. Double-labeling experiments indicated that some of these proliferating cells were macrophages. After both surgical procedures, the percentage of proliferating ED2+ macrophages increased, while neither procedure altered the proliferation of ED1+ macrophages. Axotomy, though not decentralization, increased the proliferation of OX6+ cells. Future studies must address what role(s) infiltrating and/or resident macrophages play in regions of decentralized and axotomized neurons and, if both are involved, whether they play distinct roles.

Animals↗
PubMed1984

Decrease in transmitter output and synaptic ultrastructure at lobster neuromuscular terminals with decentralization.

The effects of decentralization on the physiology and ultrastructure of neuromuscular terminals were examined by transecting the single excitor axon to the distal accessory flexor muscle in the walking legs of lobsters (Homarus americanus). Decentralization caused a reduction in the amplitude of the excitatory junctional potential without altering the resting potential or input resistance of the muscle fiber thereby suggesting a reduction in transmitter release. Confirmation was obtained by recording of synaptic currents at focal sites which showed failure of transmission and a reduced amplitude on decentralized fibers compared to their intact counterparts on the contralateral leg. The mean quantal content of synaptic transmission decreased approximately 2-7-fold at these decentralized sites compared to their intact counterparts. The ultrastructure of these identified sites was examined with serial section electron microscopy. There are few if any qualitative changes in synaptic ultrastructure between decentralized and control terminals. However, quantitatively there were changes in synaptic ultrastructure which were progressive in nature depending on the severity of the reaction to decentralization. Thus terminals showing a moderate decline in quantal content were characterized by a reduction in the number of presynaptic dense bars and synapses. Terminals showing a severe drop in transmitter release showed in addition to the above changes, a reduction in the size of synapses and terminals. These results show a progression in the loss of the structural parameters controlling transmitter release. Finally synaptic vesicles and mitochondria did not reveal any consistent or marked change with decentralization.

Animals↗
PubMed2005

Tilt and decentration of three-piece foldable high-refractive silicone and hydrophobic acrylic intraocular lenses with 6-mm optics in an intraindividual comparison.

PURPOSE: Intraindividual comparison of tilt and decentration of three-piece foldable intraocular lenses (IOLs) with 6-mm optics and different edge design and material. DESIGN: Prospective randomized study. METHODS: Twenty-five patients with senile cataract (group I) received a foldable silicone, sharp optic edge IOL in one eye and a silicone, rounded optic edge IOL in the other eye. Group II (n = 28) received the foldable silicone, sharp optic edge IOL in one eye and an acrylate, sharp optic edge IOL in the other eye. Scheimpflug photography was performed after the procedure with an anterior eye segment analysis system. Tilt and decentration of the IOL optic were measured 1 week, 6 months, and 12 months after the procedure. RESULTS: In group I, the foldable silicone, sharp optic edge IOL showed a mean optic tilt of 3.03 +/- 1.79 degrees and an optic decentration of 0.24 +/- 0.13 mm; the silicone, rounded optic edge IOL showed a tilt of 3.26 +/- 1.69 degrees and a decentration of 0.23 +/- 0.13 mm. In group II, the foldable silicone, sharp optic edge IOL showed an average tilt of 2.34 +/- 1.81 degrees and a decentration of 0.29 +/- 0.21 mm after 12 months; the acrylate, sharp optic edge IOL had a tilt of 2.32 +/- 1.41 degrees and a decentration of 0.24 +/- 0.10 mm. There were no significant differences in either group. CONCLUSION: The examined IOLs showed a stable position regarding tilt and decentration in the first 12 postoperative months, independent of material and edge design. Slight deviations from the optical axis might affect the outcome in aspheric or multifocal IOLs.

Acrylic Resins↗
PubMed2005

Comparison of tilt and decentration of 1-piece and 3-piece hydrophobic acrylic intraocular lenses.

PURPOSE: To determine the amount of tilt and decentration of 1-piece and 3-piece hydrophobic acrylic intraocular lenses (IOLs) in patients having cataract surgery. SETTING: Department of Ophthalmology, Gulhane Military Medical Academy and Medical School, Ankara, Turkey. METHODS: Eighty-eight patients having phacoemulsification with IOL implantation were divided into 2 groups. One group received a 3-piece hydrophobic acrylic IOL with 12.5 mm poly(methyl methacrylate) haptics and the other, a 1-piece hydrophobic acrylic IOL with 12.5 mm haptics. The amount of IOL decentration and tilt was quantitated using Purkinje reflections and photographic documentation at the last postoperative control. The results of the 2 groups were compared. RESULTS: Bag fixation of the IOL and an intact continuous curvilinear capsulorhexis (CCC) were confirmed in all cases at the last postoperative control, which was at a mean of 27.1 months +/- 5.4 (SD) and 26.7 +/- 4.4 months in the 3-piece group and 1-piece group, respectively (P = 0.659). There was no significant difference between groups in the percentage of patients with measurable tilt and decentration and of patients without measurable tilt and decentration (P = .956). The mean IOL tilt was 2.72 +/- 0.55 degrees in the 3-piece group and 2.70 +/- 0.84 degrees in the 1-piece group and the mean IOL decentration, 0.39 +/- 0.13 mm and 0.34 +/- 0.08 mm, respectively. There were no significant between-group differences in tilt or decentration (P = .897 and P = .103, respectively). CONCLUSION: There were no significant differences in tilt and decentration between 1-piece and 3-piece hydrophobic acrylic IOLs in eyes with capsular bag IOL implantation and an intact CCC.

Acrylic Resins↗
PubMed2005

Pupil decentration and iris tilting detected by Orbscan: anatomic variations among healthy subjects and influence on outcomes of laser refractive surgeries.

PURPOSE: To investigate the anatomic variations of entrance pupil decentration and tilting angle of the iris in healthy subjects and the influence of these factors on the outcome of laser in situ keratomileusis (LASIK). SETTING: Minamiaoyama Eye Clinic, Tokyo, Japan. METHODS: The degree of pupil decentration and tilting angle of the iris in 2280 eyes of 1144 myopic patients without abnormal findings by ophthalmologic examination were assessed using Orbscan. Of these, 901 eyes of 467 patients had LASIK. Multiple analysis of variance (ANOVA) was used to determine risk factors for reduction of postoperative best spectacle-corrected visual acuity (BSCVA) considering patient age, refractive power, tilting angle of the iris, pupil decentration, and corneal power. RESULTS: The mean pupil decentration in all eyes was 0.19 mm +/- 0.11 (SD) (range 0 to 0.9 mm); tilting angle of the iris was 4.06 +/- 1.41 degrees (range 0.19 to 12.69 degrees). By multiple ANOVA, refractive power, pupil decentration, and tilting angle of the iris were significant for the reduction of BSCVA. CONCLUSIONS: Some eyes with pupil decentration or tilting angle of the iris could not be detected under typical ophthalmologic examination but only with topographic examination. Attention should be paid to eyes with large pupil decentration and tilting angle of the iris because these may be risk factors for reduction of postoperative BSCVA during corneal refractive surgeries.

Adult↗
PubMed1984

Supersensitivity to carbachol in the parasympathetically decentralized feline urinary bladder.

We investigated the concentration-response relations for carbachol, the morphological characteristics and the mechanical properties of feline detrusor strips from 1) normal cats, cats subjected to 2) parasympathetic sacral decentralization, 3) urinary diversion followed by parasympathetic sacral decentralization and 4) urinary diversion only. Hypertrophy of the detrusor and supersensitivity to carbachol (a decrease of EC50) were found only after parasympathetic decentralization. No hypertrophy developed and no change in the EC50-value for carbachol was found if urinary diversion preceded the parasympathetic decentralization. A decreased ability of force production per unit cross sectional smooth muscle area was found in the decentralized bladders compared to the controls. However, the total ability of force production and hence also pressure production of the decentralized bladders would be expected to be enhanced due to a 4 to 5-fold increase of bladder weight (mainly muscle mass). No differences in the active length-tension relations were found in the 4 groups. It is suggested that parasympathetic decentralization per se does not give rise to detrusor hypertrophy or increased sensitivity to carbachol. Provided that the situation in man is comparable to that in the cat, it might be that the supersensitivity test a.m. Lapides-Glahn reflects the presence of detrusor hypertrophy rather than the presence of a neurogenic lesion.

Animals↗
PubMed1997

Decentration and tilt of polymethyl methacrylate, silicone, and acrylic soft intraocular lenses.

PURPOSE: The purpose of the study is to investigate the periodic changes regarding the decentration and tilt of the intraocular lens (IOL) and to compare any differences in the decentration and tilt among polymethyl methacrylate (PMMA), silicone, and acrylic soft IOLs. METHODS: A total of 225 cataractous eyes undergoing IOL implant surgery were randomized into 3 groups based on the type of IOL: group A, one-piece PMMA IOL; group B, three-piece silicone IOL; and group C, three-piece acrylic soft IOL. Both the length of the decentration and the degree of the tilt of the IOL were quantitated using the Anterior Eye Segment Analysis System (EAS-1000). All eyes underwent EAS-1000 examinations at 1 week as well as 1, 3, 6, 9, and 12 months after surgery. RESULTS: All IOLs were confirmed to be implanted accurately in the capsular bag after continuous curvilinear capsulorhexis was accomplished. No statistically significant differences were observed regarding the IOL decentration or tilt between the various postoperative periods in any of the three IOL groups. Furthermore, the differences regarding both the IOL decentration and the tilt between the three IOLs were not determined to be statistically significant throughout the observation period. CONCLUSIONS: As long as the IOL was placed properly in the capsular bag after the continuous capsulorhexis, neither the decentration nor the tilt of the IOL showed a significant progression up to 12 months after surgery. Furthermore, both the extent of the decentration and tilt almost were the same among the PMMA, silicone, and acrylic soft IOLs.

Acrylic Resins↗
PubMedDate not supplied

[Decentralization of the health sector in Latin America].

This paper analyzes the Latin American experience of decentralizing health services within the context of health reform. We examine the meaning of the term decentralization and discuss the various modalities of this concept: geographical, institutional and functional. The objectives that, in general, these objectives have not been achieved. After reviewing the literature and drawing on our own fieldwork, we conclude that in many instances the Latin American decentralization programs have produced results opposite to those intended, i.e., these programs have increased inequality and the cost of services and have reduced efficiency and quality of care. We point out that existing information is insufficient to determine with exactitude whether the failure of decentralization is due to the selection of inappropriate policies or to failures in the implementation process. Decentralization is a complex political process, policy makers should decide on the modality of decentralization they wish to implement, estimate the costs, identify the potential obstacles that could surface during the implementation phase and provide solutions. We conclude by suggesting that the multilateral banks have erred by pressing governments to improvise the implementation of decentralization programs without taking into account the different historical, political and socioeconomic contexts.

Delivery of Health Care↗
PubMed1998

Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance.

Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that is transferred from central institutions to institutions at the periphery of health systems, (2) what choices local officials make with their increased discretion and (3) what effect these choices have on the performance of the health system. This article proposes a framework of analysis that can be used to design and evaluate the decentralization of health systems. It starts from the assumption that decentralization is not an end in itself but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality and financial soundness. Using a "principal agent" approach as the basic framework, but incorporating insights from public administration, local public choice and social capital approaches, the article presents a decision space approach which defines decentralization in terms of the set of functions and degrees of choice that formally are transferred to local officials. The approach also evaluates the incentives that central government can offer to local decision-makers to encourage them to achieve health objectives. It evaluates the local government characteristics that also influence decision-making and implementation at the local level. Then it determines whether local officials innovate by making choices that are different from those directed by central authorities. Finally, it evaluates whether the local choices have improved the performance of the local health system in achieving the broader health objectives. Examples from Colombia are used to illustrate the approach. The framework will be used to analyze the experience of decentralization in a series of empirical studies in Latin America. The results of these studies should suggest policy recommendations for adjusting decision space and incentives so that localities make decisions that achieve the objectives of health reform.

Decision Making, Organizational↗
PubMed1998

Decentration of 3-piece versus plate-haptic silicone intraocular lenses.

PURPOSE: To compare the incidence of decentration with 2 types of silicone intraocular lenses (IOLs). SETTING: John A. Moran Eye Center, University of Utah Medical Center, Salt Lake City, Utah, USA. METHODS: Selection criteria for this retrospective study included patients who had uncomplicated cataract surgery with a clear cornea or scleral tunnel incision with a curvilinear capsulorhexis and capsular bag implantation of a silicone IOL. After a mean follow-up of 14 months (range 12 to 18 months), 54 eyes implanted with a 3-piece lens (AMO SI-30) and 58 eyes implanted with a plate-haptic lens (Staar AA403) were examined for posterior chamber IOL decentration. The decentration criterion was 0.5 mm or more from the center of the pupil. Detailed chart review of preoperative and postoperative measurements was performed for each patient. RESULTS: Eighteen of the 3-piece IOLs (33%) and 11 of the plate-haptic IOLs (20%) were decentered 0.5 mm or more (P = .129). Using photographic analysis, the mean IOL decentration with the 3-piece IOL (1.12 mm +/- 0.198 [SD]) was significantly greater than with the plate-haptic IOL (0.632 +/- 0.278 mm)(P < .001). No statistically significant correlation was found between the centered or decentered IOL groups' preoperative refraction, axial length, capsulorhexis size, type of incision, or rate of neodymium:YAG laser capsulotomy. CONCLUSIONS: No statistically significant difference was seen between the decentration rates of 3-piece and plate-hepatic IOLs; however, the amount of decentration with the 3-piece IOL was significantly greater than with the plate-hepatic IOL. Other factors did not contribute to IOL decentration.

Follow-Up Studies↗
PubMed1983

Educational decentralization and deployment of physician's assistants.

A community-based educational network was established to improve the deployment of physician's assistants away from the original site of training in California's San Francisco Bay Area. The philosophy underlying the program decentralization, lessons learned during its implementation, and outcomes of the decentralization are discussed. The graduates' practice locations for a seven-year period are compared before and after the decentralization of the program. Before decentralization, 58 percent of the graduates established their first practice outside of the Bay Area. Following decentralization, 100 percent of the students trained entirely within community settings took their first jobs away from the Bay Area. Unique aspects of this decentralization experience compared with those reported previously included the lack of a required student-preceptor match at the time of entry into the program, the provision of clinical training in or near the site of student residence, and the opportunity to compare before and after effects of decentralizing educational components other than preceptorships.

California↗
PubMed1996

Decentralization in a sick fund: lessons from an evaluation.

In 1988, Israel's largest sick fund embarked on a process of decentralization, which consisted of the delegation of authority from central management to two regions that were chosen as demonstration sites. Aims to examine the extent to which the decentralization plan was implemented, to identify the major difficulties in implementation and to evaluate the process of implementing organizational change. Contends that the demonstration programme was implemented in part only, and that difficulties did arise during implementation. Our evaluation of the decentralization process led us to develop conceptual diagnoses of the various problems that might arise during decentralization and derive lessons for successful implementation. Evaluation taught us that when implementing a plan of decentralization, it is beneficial to make a clear division of responsibilities; develop control instruments and an information infrastructure; improve the skills of managers; appoint a team responsible for implementing decentralization, and establish a joint forum for working out problems between central management and sub-units; and clarify organizational policy on the central operational issues facing sub-units. Expresses the hope that the conclusions drawn here will help other organizations in Israel and abroad in planning and implementing decentralization.

Decision Making, Organizational↗