Alliance for Health Policy and Systems Research Research to Policy Abstract Community participation in decentralisation: fact or fiction? A study of the decentralization of the health sector in Jamaica Tanya Bedward Tropical Institute of Community Health and Development (TICH), Kenya [email protected] Problem For the past thirty years, Jamaica has embarked on several health sector reform programmes in collaboration with various multilateral and bilateral agencies. The most recent of which, the Health Sector Reform Programme, has as one goal the fostering of greater community participation. If this is to occur, adequate linkages between the community, local and national systems of governance are needed in order for decision-making to be brought closer to the community level. Aim The aim of this study was to investigate the current decentralisation policy in its provision of mechanisms for communities to participate in the decentralised sector. Methods Policy documents were content analysed and key informants used to determine the mechanisms in which communities could participate in the decentralised sector. Data was analysed according to a partnership-based framework of community participation. Findings Findings revealed that the State is practically limiting community participation by the legal control of decentralised structures in which community members can participate. A re-orientation of decentralised structures to reflect a synergistic type of partnership with communities is needed to bring decision-making closer to the community level. If this does not occur, restrictive mechanisms for community engagement and top-down implementation of a decentralised system will most likely hinder its own objectives. Return

COMMUNITY PARTICIPATION IN D ECENTRALISATION: FACT OR F ICTION? A STUDY OF THE DECENTRALISATION OF THE H EALTH S ECTOR IN JAMAICA Abstract For the past thirty years, Jamaica has embarked on several health sector reform programmes in collaboration with various multilateral and bilateral agencies. The most recent of which, the Health Sector Reform Programme, has as one goal the fostering of greater community participation. If this is to occur, adequate linkages between the community, local and national systems of governance are needed in order for decisionmaking to be brought closer to the community level. The aim of this study was to investigate the current decentralisation policy in its provision of mechanisms for communities to participate in the decentralised sector. Policy documents were content analysed and key informants used to determine the mechanisms in which communities could participate in the decentralised sector. Data was analysed according to a partnership-based framework of community participation. Findings revealed that the State is practically limiting community participation by the legal control of decentralised structures in which community members can participate. A re-orientation of decentralised structures to reflect a synergistic type of partnership with communities is needed to bring decision-making closer to the community level. If this does not occur, restrictive mechanisms for community engagement and top-down implementation of a decentralised system will most likely hinder its own objectives.

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ACKNOWLEDGEMENTS Dr. Dan C. O. Kaseje, Dr. Jack Bryant, Professor Joseph Oteku, Dr. George Rae, Ms. Alice Mudiri, Mr. Charles Oyaya and my fellow students at the Tropical Institute of Community Health for their creative criticism and guidance – Ms. Selam Mengesha, Mr. Maxwell Moya, Mr. Paul Mbanga and the late Mr. Sylvan Oteku Mrs. Lorna Stanley, Dr. Marjorie Holding-Cobham, Dr. Sheila Campbell-Forrester, Mrs. Stephanie Lawrence, Ms. Denise Adams, Mr. George Briggs and the staff at the MOH Resource Centre for their assistance and support. The Alliance for Health Policy and Systems Research who, in collaboration with the World Health Organisation, provided generous support through their Small Grants Programme for Young Researchers. My family – Dad, Mom, Garth, and Mo – whose prayers and sacrifice has allowed me to be where I am today. To them I am eternally grateful and indebted. Finally, I would like to thank my Lord and Saviour, Jesus Christ for providing this incredible opportunity for me to study a field that is so rewarding, among people who hold such rich experiences. I thank Him for blessing me with the wisdom, understanding and perseverance needed to carry out this task and the others that have been handed to me. To Him I dedicate my research. Note: This article is based on a Masters dissertation submitted in partial fulfilment of the Masters degree programme in Community Health and Development at the Tropical Institute of Community Health and Development, Kisumu, Kenya.

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INTRODUCTION Independent since 1962, Jamaica is the largest of the Anglophone Caribbean islands both in size and population, encompassing over 11,000 square kilometres and holding a population of 2.6 million people who reside within its fourteen parishes (Daily Gleaner Online, 2001). Jamaica, patterned after the Westminster model of England, consists of a Head of State, Cabinet of elected ministers, House of Representatives (Lower House) and Senate (Upper House). When compared to most countries with similar levels of per capita income, Jamaica enjoys relatively high social indicators due to the Government’s efforts to provide basic social services to all its citizens 1 (IDB, 1997). Despite Jamaica’s progressive social indicators, over 30% of the population live below the poverty line (World Bank, 1996). Global changes in market patterns have caused financial strain, forcing social services, particularly health services, to operate under even tighter resource constraints to achieve greater economic efficiency (PAHO, 1999). The Government of Jamaica (GOJ) is currently involved in the Health Sector Reform Programme (HSRP), based on a regional structure of management and care delivery, begun in 1997 in partnership with the Inter-American Development Bank (IDB). The four new regions implemented in 1998, Regional Health Authorities (RHAs), are each semi-autonomous corporate entities with the ability to contract with the Ministry of Health (MOH) for the provision of health services in their respective regions (IDB, 1997). The new role of the Head Office is to set standards and act as a regulator for the entire health care industry which consists of about 33 hospitals, 23 public and 10 private, 1800 physicians and 1200 nurses (PAHO, 1999). The GOJ is also involved in the Local Government Reform Programme (LGRP), a programme aimed at utilising a participatory framework of local self-governance. Through an elaborate system of Parish Committees and community cluster groups, the Social Development Commission, the development agency of the GOJ, aims to move from a welfare-based system to a development-based system (Personal Interview, 2001).

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Health sector reform (HSR) has a long history in Jamaica, the first phase of which began in the 1960s with the legal creation and implementation of Hospital Boards responsible for the management of designated hospitals in a local region (Patterson, 1996). The implementation of the Cornwall County Health Administration in the late 1970s, a pilot project marking the second phase, was carried out with the hope that the delivery and monitoring of services would be moved closer to the community level (PAHO, 1999). However, hospital regions created earlier during the first phase of reform did not coincide with the new primary care regions, in effect creating two parallel health systems operating on the field. Community Health Committees (CHC), a nation-wide system mandated by the Ministry of Health, were promoted to increase community participation at the local level, but failed to generate sustained response due to lack of interest from both community members and health workers (Kahssay and Baum, 1996). Attempts to integrate the parallel systems of health service provision continued into the 1980s, as did subsequent attempts to replicate the Cornwall experience in other areas of the country, however, replication attempts were stalled due to severe economic recession in Jamaica (Patterson, 1996). Subsequent programmes of health sector reform have targeted specific health service delivery problems (PAHO, 1999). The Jamaican health sector is now faced with the task of balancing an increasing burden of disease and significant changes in consumer demand with a persistently under-funded sector (PAHO, 1999). Furthermore, a severe lack of inputs has led to critical gaps in service delivery, deterioration in quality of services, overall inefficiencies and inequities in access (IDB, 1997). Due to these changes in consumer attitudes and behaviour as well as the effects of structural adjustments, the role of the Jamaican health sector as provider and payer of health care services has diminished in the past two decades (ibid.). The changing role of the health sector extents to most every other sector as well, resulting in an increased focus to issues of decentralisation and local determination of priorities across the Western Hemisphere.

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US$ 1,510 per capita GNP in 1995 (World Bank, 1996). Life expectancy at birth exceeds 70 years while the total fertility rate is at 2.8 children per woman in the reproductive age group (GOJ, 2000).

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According to Ambassador Christopher Thomas of the OAS, Caribbean people “are always prepared to come forward in the interest of the common good, provided that they discern the presence of honesty, genuine selflessness and fair play” (Proceedings, 1998). However, present social and political conditions seldom provide for the kind of nurturing environment that is needed for effective community participation. Furthermore, as Stone (1974) states, “Jamaican society is stratified along overlapping hierarchies of power, status and wealth that derive primarily from combinations of property, occupational position and skin colour.” This legacy of elitism holds medicine among the most esteemed and powerful professions in Jamaica. In fact, the Jamaican health sector has been described as being physician-centred, with most of its decisionmakers being physicians (PAHO, 1999). This environment of social and class divisions make the task of enhancing community involvement in decision-making an especially challenging endeavour. Nonetheless, it is in this context of economic tension and social inequity that community participation in mechanisms of governance at the local level be considered with urgency in not only the health sector, but in the entire public sector. While this study does not attempt to define the complexities of the social or political dynamics within the public sector in Jamaica, it does aim to explore opportunities for the development of meaningful community engagement in the decentralised health system of Jamaica. LITERATURE REVIEW Decentralisation, though widely attempted, remains a topic in which little is known, besides what is conceptual in nature – typologies, approaches, etc. In the words of Bossert, “there has been remarkably little concrete hard research on the forms and impact of decentralisation in the health sector” (in Janovsky, 1996). Previous research has been largely confined to examining the allocation of resources and financial flows, with little research focusing on the policy process itself, including how governments adopt and implement programmes of decentralisation (ibid.). A recent qualitative study (of which Jamaica was a part) undertaken to analyse the contribution of health development structures to district health systems resulted in no cases in which communities could contribute meaningfully to policy development (Kahssay and Baum,

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1996). However, more recent studies have begun to analyse the effectiveness of community participation in local health boards (see Ramiro, et al., 2001). Rondinelli in Mills et al. (1990) defines decentralisation as “the transfer of authority, or dispersal of power, in public management and decision-making from national to subnational levels or more generally from higher to lower levels of government.” It is often argued that decentralised systems of local government make accountability possible because citizens are more likely “to have direct encounters with and exercise control over government organisations” (Hague, 1997). However, according to Jones (1998), mechanical movements of power from central to local government will not enhance local self-governance capacity. Mills et al. (1990) agree, in that the top-down implementation by a strong central government of a new policy for decentralisation, without due regard for a process of consultation and adaptation, is very likely to fail. Though the policy may be adopted, there is likely to be a wide gap between the intentions and the reality. Adequate linkages between the community and local and national systems of governance are needed in order for decentralisation to be effective in its aims and objectives (ibid.).(Figure 1.0)

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Figure 1.0: Decentralisation – top-down implementation versus top-bottom interaction Decentralisation Policy

Top-down Implementation

Top-Bottom Interaction

Mechanical transfer of power from central to local level to reflect a parasitic relationship

Re-orientation of structures to reflect a synergistic relationship between all levels

Parasitic Relationship • • • •

Restrictive Exclusive Protective Dependent

Synergistic Relationship

Stops at District Level

Continues to Community Level

Community Input Marginal

Continued Inequity

• • • •

Community Input Great

Continued Inefficiency

Marginal gains in health status

Improved Equity

Improved Efficiency

Marked gains in health status

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Builds capacity Inclusive Transparent Relatively interdependent

In order for effective decentralisation to take place, community participation has to be conceptualised differently as “a process by which partnership is established between the Government and local communities in the planning, implementation and utilisation of health activities” (Rifkin in Kahssay and Oakley, 1999). A symbiotic relationship of absolute interdependence, where no member of the partnership can achieve any results without the other(s), is necessary for success (Table 1.0). This type of relationship, which is nurtured over time, encourages an atmosphere of positive interchange and mutual support, whereby partners recognise that the skills and contributions of all parties are of equal value. While areas of need are not the basis for the partnership (though partners may benefit in areas of need), “partners engage in joint action focusing on their own positive influence – capacities, assets, experiences” (Kaseje, 2000). Through a mutually developed and agreed upon memorandum of understanding (MOU) where clear guidelines are developed for involving all partners in all stages of the planning process, the partnership will be secured and will help to ensure sustainability. This will guide the development, management and sharing of results (ibid.). Table 1.0: Partnership Relation Types (Kaseje, 2000). Parasitic (dependence)

§ §

§ Neutral (independence)

§ §

Synergistic

§

§ § §

One partner receives or is seen to receive Any contribution from the one who receives (or is perceived to receive) is not recognised. The relationship is parent-child in character Partners do not see the need for each other in order to succeed Partnership adds no tangible value.

§

Partners realise that working with the other partner adds value to their own efforts Contributions from partners are recognised Each one achieves more by working together. The whole is greater than the sum of its parts.

§

8

§

§

§

§

“You” must take care of “me”; you are responsible for the results; I blame you for the results. I will do all I can for you; I am responsible for the success or failure, etc. I can do it; I am responsible; I am self-reliant; I can choose to act without you. I can make it just as well with or without you. Together we can do it better than any one of us alone. We can co-operate; we can combine our talents and abilities and create something greater together.

Symbiotic

§

§

No member of the partnership can achieve any results without the other(s). Co-operation is absolutely necessary for success.

§

If I am intellectually interdependent, I realise that I need the best thinking of other people to join with my own in order to achieve the best results.

This study rests on the assumptions that a genuine commitment on the part of policy makers and implementers at all levels of the health sector can promote and make active community participation in the decentralisation process. With fully defined mechanisms and structures, the community is fully capable of identifying their own health needs, planning how to meet them and implementing the agreed plan to achieve the expected health outcomes. The study aims to provide practical suggestions for increasing community participation with the potential of improving equity and efficiency of the provision of health services to the public at the local level. In addition, the study aims to enhance the community’s sense of ownership in their own development by increasing their voice in health development systems through the development of synergistic partnerships at the local, sub-national and national levels. The development of synergistic partnerships at these levels aim to then improve the accountability of government systems to all partners while at the same time lead to sustained improvements in the well-being and standard of living of the community. METHODOLOGY This study was an exploratory descriptive study utilising document review. The desk review was used to study secondary data for the purposes of reviewing, analysing and establishing an existing baseline in information on the subject. Key secondary data (policy documents, etc.) were first gathered from the Ministry of Health Resource Centre as well as the University of the West Indies Main, Medical and Public Health Libraries. To guide the document review, a guideline was produced to facilitate the collection of relevant policy information regarding the inclusion of communities in the decentralisation process.

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Interviews with key informants were used to clarify any gaps in the literature that existed. Formal interviews were conducted with employees at the Ministry of Health to provide missing information about the decentralisation process as well as to gain their perceptions and opinions about community participation in the process. Interview guidelines were created to obtain not only a historical perspective of the decentralisation process, but to also obtain the interviewees opinions and knowledge about the process in terms of community involvement. The lack of consistent documentation of policy in the MOH was one issue that may have hindered the provision of more detailed chronological information concerning the decentralisation process in Jamaica. The lack of co-operation from community members at the Regional and Parish levels prevented the collection of more in-depth information which may have provided the means for a more detailed description of the current situation. STUDY RESULTS The decentralisation policy in Jamaica is based on the National Health Services Act of 1997, which provides for the legal establishment of the Regional Health Authorities (Table 2.0). The Act provides a general framework of discretionary power allotted to the Minister of Health and to the Authority in the creation, development and implementation of RHAs. Subject to the provisions of the Act, the Minister may make regulations that provide for “the regulation and constitution of Hospital Management Committees, Parish Committees or any other Committee appointed pursuant to this Act” (GOJ, 1997). Under the Act is a National Health Service Management Scheme for each region – Southern, South-East, North-East and Western – each providing an account of the provisions establishing each RHA. Included are the provisions of structures – the Hospital Management Committee (HMC), the Parish Health Committee (PHC) and the Regional Health Authority Board (RHB) – that serve as the only formal means by which communities can participate at Regional and Parish levels.

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Table 2.0: Mechanisms for Community Participation

Membership

Chairman

Appointment /Tenure

Procedures at Meetings

Regional Health Board 11-14 total members 6-8 community representatives selected from the fields of engineering, law, management, finance, sociology and clergy. Appointed by the Minister of Health; Members elect one among them to serve as Vice-Chairman. Appointment for three years; Appointment may be revoked by Minister for reasonable cause at any time where any such member fails, without reasonable excuse, to attend three consecutive meetings of the Board; Any member may resign in writing addressed to the Minister and transmitted through the Chairman.

Hospital Management Board 15 members, 7 of which are to be community representatives selected from “the usual fields of endeavour”.

Parish Health Board

Same as RHB

Same as RHB

Same as RHB

Same as RHB

All three structures are to meet “as necessary” at least 6 times in a financial year, with a quorum being 10, except for the RHB, which is 7. All structures have the freedom to regulate the procedures at meetings. The Chairman, ViceChairman and acting Chair has an original and casting vote.

See RHB

See RHB

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13-15 members, 4-6 of which from the community and the usual professions.

Duties/Power s/Delegation of Powers

Maintain and manage public health facilities, appoint and remove staff from public health facilities within the Region, collect fees, make recommendations to the minister regarding matters that directly or indirectly affect public health facilities, appoint committees, exercise control over expenditure and other duties in relation to management of public facilities as the Minster may require. The Act stipulates that the Board may delegate functions to the Chairman, other members, committees appointed by the Minister or public officers in a public health facility in the Region.

Set terms of contracts between the regional hospital and others, advise the RHA on all matters of public health in the hospital, monitor the delivery of health services in the hospital, manage the expenditure of all funds earned by or forwarded to the hospital, other matters as the minister directs in writing. There is no stipulation for the delegation functions.

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To advise the RHA on all matters of health in the Parish, planning and monitoring the delivery of health services in the Parish, take initiatives to promote health in the Parish, manage expenditure of funds forwarded by the RHA for use by the Parish and such other matters as the Minister directs in writing. There is no stipulation for the delegation of functions.

DISCUSSION From the data available, it appears that the decentralisation policy is vague in terms of provisions for the creation of structures that allow for community participation at various levels of the health sector. Because the structures and mechanisms appear undefined, the space provided for in the Act is left to the interpretation of the Minister. Because the Minister has the explicit authority to create these structures, such as regulatory committees, there is a large amount of discretionary power allotted to the office holder. Therefore, the possibility for the creation of these structures appears to be determined in a top-down, centralised fashion. Though his technical staff may advise the Minister, this basically leaves the locus of decision-making power in the hands of the few at the top. Key decision-making powers, then, appear to still be centralised to a large degree at Head Office. Furthermore, when discretionary powers are awarded to the few at the top, it enables them, not the people, to maintain control over the system. A bureaucratic system such as the Jamaica MOH relies heavily on the leadership at the top, making it vital that those decision-makers hold the best interest of the people at large. However, without representation of the community within the upper echelons of decision-making processes, this is unlikely to happen. If this type of top-down determination and control of “decentralisation” processes continues, there will most likely be a large gap between the intentioned objectives of decentralisation and reality spoken of by Mills, et al. (1990). The structures the policy calls for appear to reflect “a mechanical transfer of power from central to local level,” and as Jones states, is decentralisation in its conventional sense. The fact that Boards and Committees have only been created at Regional and Parish levels reflect this fact clearly. The policy does not require that structures at the community level be put in place to enable the society to relate to the State, a condition necessary for the community to actively become engaged in the decision-making process. Apparently, there has not been the redesign of structures that would enhance local governance capacity. Moreover, this type of policy creates an environment that is unfriendly to democratic processes. Instead, law has potentially hindered local

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governance, an action typical of Latin America and the Caribbean (PAHO, 1994). According to the Act, most community members would not be given an opportunity to participate in the governance of the country, though they may have a desire to do so. The structures that have been put in place are exclusive in that they are not representative of the people. Because the community members on Boards and Committees should be appointed professionals through the party network, they would then be representative of a select few of the population – a distinct minority. Benefits would most likely, then not be felt by the majority, but by the few. The fact that the MOH planned to “reorient the thinking” of the new Board and Committee members reflects a great deal of institutional rhetoric whereas community participation is concerned. There does remain, however, the likelihood that there exists community representatives who do have a sense of social responsibility to the greater community to act on their behalf. The appointment of professionals to Boards and Committees point explicitly to observations made by PAHO (1999) that the health system is physician-centred. An obvious bias to professionals exists not only in the health sector, but also in all of society. This stratification of the society according to profession has an obvious effect on the health sector and holds serious implications for society as well. The marginalisation of the poor and the uneducated is continuing and is actually sanctioned by the government. With a society that consists of over 30% living below the poverty line and a history of political unrest, institutionalised alienation of the poor may create a volatile environment that may erupt at any time. Duties and powers stipulated by the Act appear vague, leaving a large amount of room for interpretation. Committees and Boards relate, not horizontally, providing some means for information flow and accountability, but vertically, each to the Minister of Health. Boards must still receive policy approval from Head Office. Unfortunately, a system of this type may be vulnerable to corruption, as those among the top core of decision-makers may be allowed to make decisions without having to justify them.

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This aspect raises the issue of accountability. In theory, government should be accountable to the people because it is they, after all, who elect officials to their place of office. However, in the case of the Committees and Boards, community representatives are not accountable to any group of people, except the Minister of Health and maybe their political party, in effect producing a gap in political accountability. This type of policy also in effect goes against some of the very reasons given for decentralisation, increased community participation and efficiency in service delivery, as raised by Mills, et al. (1990). There is no environment that enables people’s voices to be heard in the process of governance and management. This issue further confirms findings raised by the IDB that health care services in Jamaica have not kept pace with the changing epidemiological profile of the country, but rather are still focused on tackling communicable diseases and maternal and child health. A Government of this kind is then inefficient with their resources by not listening to the people when it comes to planning and implementing social programmes. There is clearly a gap in information sharing between the government and the community. The apparent lack of feedback mechanisms from the people to the government implies that communities’ opinion on issues concerning the health sector is not a priority. The health sector does not, apparently, see the need for communities in order to succeed in its objectives of reform. CONCLUSION It appears that the decentralisation policy in Jamaica remains in fact quite centralised. The fact that the policy is implemented on a top-down basis goes against the very intent and objectives of decentralisation. The track of implementation taken by the Jamaica MOH most clearly reflects a parasitic type of relationship in terms of community participation, as opposed to the ideal – a synergistic relationship (Figure 1). The relationship is parasitic in that the Government is feeding off of the people, in terms of their votes and their resources without recognition of receipt. This relationship is nurtured in the present environment of professional elitism and class domination,

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not to mention politicisation of democratic processes. Mechanisms to enhance local governance are hindered by the halt of decentralisation to the Parish level. However, even at the Parish level, community participation can only be marginal at best due to the limitations placed on membership in Parish Committees to a pre-selected cadre of professionals. The mixed roles of these structures also present a limitation in that community members may be silenced in their ability to challenge the decisions of health professionals. Accountability is also thwarted in the process in that members are not responsible to a constituency, but rather to the Minister (Figure 1). Though opportunities for meaningful community engagement in Jamaica appear nonexistent, there is nonetheless hope for change. Because the stipulations governing Regional Health Boards, Hospital Committees and Parish Health Committees are flexible, there still remains opportunities for change and room for improvement. With a government that remains committed to the ideals of democracy and community empowerment, synergistic partnerships between the government and communities can be achieved and sustained. If the Government of Jamaica is serious in their intentions to reform the health sector by bringing decision-making powers closer to the community, then only a redesign of structures to ensure that the community is indeed part of the decision-making process will bring this about. However, for this to even begin to occur, there must be a re-orientation in the thinking of health professionals from both the public and private sector to recognise the inherent potential that is held within the community. Without an understanding and an appreciation of the experiences and resources that are within the community, partnership of this nature cannot take place. The community must also be re-oriented to the understanding that health is a holistic concept, encompassing more than a “disease-cure” relationship and not solely the responsibility of the Government or the health professional. Furthermore, the partnership must be built on a shared philosophy of capacity-building and mutual interdependence. Capacity-building on the part of the community will involve the process of improving their ability to participate actively in their

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development by developing context-specific mechanisms and strategies as they best see fit. All partners must realise the benefits that will be brought about by working in partnership with one another. Within the partnership, there also exists a spirit of inclusiveness brought about by the involvement of all groups representative of civil society. Particularly important within this context is the inclusion of Community Based Organisations, such as Community Development Committees from the marginalised sectors and groups of society. Partners will then be held accountable to their representative groups of the society. The creation of partnerships of this nature will then improve the ability of the community to not only contribute to, but to also take part in the development of health services that will meet their needs.

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Figure 6.1 Actual vs. the Ideal, Decentralisation in Jamaica

Decentralisation Policy

Top-down Implementation

Top-bottom Interaction

Mechanical transfer of power from central to local Level to reflect a parasitic relationship

Re-orientation of structures to reflect a synergistic relationship between all levels

Parasitic Relationship • • • • • •

Synergistic Relationship •

Restrictive Sole ownership Exclusiveness Protection Control Dependency

Stops at Parish Level

Continues to Community Level

Input Marginal

Input Great

Continued Inequity

Continued Inefficiency

Improved Efficiency

Marginal gains in health status

• • • •

Improved Equity

Marked gains in health status

18

•

Capacity building Shared ownership Inclusiveness Transparency Recognition of others’ resources Relative interdependence

REFERENCES

Collins English Dictionary. 1999. Glasgow: Harpers Collins Publishers. Daily Gleaner Online. April 3, 2001. “Jamaica’s Official Population at 2.6 Million.” Government of Jamaica. 2000. MOH Performance 1999-2000 Annual Report. Kingston. (unpublished) IDB. 1997. Health Sector Reform Programme. Inter-American Development Bank. (unpublished) Kahssay, H. M. and Baum, F., eds. 1996. “The Role of Civil Society in District Health Systems: Hidden Resources.” Geneva: World Health Organisation. Kaseje, D. 1999. Class Notes. Kisumu, Kenya: Tropical Institute of Community Health and Development. (unpublished) Mills, A., Vaughan, J. P., Smith, D. L., Tabibzadeh, I., eds. 1990. Health System Decentralization: Concepts, Issues and Country Experience. Geneva: World Health Organisation. ____. 1994. Development and Strengthening Of Local Health Systems In the Transformation

Of

National

Health

Systems:

Social

Participation

In

Health

Development. Washington, D. C.: Pan American Health Organisation. HSS/SILOS-26. ____. 1999. Jamaica: Health Systems and Service Profile. Washington, D. C.: Pan American Health Organisation. http://www.paho.org

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Patterson, A. W. 1996. Decentralisation and Health Systems Change. Kingston. (unpublished) Proceedings. 1998. Sub-regional meeting of the Program of Co-operation in Decentralisation, Local Government and Citizen Participation. Kingston, Jamaica. 8-9 June 1998. Kingston: Organisation of the American States. Stone, C. 1974. Electoral Behaviour and Public Opinion in Jamaica. Mona, Jamaica: Institute of Social and Economic Research, University of the West Indies. World Bank. 1996. The World Bank Group Countries: Jamaica. Washington, D. C.: World Bank. http://www.worldbank.org/html/extdr/offrep/lac/jm2.htm WHO. 1995. Renewing the Health For All Strategy. Geneva: World Health Organisation. Consultation document.

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APPENDIX 1.0 MAP OF JAMAICA, Showing Parish and Health Regions

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APPENDIX 5.0 JAMAICA MOH ORGANOGRAM

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