Decentralizing the Provision of Health Services : An Incomplete Contracts Approach

Jack, William

World Bank Group, Washington, DC

关键词: AGENCY PROBLEMS;    ALLOCATIVE EFFICIENCY;    ASSETS;    ASYMMETRIC INFORMATION;    AUTHORITY;   

DOI  :  10.1596/1813-9450-2395
RP-ID  :  WPS2395

学科分类：社会科学、人文和艺术（综合）

来源: World Bank Open Knowledge Repository

【 摘 要 】

The author studies theallocation-between a central government and a localauthority--of responsibility for planning, financing, andoperations for the delivery of health services, in thecontext of an incomplete contracts model. In this model,inputs are required of both the central government and localauthorities but they are unable to write down, and committo, a complete and binding contract describing the actionsboth should take. The model is meant to capture the tradeoffbetween central and local authority in decisions about bothfinancing and the provision of services. Each party providesa specific input--for example, the central governmentestablishes a drug procurement system while the localauthority designs and implements an incentive scheme to getdoctors to carry out their responsibilities appropriately.The responsibility for delivery of services is identifiedwith the ownership of essential infrastructure, such as theclinic or hospital. The author finds that to maximize thejoint surplus of the two public bodies: Ownership of thefacility should be given to the party that most values thewell-being of local residents. (This way, if ex postbargaining breaks down, each still enjoys some benefits fromthe other's actions.) Financing authority andresponsibility for delivering services should be negativelycorrelated. Generally it is optimal to allocate taxauthority to the party that values the residents'well-being less--in other words, separate spendingresponsibility (ownership) from financing authority. Aheavier financing burden (access to a small and inefficienttax base) has the same incentive effect as asset ownership:It increases the return to effort. If transferring ownershipof the physical asset is costly (because the party thatbuilds the asset has an inherent advantage in operatingit-that is, there is some human capital embodiment), it maybe optimal for the party with the higher construction coststo have planning authority. Somewhat paradoxically, thegreater the costs of transferring assets from one party tothe other, the more likely that ownership of the facilitiesand their provision should be separated.