Enhancing Accountability and Incentives in Public Health
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health system. As mentioned previously, not only are transfers from higher levels of government small, but the transfers have relatively few conditions attached, and the ones that are attached are not strongly enforced. This gives local governments considerable latitude to choose their own health priorities and, within these, their public health priorities. The risk is that local officials will choose priorities that reflect narrow rather than broader concerns. Local populations have limited influence on decision making by local government officials, who may be more attuned to special interests with vested concerns such as the pharmaceutical and tobacco industries, health providers, and so on. And local officials preoccupied with their own affairs may overlook how their decisions affect neighboring counties and the country as a whole. The recent experience with SARS was a powerful reminder that communicable diseases do not respect county, provincial, or national borders—failure to detect and control a disease outbreak in one locality has profound implications for China as a whole, as well as for other countries. But because county governments naturally will tend to prioritize local benefits in deciding how much to spend on disease control activities, even jurisdictions with less binding resource constraints will tend to “underspend” on public health. This section reviews the relevant evidence. It discusses how higherlevel governments influence lower-level governments. It then asks whether lower-level governments set the wrong priorities, and concludes they do. It goes on to suggest some reform options.
Higher-Level Government’s Limited Influence on Local Priority Setting With limited financial leverage over lower-level governments, higher-level governments have resorted to other mechanisms to promote public health goals (figure 7.5). For policy and technical direction, MOH develops annual work plans that are disseminated to provinces and municipalities at an annual National Health Conference, and then further disseminated to local government through local work-planning meetings. This planning process is meant to provide overall direction for public health activities at the local level, although no formal mechanism exists for ensuring that plans actually are implemented. MOH also has issued standards for the organization and activities of CDC/EPS, including staffing guidelines, organizational structure, and operating protocols that specify the tasks, monitoring arrangements, division of labor, and so forth. Similar, albeit less detailed, standards have been issued for other institutions with public health responsibilities. These standards form the basis for performance assessment by local health bureaus. There are also a