Wednesday, June 10, 2009

Centralization of decision making?

Something to think about. What value is there to centralization of decision making--or at least of a part of the process?

Here is a short report in a statement from the Commonwealth Fund--a nonprofit foundation that aims to promote a high quality health care system.

"Despite overwhelming evidence that experiences during the early childhood years contribute greatly to later health and educational attainment, the United States lacks a clearly articulated policy to address the needs of young children and their families during this crucial period.

The U.S., however, is not the only country to struggle with the direction of early childhood policy, according to An International Comparison of Early Childhood Initiatives: From Services to Systems, a new Commonwealth Fund report by Neal Halfon, M.D., M.P.H., and colleagues. England, Canada, and Australia all started with similarly fragmented early childhood services, and families in these countries are facing similar pressures resulting from long hours at work, irregular work schedules, and limited child care options.

In the report, Halfon, the founding director of the University of California, Los Angeles (UCLA) Center for Healthier Children, Families and Communities, and his team detail each country's efforts to develop policies that they hope will produce lasting gains for their youngest citizens. The authors also consider the implications of these nations' experiences for the development of early childhood policy in the U.S.

As the report shows, the building blocks for the early childhood system of the future are already emerging. Approaches that align strategies across multiple levels of government—local, state, and national—and that integrate health, education, and family support services are proving to be the most successful. "

This is the type of argument that I have been making for years in a variety of contexts in the research and policy related work that I do. It started with work on the Healthy Start project in Baltimore City. If we take it as a given that we are likely to have some form of government public health intervention (and I realize that not everyone even agrees with that premise) then the even more difficult question is how to get multiple levels of government or even multiple agencies within the same level of government to cooperate. To share resources to use for a program. To share savings from a program that works.

In some cases we have to ask whether all the resources used by all levels of government are less under a new system. Unfortunately, our system is so fractured that we have great difficulty to align everyone's incentives. The report from the Commonwealth Fund mentions this as a key issue. I find it hard to believe that we can do that in the United States. I find it particularly hard to believe since there are so many different interests aiming for political power at each level and so many vested interests in not sharing this way. I find it particularly hard to believe since Americans--in general--are not big fans of centralization. However, we may consider at least some additional centralization--even if we only centralize discussion--to stop having to focus so much on individual winners and losers and to think harder about whether society wins or loses when we make decisions.

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