Conference

1

• Conference
• Effective Aid Effectiveness?
• The effectiveness of development cooperation
• in the field of Primary Health Care
• The Bolivian Case
• Berlin, February 11, 2009
• Nathan Robison

2
Overview - health situation Bolivia

• Bolivia continues as the country in South
  America with the worst health indicators, many of
  them comparable to several countries on the
  African Continent

3
Underlying Causes

• The general poverty of the country including the
  lack of adequate basic water and sanitation
  infrastructure, unemployment and low levels of
  income, low levels of education, and precarious
  housing conditions
• Deficient organization and management of the
  Health Sector

4
Service distribution by sub-sector

• 10 of the Bolivian population served by private
  sub-sector
• 22 served by formal Social Security system
• 43 to 48 served by Public sub-sector
• 20 al 25 without access
• 90 of Bolivia depends on the government for
  provision of health services
• 77 of population severely underserved
  (governments own estimate)

5
Health expenditure in Bolivia

• Should be oriented toward improving investment in
  human capital
• 96 spent on curative services - consumption
• 4 spent on prevention and promotion investment
• Percentage of national Income spent on health
  (2001)
• Regional average 11.3
• Bolivia 6.5

6
Health systems constraints

• Existing funds poorly distributed between
  curative care vs. prevention/health promotion
• Weak separation of functions between norm
  development and regulation, financing and service
  provision.
• Weak articulation among the sub-sectors Social
  Security/Public/private/non-profit
• Poor public management results in ineffective use
  of existing resources and poor quality services
  (principal cause

7
Health systems constraints

• Power of the government health workers unions
  (professional and nonprofessional) undermines
  periodic government efforts to reform the health
  sector.
• Poor management of national health information
  hides poor health indicators
• Lack of resources

8
Perception I

• The main responsibility in the ineffective use of
  donor resources falls in the hands of recipient
  countries - Bolivia

9
Donors role - health sector Bolivia
Health expenditure by source of funds in 2002
Source Health Sector Funding and
Expenditure Accounts - Marina Cardenas 2004
10
Expenditure on PHC

• According to this source, 2 spent on promotion
  and prevention
• External sources spent primarily on PHC (7)

11
Perception II

• Despite criticism, international donor funds
  drive the limited efforts and results in PHC.

12
Main problems with Official Aid

• Most serious problems with aid are the
  indivisible responsibility of donors and
  recipients
• Most aid poured into attempting to strengthen
  poorly managed existing government services
• Not enough thought put into implementing accepted
  national and international best practices,
  particularly in health system design and
  strengthening

13
Main problems with Official Aid

• Dangerous interaction between improvised donor
  driven agendas and receptor country inability to
  develop (design and implement) sound, long-term
  public policy in the health sector

14
Non-profit Sector Aid

• Increase in donor agenda driven funding matched
  with a decrease in NGO receptor agenda driven
  funding
• Ineffective outcomes
• Reverse subsidization
• Non profit receptors have waited too long to
  shift from model implementers to sophisticated
  advocates for transformation of public policy

15
More effective spending

• More effort into health system issues
• More effort into joint (donor/recipient
  government/ civil society) design, adaptation
  and promotion (read selling) of national and
  international best practices
• More effort into design and use of public-private
  partnerships

16
More effective Non-profit Sector Aid

• Top priority
• Same issues (use of effective non-profit Southern
  partners to foster these changes)
• However, still effective
• Continued support of model development
• Direct service provision (the poor and
  underserved deserve quality services, now)

17
Main obstacles

• Case of Bolivia today
• The lack of interest (knowledge?) on the part of
  the government to learn about and implement
  accepted international best practices in health
  system design and implementation
• The opposition of health professionals and
  workers to health reform
• Civil Societys lack of knowledge of new options
  and models of health service provision

18
Role of Civil Society

• Definition of who constitutes civil society
• Social Movements highly active, but diverse,
  politicized and uninformed.
• NGOs effective, but most stuck in service
  provision paradigms
• Other relevant key actors??

19

• Thank you