Organizational Barriers and Equity: Lessons from Decentralization in LAC

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Organizational Barriers and EquityLessons from
Decentralization in LAC

• Daniel Maceira, Ph.D.
• danielmaceira_at_cedes.org
• Center for the Studies of State and Society
• Buenos Aires, Argentina

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LAC Context During the 80s and 90s

• Highly Volatile Economies,
• Profound Gaps in Income Distribution,
• Implementation of Macroeconomic Adjustment
  Policies with Negative Effects on Social Sectors
  (Education and Health),
• Social Sectors have been subject to a Series of
  Reforms. Goals Achieve Social Objectives s.t.
  Financial Restrictions (WDR93).

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Two Dimensions of Health Care Systems in LAC
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Political Economy of Health Care Reforms

• Executive Power
• Ministry of Health
• Ministry of Finance
• Congress
• Local Governments
• Multilateral Organizations
• International Donors
• Social Security Institutions
• Private Health Care Plans
• Health Providers Chambers
• Physicians Prof. Organizations
• Health Care Workers
• Drugs Input Producers
• Patients
• Consumers Associations

Political Level
Goals Strategies Actions Beliefs
International Level
Sectoral Level
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Framework Organizational Barriers

• Reforms trigger Changes in the Structure of the
  Sector.
• Policy Markers should select clear Goals to
  contrast them against othersAction Plans,
  identifying potential Partners designing
  Mechanisms to align Interests.
• Decentralization requires
• Willingness to Distribute Political Financial
  Power.
• Strong Investments in Management and Social
  Control at the Local Level.
• Any reform should forsee a complete Action Plan
  considering
• Spillovers over other sub-sectors (private,
  social insurance)
• Cross subsidies to avoid increasing equity gaps.
• History Matters (federalisms, socialisms,
  authoritarisms).

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Financial Reforms in LAC
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Bolivia

• Structural Reform Health Care Strategy
  (MaternalChild Insurance)
• Law of Municipalities (85)/ Popular
  Participation Law (94)
• Coparticipation Funds New rules of Distribution,
  
  based on Population at Departament Level.
• Popular Election of Municipal Authorities.
• Decentralization of Resources (Broken production
  function).
• Social Control (Popular ME Commitees).
• Actors
• Neoliberal reforms (Sanchez de Lozada)
• New economic and political Stakeholders,
• Municipalities vs. Departments (Santa Cruz
  Tarija),
• Declining Unions Political Power (post 1985)
• Strong influence of Intl. Donors and Multilateral
  Organizations.
• Results
• HC Coverage Increased,
• Strong non-planned Subsidies,
• Empowerment of Local Leaders,

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Distribution of Resources, by quintile of UBN
and by Source
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Econometric estimation I TFR 2001 (with and
without constant) and IMR 2001
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Decentralization in Bolivia Some Conclusions

• Administrative/Managerial expertise of major
  political parties are significant Quality
  Shifters in some Public Policy Outcomes.
• Urbanity proves to be a relevant issue when
  planning Health Care Strategies.
• Financial Resources, as proxy of Decentralization
  Commitment have a significant, positive and
  similar effect on Social Outcomes.
• Local Managerial Capacity has significant and
  similar effect on Health and Education Outcomes.
• Community-type variables do not show influence on
  Social SectorsResults.

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Argentina

• Federalism Decentralization (late 80s).
• Provintial Authorities kept ownership control
  of Health Care Resources (human, fiscal,
  infrastructure), defining own Public Health
  Strategies.
• COFESA Federal Health Council Deliverative
  Body with no enforcement power.
• 60 of Population covered by Transversal Social
  Health Insurance Plans.
• Main Social Security Institution PAMI (Public
  insurance for edlery),
• Unions and Provintial Public Bureaucracies
  control circa 50 of formal health coverage,
  divided into 300 social funds
• Fragmentation of resources weak risk pooling
  mechanisms.
• Limited solidarity among funds.
• Provision of care is mainly contracted to Private
  Providers (no VI
  financing-provision of care).
• Therefore
• Limited capacity of National Ministry of Health
  to align interests,
• Results
• Increasing financial gaps in HC among provinces,
• Inefficiency in Resource Allocation,
• Crisis 2002 Alignment of National and Provintial
  Goals helped to support partial reforms
  (Remediar, Law of Generics) .

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Out-of-pocket in Health Care, by Component (in
), By Household Income Quintiles (Indec-EGH98)
Health Care Expenditures

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7.5
Total

Health Care Services Private Insurance

Pharmaceuticals
Q1
Q2
Q3
Q4
Q5
0

1794
190

3204


Household Income
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Provincial Expenditures in Health per Capita, 2003
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Health System Indicators Supply and Needs
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Health Care Expenditures, by Source
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General Policy Implementation Issues

• Scarce Empirical Literature on Decentralization
  in LAC.
• Lack of ME Mechanisms affects Documentation of
  Results.
• Limited Institutional Capacity at Public Level
  provokes Organizational Constraints in Policy
  Implementation.
• National Governments do not coordinate Health
  Care Strategies with Governors and Municipal
  Authorities.
• Rules/ReformsMain Actions are defined by Actors
  with strong bargaining power, implying
• Financial and Epidemiological Risk Transfers,
• Poor Equity Indicators, leading to inefficient
  allocation of resources,
• High Transaction (administrative, bargaining)
  Costs,
• Poorly Effective Reforms,
• Lack of Sustainable ME Tools to improve feedback
  and Sound Advocacy Agenda.

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Income, Expenditures and HC Needs