Local health services: some lessons from their evolution in Bolivia

Abstract

For a decade, numerous projects in Bolivia have tried to put in practice the concept of local health systems. But, so far, no significant changes have been made and local health services still are the 'poor relation' of the system. The main components of the projects-expansion of health facilities, training of health personnel and institutional decentralization-were not designed to respond to the complexity of the problems encountered. Decentralization was implemented at the level of health districts but not accompanied by redefinition of functions at the central level, and challenged by civil servants' attempts to save their jobs. While training activities did introduce new methods and subjects, they were too often reduced to short workshops or seminars. Health facilities were built without regard for their significance beyond health care. A strategic approach is needed to adapt the planning process to the degree of liberty allowed by society. keywords local health services, strategic planning, decentralization, teaching methods, Bolivia

Is decentralisation the real solution?

“…• A decentralised system can have more difficulties in establishing a cohesive national health system. The autonomous sub-units often follow their specific interests and this puts hurdles in the establishment and achievement of national priorities [31]. • Both Italy and Spain experience a split between the funding function, pursued by the central state, and the management task, carried on by regions and communities.…”

Applying the Principle of Decentralization Within Public Health Services

“…However, a decentralized system may have more difficulty in creating a coherent national health system as autonomous local authorities can pursue specific interests which can be an obstacle in achieving national priorities. 8 In this context, we conclude that although decentralization of public health is positive, we must avoid the danger of exacerbation of decentralization. There must be a balance between central and local level, too much decentralization will lead to fragmentation, the weakening or even the dissolution of state authority.…”

Estimation of Association between Healthcare System Efficiency and Policy Factors for Public Health

“…This is partly because a national health system might lose cohesiveness due to the decentralized system as Mosca [51] pointed out previously. That is, the achievement of national priorities can be more difficult as the local units exercise their authority for specific interests [52].…”