starting in the late 1980s, Latin american governments
launched a massive effort to decentralize their
public health systems. twenty years later, no one
knows whether it has improved health care.
by Thomas John Bossert
role of setting standards for the kinds of health ser-
Decentralization has emerged as a major tool for improving the delivery of health services in Latin America. But has it worked? This is a crucial question for policymakers in the region—and elsewhere— and not only in the health sector. One of the major public policy debates of our time is to what extent
decentralization of government decision making
promotes or reduces the effectiveness of policy initiatives. This is directly related—especially in our region—to the larger challenge of how to strengthen
institutional capacity in areas ranging from education and security to public investment.
Discussion of decentralization has been dominated by anecdotal evidence that is used to support arguments for or against the practice. There
have been few systematic, evidence-based evaluations of the region’s experiments with health care
decentralization.
In fact, the region’s health care decentralization
efforts over the past two decades ought to serve as
a laboratory for deeper and more scientific studies
that could help policymakers choose what kinds
of decentralization are more likely to achieve policy objectives.
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During the 1980s in Chile, for example, a major reform effort under the military government shifted
responsibility for primary care clinics to municipalities throughout the country. The municipalities took over human resource functions such as
hiring and firing and setting salary levels—thus
becoming responsible for, on average, one-third of
the expenses of running the system. However, the
illustration by brian stauffer
vices provided by municipalities remained defined
by the central government.
Colombia followed suit in the 1990s by decentralizing almost all the country’s health services, including hospitals, to the provinces and municipalities.
Each level was given fairly wide authority over human resources and budgeting. The national budget
assigned to localities significantly increased, and
the formula for assigning resources became more
equitable. Before decentralization, the richer municipalities received more than six times more per
capita funding from the central government than
the poor municipalities; after decentralization the
difference was minimal. In addition, and perhaps
more unexpected, before decentralization richer
municipalities had, from their own local revenues
(taxes and other sources), allocated forty-t wo times
more than the poor municipalities. After decentralization, that gap was reduced to twelve times.
Brazil and Mexico also initiated major decentralization reforms but with different nuances. Mexico
granted significant new powers to the states, but little decentralization occurred from the states to municipalities. In Brazil, states were progressively given
greater financing and managerial responsibilities,
and municipalities were categorized by their differing capacities, with the wealthier and more effective
municipalities gaining greater responsibilities for
management and regulatory decisions. Later, however, those functions were recentralized to the states.
In assessing these and other examples, it is important to keep in mind the larger policy objectives. These
objectives center on improving a population’s health.
