Colombia - Toward increased efficiency and equity in the health sector : can decentralization help?

Report No. 11933-CO Colombia Toward Increased Efficiency and Equity in the Health Sector. Can Decentralization Help? Sector Report March 2, 1994 Country Department Ill Human Resources Operations Division Latin America and the Caribbean Region FOR OFFICIAL USE ONLY MICROGRAPH1CS, : .' ,.@S ' . ~~ipe:SE ,, . --- -- Docuenr of , Worl, Ba: 'Thisdocument hasamrstrcted ditrbuton and may be used b~ recipientsgorly in the performance of their official duties. tts' conteints may not otherwise be disclosed without World Bank a'uthorization.  CURRENCY EQUIALENTS Cunrency Unit = Peso (COL) COWI - US$.00125 (as of August 1993) US$1 = COL$801.86 (as of August 1993) PRINCIPAL ABBREVIATIONS AND ACRONYMS USED DMIN Information Bank of Inveameat Proects DANE National Department of Statistics DASALUD Health Dretate for the DepartmetA of Adantico DHS Demogaphic Health Survey DNP National Planning Department ESS Solidarity Health Enteprie PINDETER NationalMunicipalDeveopmentFinancialItermediary FILS Social Investement Fund FONDO DRI Integted Rural Develpment Fund FONDOIM Ministry of Education Development Fund FNCV Rural Roads National Ftund FNH National Hospital Fund IVA Value Added Tax MdS Ministry of Health NBI Unsatisfied Basic Needs Index NGO Non-Governmental Onition PNR National Rilitation Program SSD Departmental Health Secaiat SSM Municipal Health Secretariat SSS Regiinal Health Dirtrates of the Ministry of Health  FOR OICIL USE ONLY This report was prepared by Scott Quehl and Xavier Coll. It draws heavily from case studier based on a background paper submitted to the World Bank in July of 1992 by Gerd M. La Forgia and Nuria Homedes. The case studies were undertken during their mission to Colombia in May of 1992. The Colombian consulting firm Econometdfa and LA3C1 consutant Leora Friedburg contributed to the chapter on health sector finances. This document has a restricted distribution s nd may be used by recipients only in the performnance of theit oMcial duties. Its contents may not otherwise be disclosed without World Bank authorization.  Table of Coates I TABLE OF CONTmNS F-ecutve Smunary Spanlsh version) ................................ Iii-xiji Eeutive Summary (igsh version) .. .............................. xiv-xxii Introduelon ................... * ........ . 1-2 Chapter L Backgrand ................................. 3-11 A. Context for Decentralization .................................. 3-6 B.TheHealth CareSystem AnOvervew .................................. 6 C. From r ont Decentralization ............................ . 74 D. Legal and Admn tmttive Hurdles ................................... 9-11 Chaptr -:EaltbhS Stor hleutiesadln den . 12-22 A. Jequities inHealth Stus ....... 114 B. Constrait to hnpved Efficieny .................................. 14-22 Chapter Ilt Dhre F_nandn ofPublic HalhSwvlces .......................... 23-34 A. Oveffl Fmancing ............................................... 23 B.FinancinybyEahheevelolof Gov nmea ............................... 24-25 C. Distrbton of Financial Resourcs ........ .......................... 26-34 ChaptIr n: Decentralization to Date What Works, Wt Doesan't ................... 35-8 A. FullyDecentralized Municipalities: Manizales andC ......................3 3S36 B.Parti Dcntra awith Depatment Leadenhip in Aantio and Huia. ........ 36-38 C. Mu paltes EtaveNotIniawd Deentrlization .............. ......... 38 D. Factors Advancig or Constrain Dei etakn . ....................... 3948 Chapter V.:nprovinglzePbntazdPb Health Swvke-n .....ealth e........... 49-57 A.BalancingExternalOversight wthLoaAutonmy .. . 49-S4 B. Promotig Conmmuniy Patipation ............. . s C.Professionalizing MunipAdml fitnolon .............................. 56-S7 Chapter V Condudons and ssuestoBeAddresed ............................ 58 A. Who Deldes: Politics of Decentraization .............................. S8 B. Who Beneis: Ibe Equity Issue .................................... 60.61 C. Who Pays . ................................................. 61 63 D.AtYWatCos .. ............................................... 64 E. Otha Issues to Be Addressed ...................................... 6566 Chapter Vll: emmendatlons for Facdltating n ................... 67-70 A. FaciliungDecentralization: Beyond Certification to Guidance ................. 67-68 B. IplementingDecertalization: A New Tmen Table .......... .. ............ 69-70  Table of Contents/ U Biblogmhy .......................y...................... .. 71-74 Annex A-: Faon Procedur for Decentaiaon .......... ................. . 75-79 AnneB:MheliquorTaxinSelected.Dep .................................. 80 Annex C: Dibu in of Natina Transfers: Situado Fial, IA, and Sociavetmen Tndser . 8142 Annex D: ProposedTechnical Assbta Modules ............................... 83-86 Annex E: Selected Heath Indicators ........................................8 -88 AnnexF:Anmproved Approach towardCommunityPPartclpatn ....................... 89 Annex G:A TheoreticalContextfbor DecentralizedGovemance ....... ................. 90-91  1!~~~~~~~~-- . .... :| I'S E E E |~~~~~~~~~~~~~0 ta101 ~d tj |~~~~~~~~~~~~~~~~~...... g '.g E m Amms "or. iw v awwpoa ~~~~~~~~~~~~~dc 1~SjI1Qp t| onb B~~~~ Ew~p E~ ~ Q0Lo ~~b~o~oj t~ PH E E X'~jn X | r S~ ~~w~~, $;qIpE Eizn _W =UEUO fflM too 9@ W! uqn uod|uu so|b E w - E E. . E. . l~~~~ X Jg1 i9*W Jp~X E E~~~~~~~~~~~~' I_p~~. pwts p ~ r q~w#~wj~ ouoqt uYu*d woS=wt ==~dUzuuo~w II EL3u~ 0fU2  Es jeutive summary/ IV P'ropdo de Este Inforn 1. Este infome se presenta a la luz del apoyo que el Banco Mundial ofreco a los amplios objedvos o quo el gobiemo buxca a travds de la de i -Mn. Basados en una seoe de documentos previos y estudios de casos, el Banco intenta evaluar objedvamento tanto los factores que ficilitan como los que limitan la tmnicidn bacia la de ii6. Este infrme tambidn enfoca aquellos elementos de la administi6n descentalizada de los sricios de salud primarios que deben perfeccionarse si los cbjetivos del gobierno para mejrar el sistema de atencidn en salud han de loevars a cabo. Objetivos do Ia Desca cl 2. La descentlizaci6n debe mejor desmrbirso como devokwin: transferencia de la toma de derAsiones polfticas, finacira y tivas bacia las undades do gobiaw regkoal. En il caso de ColombiaX estas unidades son los municipios y dp mn . En el sentido mis amplio, los objetivos de la poLfica de desnaiai6n involucran la reonfgaci fundamental del estado. Polticamente, la elcci6n popular de akakds, gobenadores y concejaes busca fortalecer el proceso democriico y acerar mis comudades a la exigencia de aioes gubernamentales. inancemente, ciertas resonsabilidades pam inversdn en servicios locales, se trasladan del .gobiemo cental a las autoridades locales. dministativamente, los servcios pdblicos locales se ofecen mis de acuerdo con los deswos y necesdades de los conmidor, quienes apLcardn la wvoz del usario mediante las ciecciones poulas, grupos con races popares, y foros pdbLhcos pam mpoo la prestaci6n de mejores sevicios a menores costos. 3. La descetliacid se ntegra dentio de una polftica geral de salud conocida iomo tu a la salud'. El gobieno central asegura quo la princi meta es iorementar el stbs do la salud mediante la promoid6n do la misma y prevencidn de la nferedad. La dscentralizac6n en si es la principal estrategia pam lograr un subconjunto de ob jetvos de poifua mis amplios que mcluyen (a) extensi6n de los servicos de salud gubemamentales a las poblaciones de bajos ingresos menos favorecidas o desp