Responsibility without power – decentralisation of primary healthcare in Chile

Chile began health sector reform in the 1980s as part of broad economic restructuring, closely guided by World Bank guidelines. Healthcare decentralisation was an important feature of these changes. How successful was it? Research from the UK University of Manchester highlights some of the drawbacks.

Key reforms in the 1980s included the transfer of responsibility for primary healthcare from the Chilean Ministry of Health to municipalities. By 1988 over 90 per cent of primary-level clinics were under municipal authorities. The aim was to improve control and regulation, ensure that local needs were reflected in health provision, and channel municipal funds into local facilities and infrastructure. A new financial system, FAPEM, was developed, where health centres were reimbursed for the cost of services delivered to patients, subject to a somewhat arbitrary monthly ‘ceiling’.

Criticisms of this model prompted changes in the 1990s which sought to apply a more holistic model of health. Users of the state health insurance scheme now receive a basic package of services, including home visits. A network of family health centres delivers these services. The financing system was also reformed and reimbursement is now on a per capita basis. The transfer of resources per patient varies according to each municipality’s urban/rural mix and poverty level.

The study found several general limitations of this system in primary healthcare delivery at the local level:

• Each municipality has a fixed amount of expenditure per user, but each user can demand full use of all the services that are offered.
• Many municipalities do not know the real costs of health activities. So many of the health centres still operate at a loss.
• Local administrative capacity may be limited.
• Health has to compete with other sectors for municipal funds.

A case study reveals more specific problems in El Bosque, a low-income neighbourhood in the capital city, Santiago. The new family health centre there receives an additional 25 per cent per capita per user. However, running costs are higher as more money is spent on salaries. Resource allocation does not take into account the cost of home visits, fieldwork and other activities based outside the health centre. This lack of funds means that:

• Implementation of the new model is limited.
• Some expensive equipment cannot be used.
• Fewer home visits are possible.
• The health centre can only provide curative healthcare, yet is expected to promote prevention and health education.
• Staff are obliged to work extra hours without being paid.

The report concludes that administrative decentralisation has been disempowering because it has not been linked to effective fiscal and political decentralisation. Some municipalities struggle to find resources for primary healthcare and local health centres are not able to participate in decision-making processes.

Source(s):
‘The decentralisation of primary health care delivery in Chile’, Public Administration and Development 21: 223-231, by J. Gideon, 2001 Full document.

Funded by: UK Economic and Social Research Council; European Commission

id21 Research Highlight: 5 February 2003

Further Information:
Jasmine Gideon
School of Geography
Mansfield Cooper Building
University of Manchester
Oxford Road
Manchester
M13 9PL
UK

Contact the contributor: Jasmine.Gideon@man.ac.uk

Manchester University, UK

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