Knowing me, knowing you: decentralising health care in Brazil

The World Bank’s 1993 World Development Report highlights the typical package of health reforms used by many governments worldwide. The measures are widely implemented with the aim of improving the performance of a health system. Decentralisation is core to these reforms, but does it produce the benefits to health outcomes that are so often assumed? How do decentralisation policies deal with the challenge of local political culture and values? A report by the University of Manchester investigates the experience of north-east Brazil.

In north-east Brazil, the political and economic system has historically been based upon the control by small but powerful local land owning families. The rest of the local population had to access resources through a political culture characterised by the exchange of local political support for favours. Recent regional policy has explicitly aimed to undermine this system. In this context, the research explored the influence of local political culture on the implementation and impacts of decentralised health systems.

The researchers focused on three districts: metropolitan, rural and urban. In addition to the case studies, questionnaires were used to obtain more information. As well as observing how well the health system performed, users were asked a number of questions, including how satisfied they are and how easy it is to access local services.

The reports findings include:

• The effect of decentralisation on the local health system performance is more influenced by the local political culture than by resources from central government, sometimes positively, sometimes negatively.
• Without taking local political culture into consideration, decentralisation can provoke greater inequity between the performance of local health systems.
• The rhetoric of decentralisation is not matched by real change in the rural district in political culture, system management or system performance.
• In the well performing urban district competition between health professionals creates an environment of scrutiny and transparency.
• Established social organisations in the urban district facilitate popular participation in the health system.
• The health professionals’ maintained a distance from the direct influence of local political culture in the metropolitan district by presenting healthcare as a technical issue, a strategy that brought a mix of advantages and disadvantages.

The failure of reform to produce improved performance too often ignores the importance of local issues and structures. Future reform of health systems, and particularly attempts to decentralise, should:

• avoid strict inflexible policies
• consider the influence and diversity of local political cultures and values
• recognise the important relationship between successful reform and the local political environment
• identify ways to encourage participation and dialogue.

Source(s):
‘Political cultures, health systems and health policy’, Social Science and Medicine 55: 113-124, by S. Atkinson, 2002
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 17 March 2003

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

Tel: +44 (0) 161 275 2647
Fax: +44 (0) 161 275 7878
Contact the contributor: sarah.atkinson@man.ac.uk

University of Manchester

Other related links:
'Decentralisation: not necessarily always a good thing?'

'Freedom at a cost? Pros and cons of greater autonomy for public hospitals'

'Responsibility without power – decentralisation of primary healthcare in Chile'

'Change for the better? Health reform in Latin America'

See id21's collection of links relevant to health systems and economics.