(June 2008) In recent decades, several countries throughout Latin America have undergone health sector reform in efforts to improve the quality of care and the level of coverage. Among the most common of these reforms is the decentralization of health services. To ensure that individuals have the ability to choose, obtain and use quality contraceptives whenever they need them—a goal referred to as "contraceptive security"—requires that policymakers, program managers, and advocates address a number of factors. This article examines the experiences of some Latin American countries in addressing contraceptive security and decentralization.
Contraceptive Security: A Coordinated Response
Achieving contraceptive security (CS) requires addressing a complex set of interrelated issues, regardless of decentralization. Program managers must estimate the supply of different contraceptives to meet demand from clients, taking into account changes in this demand over time. In addition, they must place the order for those commodities from the supplier or purchasing organization with an adequate lead time. The funds must be available to pay for the contraceptives, and systems must exist to get them to the health facilities where clients can obtain them.
Governments, civil society organizations, and advocates may have to raise the awareness of decisionmakers about the benefits of family planning if contraceptive security is to be a priority. For example, framing the importance of family planning as a means of birth spacing that contributes to reductions in infant, child, and maternal mortality may be an effective way to focus attention on contraceptive security and ensure that supportive policies, funding, and systems are in place. This step is especially important in decentralized settings to ensure that family planning and reproductive health is a priority for all decisionmakers.
Decentralization as a Trend in Health Sector Reform
Through decentralization, different aspects of decisionmaking authority are transferred from the central government to the regional, provincial, or local level (referred to as "local" governments). The timeframe for decentralizing different services, as well as the extent to which authority is decentralized, varies by country.
In theory, decentralizing the health sector should lead to a number of benefits. For one, local governments should be more responsive to local priorities than central governments are. Because more authority rests at the local level, local decisionmakers are given freedom to identify health program priorities based on local needs. At the same time, local constituents can also hold local decisionmakers more accountable to ensure that health issues are resolved. With priorities identified at the local level, funding should also be allocated in a way that best responds to local priorities. In many countries, the central government's annual planning process helps identify which local areas have the most urgent need for resources and allocates funds to local areas accordingly. How those resources are allocated to specific types of health programs is generally left to local decisionmakers.
Contraceptive Security in a Decentralized Setting
Achieving contraceptive security in decentralized settings poses challenges and opportunities. Both central and local governments have to understand and agree about the autonomy that the local government will have, and local governments need to be trained to carry out their roles. For contraceptive security, local governments need to forecast the types and numbers of contraceptives needed, and ensure that staff are trained in how the logistics system operates. Bolivia included a training module on the logistics system as part of nursing and medical school curricula. When students graduated and began working, they already knew how to order commodities.
For many years, advocacy efforts related to family planning and contraceptive security focused on the central government. These efforts have contributed to many successes, including the creation of budget line items for contraceptives, laws that guarantee funding for family planning programs, and some success in building the capacity of policy champions—individuals who are able to influence high-level policymakers. As decentralization moves forward, advocacy efforts will need to be focused at the local area as well, where priorities are identified and funding decisions are made. As Mexico began implementing its decentralization program, for example, many state-level decisionmakers did not believe that family planning should be a priority. This situation may have arisen because at the time of decentralization, family planning was being integrated into a broader reproductive health framework. Because family planning received less attention that it had previously, Mexico's contraceptive security efforts were not as effective as they could have been. Eventually, however, through advocacy efforts, family planning became a priority at the state level and Mexico's FP programs flourished.
Although some types of authority may be delegated to local governments, other aspects of program operations may be more efficiently managed at the national level. For example, local governments may have the authority to enter into contracts to purchase contraceptives. However, because of the volume purchased by a local government, relative to a central government, it is likely to be more efficient to consolidate the orders at the central level and purchase more products at a lower price. In El Salvador, the health regions could procure contraceptives separately but opted instead to consolidate their purchases and procure them centrally, effectively reducing the administrative burden and ensuring that orders are placed on time. On the other hand, in Ecuador, the orders are not consolidated and the local governments pay much higher prices for contraceptives than they would if they procured them as part of a bulk order. Distribution and storage of contraceptives, however, may be managed more effectively by the local government because they may have better and more frequent access to hard-to-reach populations whose health needs often are inadequately met.
One of the challenges of decentralization is deciding how to allocate funds to local governments. Often, decentralization is government-wide, and the budget for the entire local government is passed from the central government to the local government, which must decide how to prioritize programs and resources. Such a situation can result in some priority issues not being adequately addressed. In Bolivia, where decentralization to 311 municipalities has taken place, the central government has enacted guidelines that ensure that funds are allocated in accordance with certain national priorities. Based on these guidelines, for example, local governments have to allocate a minimal amount of funding to the universal health insurance program for mothers and children. Without such guidance, programs such as family planning could be underfunded.
Finally, an important function that should be jointly administered by central and local government is the monitoring and evaluation of contraceptive security efforts. At the local level, program managers should document levels of distribution coverage, assess quality of reproductive health care, and ensure that facilities have an adequate and consistent supply of contraceptives. At the central level, policymakers should collect and analyze these data to ensure that national priorities and commitments are being reached, and to alternative strategies and interventions to better respond to national and local needs.
Tim Egan was an intern at the Population Reference Bureau.
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