RESUMO
OBJECTIVE: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. METHODS: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. FINDINGS: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization. CONCLUSION: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.
Assuntos
Financiamento Governamental/métodos , Alocação de Recursos para a Atenção à Saúde/ética , Política , Justiça Social , Chile , Colômbia , Tomada de Decisões Gerenciais , Financiamento Governamental/ética , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/métodos , Gastos em Saúde/estatística & dados numéricos , Governo Local , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Alocação de Recursos/economia , Alocação de Recursos/éticaRESUMO
Descentralization is often a major part of health reform policies. However, there have been few attempts to comparatively study the degree of decentralization and the effects of decentralization on equity of allocations to health, so we do not know how best to implement this reform. This article uses an innovative comparative analysis of the "decision space" that was allowed to local municipalities in the health reforms of Bolivia and Chile, two countries that have had several years of experience in implementing decentralization. The studies found that relatively little decision space was allowed to local authorities over key functions of health care systems. The studies also found that central authorities often reduce the decision space in order to direct more resources to health or to restrict local choice over human resources issues. The studies found that more equitable allocations of health funding were achieved through a common equalization fund for the municipalities in Chile and by forcing the assignment to health of a specific percentage of the central government transfers to municipalities in Bolivia
La descentralización constituye a menudo una parte importante de las políticas de reforma del sector de la salud. Sin embargo, ha habido pocos intentos de investigar comparativamente el grado de descentralización y los efectos de esta sobre la equidad de las asignaciones a la salud, de modo que desconocemos la mejor manera de poner en práctica esta reforma. En este estudio se utiliza un innovador análisis comparativo del "espacio de decisión" que se les concedió a las municipalidades en las reformas de la salud en Bolivia y Chile, dos países que han tenido varios años de experiencia en la puesta en práctica de la descentralización. El estudio reveló que a las autoridades locales se les concedió un espacio de decisión relativamente pequeño en funciones clave de los sistemas de salud. Asimismo, se verificó que las autoridades centrales a menudo reducen el espacio de decisión para dirigir más recursos a la salud o para restringir la elección local en cuestiones de recursos humanos. También se observó que se consiguieron asignaciones más equitativas de los fondos destinados a la salud, en Chile mediante un fondo común de igualación para las municipalidades y en Bolivia forzando la asignación a la salud de un porcentaje específico de las transferencias del gobierno central a las municipalidades.