International cooperation in the Bolivian health sector : a win-win game?
(2012)
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- (en) In an attempt to produce recommendations, this thesis aimed to study the impact of international (WB and USAID) aid to Bolivia on health system fragmentation and segmentation, on sustainability of promoted reforms and the reasons for these. We thus explored whether the objectives (e.g. disease control and MCH) and activities of these agencies contributed to mending pre-existing fractures in the (individual) health (care) system, or instead strained access to care and contributed unwittingly to the worsening of avoidable mortality and suffering. The methodology relied on 1. An historiographical insight into system development, assessing structure and performance across time and examining whether observed changes were linked to the cooperation’s stated / ‘undeclared’ (non-health) objectives, activities and undesired effects. 2. A comparison of USAID / WB projects, exploring their (in-) consistency and complementarity in order to delineate a possible joint strategy 3. The study of their socio-political strategy to promote health system reform (HSR) while comparing the attempts of Bolivian and Ecuadoran socialist governments to reverse it. The WB / USAID comparison revealed that the aid-promoted HSR reshuffled the Bolivian health system, although with disappointing effects on their own health objectives. Besides, aid deepened the pre-existing system fragmentation and segmentation, thereby maintaining access to care at quite a low level. Costs to high-income countries taxpayers increased significantly but were limited to less than 10 years. The Bolivia / Ecuador comparison revealed an obstacle to socially motivated health policies in Andean countries: a powerful social and political alliance (of physicians and middle classes). This was built by the studied aid agencies (amidst political instability) to support care delivery and financing commoditization and to consequently open health markets to international economic actors. This aid rationale is visible in the similarities of - The conditionalities of aid and international loans with - The terms of international economic agreements such as GATS and ALCA. Socially, not commercially motivated health policies should initially develop first line health services tailored to deliver in local health networks universally accessible, good quality biopsychosocial care. They should do so within a new, pluralist, not for-profit, multi-institutional health sector. Starting with (supply-side) financing of first line services could probably be politically compatible with financial and care delivery expectations of the above coalition - the middle class and professionals while paving the way to larger, future hospital ambitions.
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Tejerina, H. (2012). International cooperation in the Bolivian health sector : a win-win game? https://hdl.handle.net/2078.5/94409