Desigualdad Social y Equidad en Salud: Perspectivas Internacionales

a direct or indirect impact on health equity; and some studies that reported pilot ordemonstration projects.The databases included PUBMED, Scielops and journal Health policy, includingarticles from 1995 to April of 2005. The keywords included were: Delivery of HealthCare, Health Care Reform, Health Services Accessibility, Latin America, CaribbeanRegion, Health Care Sector and National Health Programs. Some other documentsconsidered relevant to understand the background of the process of reforms are alsoreferenced. Only the most relevant documents are referenced.Background of the Processof DecentralizationHealth Sector reform has been a, if not the key policy in Latin America and the Caribbeanregion (LAC) for the past two decades with a number of common ingredients(World Bank 1993). These include increased limitations on the role of the publicsector coupled with new incentives for the private sector and new forms of publicprivaterelations, decentralization, integration of vertical programmes into mainstreamdelivery, hospital semi-autonomy, greater diversity in the financing of healthcare, new processes of priority setting and resources allocation, new incentives forhealth workers, and consumer orientation to service provision and community participation.(Green and Collins 2003)During the 1970’s and 1980’s, political leaders, users, providers, and researcherswere all aware that the health care systems in Latin America had accumulated sucha large number of inefficiencies and inequities that something needed to be done toreverse and revert the increasing users’ dissatisfaction, decreasing quality of care,and the need to improve equity and efficiency to the systems. (Homedes and Ugalde2005)The International Monetary Fund (IMF) and the World Bank took advantageof the crisis of the 1980’s to press Latin American governments to introduce healthreform as a condition for borrowing (CEPAL 1994). This introduction could haveresponded more to ideological concerns and the interest on international grantingagencies and did not include the epidemiological profile, the current health systemor the resources and socio-political reality of the country. The World Bank Report of1993, which was used by many countries as the main document for reform reflectedan international ideological shift to neo-liberal or new right tendency. It is widelyaccepted that the reforms were rarely based on evidence, were top-down and wereoften externally imposed. (Green and Collins 2003)Aiming to achieve equity in health through decentralization has been one of themain drivers of the health reform in Latin America. The reforms on the health caresystem in Latin America have promoted decentralization as a means of achieving10 Decentralization And Equity