1. Bolivia Decentralization and Integration of the Supply System in Bolivia How to Protect Sexual and Reproductive Health Supplies 25 October 2007 Oscar Viscarra Zuna, MD,MPH La Paz Oruro Santa Cruz Beni Pando Potosí Tarija Chuquisaca Cochabamba

2. Bolivia Bolivia initiated its health reform based on the need to change their political system and processes. This initiative recognized and promoted community involvement. The needs of indigenous communities, rural and urban, were included within the legal, political and economic framework. It sought to improve the quality of life of Bolivian women and men, with a more equitable distribution and better administration of public resources. Justification for Health Reform in Bolivia

3. Bolivia FROM: Support in EmergenciesTO: Sustainable Support Basic NeedsRights (capacities) Ethics StatementsBinding commitments Vertical SystemHorizontal System Formulation of Government PoliciesPublic Policies IndividualsFamilies Civil SocietyCivil society and private sector Emergency ReliefSustainable Development Centralized SystemDecentralized System Sectoral approachInter-sectoral approach RepresentationParticipation Supply-based programmingDemand-based programming Source: Adapted by Carmen Helena Vergara of UNICEF (1998), for the CPPS Pilot Project (2001) [ [ Changes in Government Strategy

4. Bolivia DESCENTRALIZATION 1994: Initiated under the Law of Popular Participation (resources to 311 municipalities) 1995: Proclamation of Administrative Decentralization Law 1996: Maternal Child Health insurance 1998- 2002: Basic Health Insurance 6.4% of tax co-participation under Ministerial Resolution 6.4% of tax co-participation under Ministerial Resolution 96 benefits for pregnancy, children under 5, and general population, includes contraception + Cervical Cancer + STI 96 benefits for pregnancy, children under 5, and general population, includes contraception + Cervical Cancer + STI Technical programming based on cost effectiveness Technical programming based on cost effectiveness INTEGRATION 1989 – 1996 Implementation of logistics management information system for contraceptives in NGOs and Ministry of Health 1999: Inclusion of the Logistics System within curricula for universities, pharmacist schools, technical nursing schools, and assistant nursing schools Health personnel begin to record data on consumption of essential drugs, as part of the information system Health personnel begin to record data on consumption of essential drugs, as part of the information system Health Reform in Bolivia:

5. Bolivia 2002: Universal Maternal and Child Health Insurance: 10% of resources of tax co- participation. 10% of resources of tax co- participation. National Law (SUMI) National Law (SUMI) 96 services focused on pregnant women and children under five. 96 services focused on pregnant women and children under five. 2005: Expanded Universal Maternal and Child Health Insurance. 2002: Single National Supply System (SNUS) System (SNUS) Based upon theBased upon the Contraceptive logistics Management system 2006: Universal Health Insurance Insurance Men, women and children Health Reform in Bolivia: DECENTRALIZATION INTEGRATION

6. Bolivia Service Provider: Local Level-Municipalities Health establishments, public sector services + social security + voluntarily enrolled private services. Purchaser of Services: Municipal Level Municipalities with resources from tax co-participation. Regulator: Departmental Level Local health directories (DILOS), comprised of Mayor’s representative, municipal and community representatives (oversight committee) + social control. Roles of the Decentralized Administrative Levels in Bolivia

7. Bolivia 100% NATIONAL REVENUE National Customs and Internal Taxes National Government Investment – Public Salaries Public Universities 90% 10% SUMISUMI Municipalities Sustainable Financing SUMI: Universal Maternal Infant Insurance 10% of National Revenues go to the financing of the SUMI

8. Bolivia Evolution of the Logistics System During Decentralization BeforeAfter Forecasting: national/centralized, handled by technicians of the National Program of Sexual and Reproductive Health /MSD Forecasting: uncertain at national level; variable depending on technical help from International Cooperation for municipalities. Selection: under national norms, centralized. Selection: depends on local supply, deconcentrated Budget: nonexistent Budget: Sustainable Law on Universal Maternal and Child Health Insurance, % national taxes. Procurement: donation, centralized. Procurement: local, piece-meal, from a few qualified suppliers, high costs and according to demand. Distribution: national to regional Distribution: local, deconcentrated.

9. Bolivia Evolution of the Logistics System During Decentralization BeforeAfter Supervision: Central Reproductive Health Program, with departmental responsibility Supervision: variable, depending on Local Health Directorates and departments Information System: local to departmental level, and consolidated at national level. National registries. Only for contraceptives (Vertical) Information System: Mandatory Single Unified Supply System (SNUS) implemented at the national level, for all essential drugs and contraceptives. Human Resources: nationally trained at departmental and municipal level Human Resources: local, with low technical capacity for management Storage: national to regional Storage: municipal

10. Bolivia Effects of Health Reforms on CS Although the SUMI guarantees funds, local capacity to implement is weak Although the SUMI guarantees funds, local capacity to implement is weak FP as a priority and political commitment are low FP as a priority and political commitment are low Decision-making for budget allocation, product and provider selection done by/at municipalities and service delivery points Decision-making for budget allocation, product and provider selection done by/at municipalities and service delivery points Service delivery statistics/data are only managed/known at local level Service delivery statistics/data are only managed/known at local level There is no national strategy or common vision There is no national strategy or common vision

11. Bolivia Logistics system institutionalized in university and nursing/biochemical school curricula Logistics system institutionalized in university and nursing/biochemical school curricula Under national law, sexual and reproductive health supplies, including contraceptives, are in the public insurance system Under national law, sexual and reproductive health supplies, including contraceptives, are in the public insurance system Single National Supply System (SNUS) implemented under presidential decree Single National Supply System (SNUS) implemented under presidential decree Standardized information system for all essential drugs and supplies Standardized information system for all essential drugs and supplies Achievements of the Logistics System in Health Reform

12. Bolivia Success Factors Some functions of the logistics cycle should remain centralized (ex.): standardization, information system, procurement, and quality control. Some functions of the logistics cycle should remain centralized (ex.): standardization, information system, procurement, and quality control. Regular monitoring of the logistics system is key to ensuring its efficiency, effectiveness, and transparency. Regular monitoring of the logistics system is key to ensuring its efficiency, effectiveness, and transparency. Prioritizing the logistics management information system in times of health reform. Prioritizing the logistics management information system in times of health reform. During the process of integration, information systems must be computerized. During the process of integration, information systems must be computerized.

13. Bolivia Pending challenges Achievement of political and technical sustainability (logistics system) Achievement of political and technical sustainability (logistics system) Work with municipal governments to advocate for procurement of contraceptives (bulk procurement) Work with municipal governments to advocate for procurement of contraceptives (bulk procurement) Improve local capacity for supply chain management Improve local capacity for supply chain management Real-time data on availability of contraceptives at all levels of the health system Real-time data on availability of contraceptives at all levels of the health system Create a common vision for CS Create a common vision for CS

14. Bolivia Thank you for your attention