1. Conference Effective Aid Effectiveness? The effectiveness of development cooperation in the field of Primary Health Care The Bolivian Case Berlin, February 11, 2009 Nathan Robison

2. Overview - health situation Bolivia Bolivia continues as the country in South America with the worst health indicators, many of them comparable to several countries on the African Continent

3. Underlying Causes:  The general poverty of the country including: the lack of adequate basic water and sanitation infrastructure, unemployment and low levels of income, low levels of education, and precarious housing conditions  Deficient organization and management of the Health Sector

4. Service distribution by sub-sector  10% of the Bolivian population served by private sub-sector  22% served by formal Social Security system  43 to 48% served by “Public” sub-sector  20 al 25% without access 90% of Bolivia depends on the government for provision of health services 77% of population severely underserved (government’s own estimate)

5. Health expenditure in Bolivia  Should be oriented toward improving investment in human capital  96% spent on curative services - consumption  4% spent on prevention and promotion – investment  Percentage of national Income spent on health (2001)  Regional average:11.3%  Bolivia 6.5%

6. Health systems constraints:  Existing funds poorly distributed between curative care vs. prevention/health promotion  Weak separation of functions between norm development and regulation, financing and service provision.  Weak articulation among the sub-sectors: Social Security/Public/private/non-profit  Poor public management results in ineffective use of existing resources and poor quality services (principal cause

7. Health systems constraints:  Power of the government health workers unions (professional and nonprofessional) undermines periodic government efforts to reform the health sector.  Poor management of national health information hides poor health indicators  Lack of resources

8. Perception I The main responsibility in the ineffective use of donor resources falls in the hands of recipient countries - Bolivia

9. Donor’s role - health sector Bolivia Health expenditure by source of funds in 2002: SourceAmount% Government65,62112 Companies and institutions243,95245 Households193,88336 External38,0917 Total541,546100 Source: Health Sector Funding and Expenditure Accounts - Marina Cardenas 2004

10. Expenditure on PHC  According to this source, 2% spent on promotion and prevention  External sources spent primarily on PHC (7%)

11. Perception II Despite criticism, international donor funds drive the limited efforts and results in PHC.

12. Main problems with Official Aid  Most serious problems with aid are the indivisible responsibility of donors and recipients  Most aid poured into attempting to “strengthen” poorly managed existing government services  Not enough thought put into implementing accepted national and international best practices, particularly in health system design and strengthening

13. Main problems with Official Aid  Dangerous interaction between improvised donor driven agendas and receptor country inability to develop (design and implement) sound, long-term public policy in the health sector

14. Non-profit Sector Aid  Increase in donor agenda driven funding matched with a decrease in NGO receptor agenda driven funding –Ineffective outcomes –Reverse subsidization  Non profit receptors have waited too long to shift from model implementers to sophisticated advocates for transformation of public policy

15. More effective spending  More effort into health system issues  More effort into joint (donor/recipient government/ civil society) design, adaptation and promotion (read selling) of national and international best practices  More effort into design and use of public-private partnerships

16. More effective Non-profit Sector Aid Top priority:  Same issues (use of effective non-profit Southern partners to foster these changes) However, still effective:  Continued support of model development  Direct service provision (the poor and underserved deserve quality services, now)

17. Main obstacles Case of Bolivia today:  The lack of interest (knowledge?) on the part of the government to learn about and implement accepted international best practices in health system design and implementation  The opposition of health professionals and workers to health reform  Civil Society’s lack of knowledge of new options and models of health service provision

18. Role of Civil Society Definition of who constitutes civil society  “Social Movements”: highly active, but diverse, politicized and uninformed.  NGOs: effective, but most stuck in service provision paradigms  Other relevant key actors??

19. Thank you