Bolivia Pando Beni La Paz Cochabamba Santa Cruz

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

Bolivia Justification for Health Reform in 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.

Bolivia Changes in Government Strategy FROM: Support in Emergencies TO: Sustainable Support Basic Needs Rights (capacities) Ethics Statements Binding commitments Vertical System Horizontal System Formulation of Government Policies Public Policies Individuals Families Civil Society Civil society and private sector Emergency Relief Sustainable Development Centralized System Decentralized System Sectoral approach Inter-sectoral approach Representation Participation Supply-based programming Demand-based programming Source: Adapted by Carmen Helena Vergara of UNICEF (1998), for the CPPS Pilot Project (2001)[

Bolivia Health Reform in 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 • 96 benefits for pregnancy, children under 5, and general population, includes contraception + Cervical Cancer + STI • 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

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

Bolivia Roles of the Decentralized Administrative Levels in 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.

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

Bolivia Evolution of the Logistics System During Decentralization Before After 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.

Bolivia Evolution of the Logistics System During Decentralization Before After 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

Bolivia Effects of Health Reforms on CS • Although the SUMI guarantees funds, local capacity to implement is weak • 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 • Service delivery statistics/data are only managed/known at local level • There is no national strategy or common vision

Bolivia Achievements of the Logistics System in Health Reform • 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 • Single National Supply System (SNUS) implemented under presidential decree • Standardized information system for all essential drugs and supplies

Bolivia Success Factors • 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. • Prioritizing the logistics management information system in times of health reform. • During the process of integration, information systems must be computerized.

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

Bolivia Thank you for your attention