The introduction of user-payment for health services is frequently followed by concern about the impact on equity of access for poor people. Decentralizing governments often try to remedy the created inequities by putting in place safety nets in the form of exemptions and waivers in the user-fee systems. However, where user payments merely operate as local government strategies for health financing, without national policy they are likely to be self-defeating, as local governments are frequently more interested in raising revenue to meet recurrent costs of devolved services than in promoting equity. Thus guidelines put in place by the central government to operationalize safety nets are seen by local governments as being contradictory to this goal, and are thus ignored or altered to suit the district revenue aims. This study was carried out to investigate the context and the constraints in implementing exemption schemes. Data were collected in two selected administrative districts of Uganda (Mbarara and Mukono). Qualitative approaches to data collection were adopted, namely focus group discussions and key informant interviews with policy-makers, health administrators, service providers and community members. These methods were combined with document review. We found little evidence of safety-net guidelines initiated by decentralized/local governments, since district local governments had little motivation to extend exemptions, waivers or credits. The conclusion is that safety nets such as waivers and exemptions will only be effective if they are backed by a national health financing policy, they reconcile the often competing demands of local government revenue needs, and are strictly enforced and supervised by both the local and central governments. The implications of the findings for remedying the tension between the needs for cost recovery and for attainment of equity goals through exemption policies for the poor and indigent are discussed.
Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.
The Province of the Punjab underwent a number of attempts to decentralize the health sector in the 1990s. Among the most important were the decentralization of financial management within the district, the Sheikhupura PHC Pilot Project, the establishment of the District Health Authorities and District Health Management Teams, the creation of semi-autonomous hospitals and the programme of District Health Government (DHG). These usually received donor support and promotion, and emerged from within the provincial Department of Health, and more specifically the Secretariat and the internationally supported Second Family Health Project (FH2). Of particular significance was the DHG change, which involved a decentralization to the district, the appointment of powerful Chief Executives, the formation of District Management Committees and purchaser-provider separation. The paper reviews these proposals, focusing on the need to build on experiences and learning lessons from pilot projects, reform continuity, developing consultation and involvement and policy analysis. The latter indicates the importance of developing more in-depth policy analysis around the role of the central organization, the form of decentralization and the purchaser-provider separation. The paper concludes by underlining the need to ensure that political strategy and in-depth policy are appropriately coordinated in the policy process.
Imrana Qadeer, Kasturi Sen, Kesavan Rajasekharan Nayar
Introduction PART ONE: THE POLITICAL ECONOMY OF HEALTH AND DEVELOPMENT Landmarks in the Development of Health Services in India - Debabar Banerji Structural Adjustment and the Poor in Pakistan - Jennifer Bennett Donor-Driven Family Planning Services in Bangladesh - Farida Akhter Impact on Women's Health Changes in Health Care Systems in Europe - Meri Koivusalo Focus on Finland Structural Adjustment Policies and Health in the Plantation Sector in Sri Lanka - Indira Hettiarachchi Dilemmas for Research in Primary Health Care in the Era of Reforms - Marc De Bruycker PART TWO: CONCEPTS AND EVIDENCE Impact of Structural Adjustements Programs on Concepts in Public Health - Imrana Qadeer Health Reforms and Developing Countries - Kasturi Sen A Critique Disability Adjusted Life Years as a Tool for Public Health Policy - Ritu Priya A Critical Assessment Re-Thinking Public Health - Sheila Zurbrigg Food, Hunger and Mortality Decline in South Asian History Biological Stress and History from Below - Lalita Chakravarty The Millet Zone of India, 1970-92 PART THREE: SHIFTS IN HEALTH SERVICES AND HEALTH FINANCING Health Sector Reforms and Structural Adjustment - Rama V Baru A State-Level Analysis Reforms and Their Relevance - V Raman Kutty The Kerala Experience Health Sector and Economic Reforms - K Seeta Prabhu A Study of Maharashtra and Tamil Nadu Structural Adjustment and Economic Slowdown - S Akbar Zaidi Likely Impact on Health Outcomes in Pakistan Health Services in Bangladesh - A Q Khan Development and Structural Reforms Structural Adjustment Programs and Health Care Services in Sri Lanka - Dulitha N Fernando An Overview Evolution of India's Leprosy Program from Control to Elimination - B R Chatterjee Tuberculosis Program in India - A K Chakraborty Current Operational Issues PART FOUR: DECENTRALIZATION IN HEALTH CARE Politics of Decentralization - K R Nayar Lessons from Kerala Promises and Problems of Panchayati Raj - Anwar Jafri Experiences from Madhya Pradesh An Assessment of the Effectiveness of Decentralization of Health Services in Sri Lanka - Nimal Attanayake People's Health Care Initiative in Chhattisgarh District, Madhya Pradesh - Binayak Sen PART FIVE: PERSPECTIVES OF CLINICIANS Prescribing Practices - Anant R Phadke A Comparison of Public and Private Sectors Revisiting the Community Health Worker - Shyam Ashtekar Disturbing Trends in the Treatment of Malaria - Yogesh Jain Public Health in Vellore - Anand Zachariah Experiences with Malaria and Cholera The Revised National Tuberculosis Control Program - Anurag Bhargava A Critical Perspective PART SIX: EXPERIENCES AT THE MICRO-LEVEL The Plague, the Poor and the Health Services - Ghanshyam Shah Public Health Issues of Small Towns - K S Sebastian The Case of Alleppey The Labor Process and Its Impact on the Lives of Women Workers - Meena Gopal The Reproductive Health Package - Alpana Sagar A Chimera for Women's Health The Rhetoric of Reproductive Rights - Mohan Rao Quinacrine Sterilization in India
David Collins, Grace Njoki Njeru, Julius S. Meme, William Newbrander
An increasing number of countries are exploring the introduction or expansion of autonomous hospitals as one of the numerous health reforms they are introducing to their health system. Hospital autonomy is one of the forms of decentralization that is focused on a specific institution rather than on a political unit. It has gained much interest because it is an attempt to amalgamate the best elements of the public and private sectors in how a hospital is governed, managed and financed. This paper reviews the key elements of the concept of hospital autonomy, the reasons for its expanded use in many countries and a specific example of making a major teaching hospital autonomous in Kenya. A review of the successful experience of Kenyatta National Hospital and its process of introducing autonomy, with regard to governance, operations and management, and finances, lead to several conclusions on replicability. The legal framework is a critical element for successfully structuring the autonomous hospital. Additionally, success is highly dependent on the extent to which there is adequate funding during the process of attaining autonomy due to the length of the transition period needed. Autonomy must be granted within the context of the national health system and national health objectives and be consistent with those aims and their underlying societal values. Finally, as with decentralization, success is dependent upon the preparation done with the systems and management necessary for the proper governance and operation of autonomous hospitals.
National leprosy control programmes currently face a number of changes to the environment within which they operate. This paper examines the issues arising from these. It focuses, in particular, on those arising from changes in the structure of the health sector as a result of policies of health sector reform which are being considered or adopted in many developing countries. These include decentralization, financing strategies, greater role for the private and NGO sectors and the integration of vertical programmes. The paper is structured around a number of key steps in the development of a strategy for sustainability of appropriate leprosy services. These are the assessment of the epidemiological, social and health services context, development of programme objectives, planning of human and financial resources, development of the strategy, mapping the roles of potential actors, development of regulatory and incentive mechanism, action planning and managing change and, finally, re-evaluation of the programme objectives and service delivery organization. The paper stresses the importance of process in developing ownership of a strategy. It concludes with a set of key questions which it suggests need to be addressed by leprosy programme managers in the development of a proactive response to the changes.
Drawing from the public finance literature on expenditure assignment, this paper analyzes how devolution in the health sector is being operationalized in the Philippines. A central issue is how the central government can ensure that national and local objectives coincide. The pattern of health spending after devolution is described, and the financing of national health priorities at the local level through the Comprehensive Health Care Agreements is examined. The paper concludes by suggesting some guidelines for a financing mechanism for locally implemented health projects.
In May 1993 the Grameen Bank in Bangladesh ‐ one of the most successful and internationally best‐known self‐help projects ‐ launched a programme to provide poor people in rural areas with basic health care. The first four medical centres were followed by six more by July 1995. The organization and methods of operation of the Grameen Health Programme are based on the tried and tested self‐help principles underlying the loan programme which has been in operation since 1976. The services offered include medical care at reduced fees and free counselling. Target groups are primarily poor women, to whom the programme's women field workers initially give information on simple preventive measures plus advice on avoidance of unwanted pregnancies. This article presents a provisional evaluation based on two primary inquiries conducted in 1994 and 1995. The overall conclusion was that the health programme has still far to go in order to attain the longer‐term objective of becoming self‐financing. Nevertheless, it demonstrates that decentralized access to health services, and preventive healthcare counselling in particular, can be of real assistance to poor people in rural areas.
Abstract Since the 1980s user fees for government services have become an accepted financing option for the health and social sectors in developing countries. Even countries which had a tradition of providing health services free of charge have now introduced fees and the focus of debate has shifted from whether or not to introduce them, to when and how they should be introduced. Proponents of user fees stress that equity and efficiency gains can be achieved through the implementation of a cost‐recovery policy package. Within this package user fees are complemented by decentralization and combined with two targeting mechanisms favouring low income groups: exemptions, and the use of fee revenue to improve the services offered to them. The extension and improvement of primary health care, for example, will disproportionately benefit low income groups by addressing their health needs in a cost‐effective way. However, targeting mechanisms, and exemptions in particular, have received little attention in theoretical debates within the health sector and current practices have rarely been reviewed. Relatively little is known about their effectiveness or about the conditions required to ensure and enhance it. This paper seeks to contribute to health financing policy debates by reviewing targeting options and assessing the available evidence concerning these issues. Success in protecting the poor appears to be limited and there are considerable informational, administrative, resource and socio‐political constraints undermining the development of effective targeting mechanisms. The paper, therefore, urges‐caution in developing health care financing policy and identifies a relevant research agenda.
New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements.
<h3>ABSTRACT</h3> <h3>Introduction:</h3> Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. <h3>Methods:</h3> We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. <h3>Findings:</h3> In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. <h3>Conclusion:</h3> Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
The costs of the medical care needs of AIDS patients are well above the average per capita expenditure on health care in many sub-Saharan African countries. These costs may become completely unaffordable as specific anti-viral drugs come onto the market, and the burden will fall on health networks, whose present strained budgets show no real signs of increase. In addition, pilferage, mismanagement and inefficiency continue at the few existing hospitals. As the total number and percentage of hospitalized patients with AIDS increases, the hospital networks (and the health services as a whole) risk collapse. The risks are of the same magnitude for both rural and urban hospitals - the former will not be able to deliver the necessary minimum quality of clinical standards, the latter will be flooded by too many patients. Achieving reasonable standards of hospital management and decentralization of curative care are critical targets for at least avoiding the risk that donors may be unwilling to finance specific anti-HIV drugs for these poor (and high-prevalence) countries.
Summary This article analyses the structure and organization of RDRS, one of the largest rural development NGOs in Bangladesh. RDRS's Comprehensive Project works with 120,000 households, through small groups of about 15, motivating and educating people on joint savings and investment, agricultural and off-farm income generation, primary health and family planning, literacy, social awareness, and women's development. Groups have access to credit provided by RDRS or banks. No free inputs are given. The Comprehensive Project's Community Health Unit runs 55 antenatal centres and a leprosy treatment service. The Rural Works Project plants 250,000 trees per year, and supervises construction of schools, markets and small bridges and culverts in isolated rural communities. RDRS has almost 1,700 staff. Field implementation is decentralized to area-based units, within a common policy, activity, financial and personnel framework. Six sectoral advisory units are responsible for innovation, quality control and coordination across the whole programme. Résumé Les ONG: le cas du Service rural de Rangpur Dinajpur Le présent article contient une analyse de la structure et de l'organisation du RDRS, l'une des plus importantes ONG (Organisation non gouvernementale) rurales du Bangladesh. Le Comprehensive Project du RDRS intervient auprès d'environ 120 000 ménages sous forme de petits groupes d'environ 15 personnes; le RDRS a pour rôle de motiver et d'éduquer les participants quant aux économies et investissements conjoints dans le ménage; la génération de revenus fermiers et outre-fermiers; les soins de santé primaires et le planisme familial; les campagnes d'alphabétisation; les programmes de sensibilisation sociale; et le développement des femmes dans la population. Les groupes ont accès au crédit fourni par le RDRS ou par les banques. Aucune contribution n'est gratuite. Le groupe des Soins de santé communautaires du Comprehensive Project organise 55 centres de consultation prénatale, ainsi qu'un centre pour le traitement des lépreux. Le service des prestations rurales plante environ 250 000 arbres par an et contrôle la construction des écoles, des marchés et des petits ponts et caniveaux dans les communautés rurales isolées. Le personnel du RDRS compte presque 1700 effectifs. Les antennes exécutives rurales sont décentralisées en unités à base géographique, or elles restent liées par une organisation de gestion commune des politiques, des activités, du financement, et du personnel. Six groupes de conseil sectoral se chargent des programmes d'innovation, de contrôle de la qualité et de coordination du programme au niveau de l'ensemble. Resumen Organizaciones no gubernamentales: el caso del Servicio Rural en Rangpur Dinajpar El artículo analiza la estructura y organización del RDRS, uno de los proyectos de desarrollo rural más grandes de las Organizaciones no gubernamentales en Bangladesh. Este proyecto exhaustivo comprende 120.000 familias, en grupos de quince familias, motivando y educando a la población en áreas como: ahorro colectivo e inversiones, producción de ganancias fuera de la granja, salud y planificación familiar, alfabetización, conciencia social y el desarrollo de la mujer. Los grupos tienen acceso a créditos provistos por RDRS o instituciones bancarias. No se otorga dinero gratis. La Unidad del Proyecto de Salud Comunitaria maneja 55 centros pre-natales y un servicio para el tratamiento de la lepra. El Proyecto de Trabajos Rurales planta 250.000 árboles por año, y supervisa la construcción de escuelas, mercados, puentes y alcantarillas en comunidades rurales aisladas. RDRS tiene un personal de casi 1700 empleados. La implementación de base se descentraliza en forma de unidades en cada área, que sin embargo siguen una línea común en cuanto a a criterios, actividades y estructuras financieras y de personal. Hay seis unidades consultivas responsables por las innovaciones, control de calidad y coordinación de la totalidad del programa.
Abstract Papua New Guinea decentralized a wide range of health functions to provincial governments between 1977 and 1983. The national Department of Health (DOH) was given no role in provincial budget and staffing decisions, and the national health budget was fragmented into the health components of provincial budgets. The impact of decentralization on health workforce development was particularly severe and largely unforeseen. Many difficulties were inherent in the manner in which decentralization regulations structured power relationships. Others arose as a result of the administrative confusion and inflamed relationships that accompanied the forceful transfer of power from a very reluctant national DOH to the provinces. Even though policy formulation and planning were retained as national functions, decentralization hampered their effective execution. Human resource data bases deteriorated, responsibility for planning became confused, and the ability of the DOH to implement its planning decisions was compromised. In reality, health workforce planning was carried out by the Departments of Finance and Planning, and Personnel Management through the annual budgetary process of provincial financial limits and staff ceilings, without any attempt to assess health service needs, either in the country as a whole or between the provinces. Decentralization brought a need for new management skills, and it complicated administrative relationships between training institutions and the provinces. The Papua New Guinea experience has shown that in a decentralized health service, there is a great potential for conflict between national goals and the aspirations of individual provinces. To achieve an equitable, appropriate and effective staffing of services, standards must be formulated as the basis for planning and conflict resolution. Effective linkages between central government departments and between the national and provincial health authorities must be developed, and management and technical skills of health managers improved.
Bangladesh has a population of 115 million people, and the economic growth rate of 3.7% during the 1980s was undermined by rapid population growth. The annual population growth rate was 3% in the 1960s and early 1970s, 2.5% between 1981-91 decreasing to 2.3% in 1991. The average of number of children is 4.6/woman compared with 7 in the 1960s. Infant mortality dropped from 150/1000 births in 1976 to 118/1000 in 1991. Life expectancy rose from 47 to 54 years. The 1991 Contraceptive Prevalence Survey showed that 39.9% of married women under 50 use contraceptives in 1991 vs. 18.6% in 1981. The use of modern methods increased from 10.9% in 1981 to 31.2% in 1991, while traditional methods rose from 7.7% to 8.7%. Sterilization was most prevalent in 1981. 29,000 female family planning (FP) workers were aggressively engaged in dispensing FP services in 1990. The Social Marketing Company sells pills, condoms, and oral rehydration salts through 130,000 retail outlets. The 1989 Contraceptive Prevalence Survey showed that 40% of pill and condom users obtained them from this network, and 95.4% of women knew about 4 methods of contraception. In 1990 there were 120 private organizations providing contraceptive services. Some of the components of the government FP program include field worker distribution door-to-door of injectable contraceptives (50% injectable usage rate in the Matlab project); recordkeeping activities; a satellite clinic network with access to contraceptive services; and decentralization through the Upazila (subdistrict) approach. The logistics system of FP has improved the warehousing, transportation, and management information system. Foreign aid (mainly USAID) financing of contraceptives helped avert 14.4 million births between 1974-90. The increase of contraceptive prevalence to 50% by 1997 would avert another 21.9 million births during 1991-96 (replacement fertility requires 70% prevalence.
Thailand has a long history of primary health care (PHC) development which started before the Declaration of Alma Ata in 1978. The National PHC programme was implemented nation-wide as part of the Fourth National Health Development Plan (1977–1981) focusing on the training of ‘grass-root’ PHC workers consisting of village health communicators and village health volunteers. Since then PHC has evolved through many innovative health activities: community organization, community self-financing and management, the restructuring of the health system and multisectoral co-ordination. Many of the essential elements of PHC have been achieved. Improvements in the nutritional status of children under five households accessiblity to clean water, immunization coverage, and the availablity of essential drugs have been observed. PHC has been successful in Thailand because of community involvement in health, collaboration between govermment and non-govermment organizations, the integration of the PHC programme, the decentralization of planning and management, intersectors collaboration at operational levels, resource allocation in favour of PHC, the management and continuous supervision of the PHC programme from the national down to the district level, and the horizontal teaining of villagers to villagers.
In Burundi, the intestinal parasite, Schistosoma mansoni, inhabits the waters of the Rusizi Plain (1 of the worst affected areas), the Capital Bujumbura, the Imbo-Sud, and around Lake Cohoha. It continues to cause illness in these regions. In 1985, the Lutte Contre la Schistosomiase project implemented a control program in these regions, chiefly involving chemotherapy. In addition, the European Development Fund had financed integration of safe water supply and environmental sanitation efforts into the program. To further reduce the incidence of schistosomiasis, the control program has introduced a training program for auxiliary health workers and health education campaigns. These efforts assist the program in decentralizing schistosomiasis control to health services and communities. Auxiliary health workers in primary schools, health centers, and subcommittees for sociosanitary development are responsible for educating the public about schistosomiasis. Program workers have developed educational material which allows the educators to address consistent messages to all audiences yet also allows for flexibility. The material consists of posters demonstrating how the disease is transmitted and other preventive measures, a film on schistosomiasis control, and a flip chart. Eventually health centers will be responsible for epidemiological surveillance of schistosomiasis. Communal subcommittees for sociosanitary development play an important role in informing local authorities of needed actions to control the disease and in setting priorities.
Due to its success, China's family planning programme has attracted attention from other countries seeking to replicate its strategies. Much is known about the organization and operation of China's family planning education and service delivery programmes, yet relatively little is known about costs and programme-financing methods. The authors present information about China's family planning pro gramme from a family and county level administrator perspective, drawing extensively on unpublished recent information to provide insights into costs and methods of financing. A case history illustrates various family planning options available as well as the payment mechanisms for programme incentives. Financial responsibility for the vast majority of the national family planning effort belongs to work units such as factories, educational organizations, stores and cooperatives. Translating the cost of family planning into US dollars and comparing with comparable costs in other developing countries and translating into terms relative to average unskilled Chinese worker salaries reveals the substantial investment made per capita on behalf of the family planning programme. Factors of political will, comprehensive administra tive support, effective organization, an all encompassing motivational programme and extensive service delivery covering the entire country together with generous decentralized financing are presented as important to programme success. Implications for transfer to other countries and the associated costs of doing so are discussed.
World Bank publications have a large influence on the decisions of governments. This article analyzes the publication "Financing Health Services in Developing Countries: An Agenda for Reform" part of the World Bank Policy Studies series. This study assesses only peripheral reasons for the lack of public and private financial investments in health services. It does not include the result of economic recession, budget cutbacks, and poverty on financing systems. There has been excessive expenditure on luxury in health institutions which takes considerable finances from disease prevention and health promotion services. There is low demand for private services because of the high cost, but public health services sometimes lack tools and money necessary for adequate care. The study does not address the relationship between needs and demand and the supply of health services. It outlines "4 Policy Reforms" in which the aims are to increase to cost of curative services and to use the additional money for prevention. The World Bank favors using private sector services but does not seem to view decentralization of health care as important. Social security systems have been in place in Latin America for 63 years. These systems are funded by wage earners and do not cover lower income rural citizens. Chile was the 1st country to adopt compulsory insurance in 1924 for catastrophes and diseases. The Chilean National Health Service combines institutional and community resources to provide quality health care. Social insurance and other prepayment systems are the rational approaches for financing health care in the Americas. These systems should be based on contributions by the State, employers, and urban and rural workers. There is a need for fund redistribution from institutional curative care to community preventative care. Health care costs should reflect income proportionally. The World Bank contributes vital analysis to the problem of health service financing. Hopefully American governments will recognize the need for health care reform.