Health System Decentralisation in Venezuela during the 1990s
| Autor | Armando Barrios Ross |
| Cargo | Profesor-Investigador en la Escuela de Empresa-Universidad Sergio Arboleda e Instituto de Estudios Superiores de Administración (IESA) |
| Páginas | 119-152 |
Profesor-Investigador en la Escuela de Empresa-Universidad Sergio Arboleda e Instituto de
Estudios Superiores de Administración (IESA).
Health System Decentralisation in Venezuela during the 1990s
Armando Barrios Ross, Ph.D
ABSTRACT
This paper is a short view of the Decentralisation to the Regional Health Systems in
Venezuela during the decade of the 1990s, and it is based on my doctoral dissertation. It
begins with some theoretical and conceptual foundations used in the thesis. Second, the
paper shows the analytical framework for the “policy trajectory” followed by the
decentralisation process examined in the research. In a third section, some comments on the
main findings with regard to the institutional outcomes are analysed, but details are no
illustrated here. Section 4 is a review of the political and policy process factors
conditioning the decentralisation process. Sections 5 and 6 analysed how the changes in the
Venezuelan rules of the game impacted on decision rights and spaces in the Regional
Health Systems. Finally, some concluding remarks are show.
Introduction
Here the institutional challenges associated with the decentralisation within an inter-
governmental relations system are examined, using a specific sector, health, and a
particular country, Venezuela. To do so, we begin by analysing both the changes in the
rules of the game of the inter-governmental relations system during the 1990s as a result of
decentralisation and in the policy-arena constraints in the health sector in Venezuela. The
idea is to identify how decentralisation of authority for the health sector has created new
decision rights and spaces for Regional Governments to make reforms in terms of their
strategic guidance, organisation, financing, and management of regional health services.
From there, the paper examines the effects of these functional reforms on a set of
institutional attributes such as autonomy, accountability, civil society participation and
coordination.
Profesor-Investigador en la Escuela de Empresa-Universidad Sergio Arboleda e Instituto de
Estudios Superiores de Administración (IESA).
Given the exploratory nature of the research problem, qualitative methods and comparative
analysis were used, as is usual in public policy and management analysis. The approach of
“case studies research” served as the basis for the empirical findings, especially for the
“sample” of Regional Governments examined. When relevant, in the the research some
statistical tools were also used, to provide a quantitative support to the proposals.
In the paper the Regional Health Systems represent the main units of analysis, meaning
that each Regional Health System can be seen as an organisation able to reform its
functions of strategic guidance, financing and services delivery. But given the fact that the
original research worked with a sample of five out of twenty-one Regional Governments,
one has to be careful to refrain from making generalisations from this li mited “sample”.
The Venezuelan Intergovernmental Relations System and the health sector policy-arena
constraints are identified as the context of the analysis.
From this derives the dimensions or variables examined, classified as follows:
Ô Explanatory variables represented by changes in the rules of the game due to
decentralisation, as well as some health sector policy-arena constraints.
Ô Intermediate (policy) variables represented by the functional reforms in strategic
guidance, financing and services delivery in the Regional Health Systems, using the
new decision rights opened b y the decentralised Intergovernmental Relations
System;
Ô Explained variables represented by institutional attributes achieved by the Regional
Governments (autonomy, accountability, civil society participation, and
coordination). These attributes may be interpreted as institutional outputs generated
by decentralisation and the consequent functional reforms in the Regional Health
Systems, whenever the authorities use their decision rights and spaces to develop
them.
The use of decision rights and spaces illustrates the extent to which a specific Regional
Government exploits resources and incentives provided by the Regional Health Systems to
Profesor-Investigador en la Escuela de Empresa-Universidad Sergio Arboleda e Instituto de
Estudios Superiores de Administración (IESA).
exercise autonomy, open up to participation, and strengthen co-ordination and
accountability.
1. Some theoretical foundations
Decentralisation is a concept with multiple meanings, but in order to discuss it from an
intergovernmental perspective, the focus here is on the transfer of authority and functions
from the Central Government to the Regional Governments, such that the latter can operate
with a reasonable degree of autonomy and accountability in the performance of their
responsibilities. But some conceptual precisions are necessary.
1.1 Theoretical framework
The decentralisation of authority and functions to Regional Governments has several
dimensions: political (i.e. the open and transparent elections of Regional Governments
authorities), administrative (i.e. the assignment of functional responsibilities to the
Regional Governments), and fiscal (the assignment of sources of financing to the Regional
Governments).
In order to get a better understanding of any decentralisation process it is useful to adopt a
more comprehensive concept of intergovernmental relations. For instance, these
relationships can be modelled as a “game” (Scharpf, 1997), where participants make use of
different resources to influence outcomes, following their agendas, and subject to
contextual and policy-arena constraints.
Behind this conception of intergovernmental relations, there is a policy process perspective
where one finds: actors, interests, agendas and goals, resources, rules of the game, polic y-
arena constraints, strategies, implementation challenges, outputs and outcomes. These
policy processes extended decision rights and residual rights, room for manoeuvre, and
“policy spaces” for the actors involved. Thus, here we follows Grindle & Thomas (1991:8):
“Within issues areas, a policy space consists of the range of options that could be
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