Health Care System Decentralization, the Case of Venezuela Historic Evolution, Results, and Consequences of its Institutional Reversal

Introduction

Decentralization is a process of “redistribution” of powers of the State, in favor of greater autonomy, efficiency, and prominence of the role of the regions (States) and municipalities, and of more direct participation of society in the fulfillment of “public affairs.” It includes the delegation of the power of control to the lower levels of organizations.

Investigation Paper

It implies the distribution of the attributions of centralized power towards the authorities of the regions or local governments, be it State, Region, or Municipality, with a political component [1].

Decentralization constitutes a principle of the Administrative Organization, which lies in the transfer of decision-making powers, from a territorial political entity to another, (or others) different from the territorial public body that transfers them [2].

It is the transfer of powers that provides autonomy for all public services, but that, at the same time, depends on the National State, in such a way that the new autonomous entities cannot attempt against the State [3].

It necessarily includes the community, through citizen participation, in the administration and disposal of the goods and services that the regions possess, which leads to their intervention in decision-making at the State and Municipal level [4].

The decentralization processes that began in many Latin American countries in the 1970s, including Venezuela, were due to the governance crisis among those nations, with the disproportionate growth and accumulation of State power, (Centralism), bureaucratic, with an exhausted and inefficient management model, to deliver goods and services to the communities. The dissatisfaction of the population led to the aforementioned governance crisis, which demanded greater equity and efficiency in the distribution and access to State goods and services. To greater democracy and participation. In response, proposals for reform and modernization of the State were produced, promoted by multilateral organizations, with varied results from country to country [4, 5].

Decentralized governance of health care services means the transfer of authority in planning, management, and decision-making from the national to the subnational level, from higher to lower levels in the governance hierarchy [5].

The purpose of this article is to describe experiences of the decentralization process that occurred in Venezuela, particularly in the Health Care System (HCS).

For the effective application of the decentralization plans, a set of requirements and conditions was required: political will and commitment between the stakeholders. The existence of fundamental rules that would guide the relationship among the stakeholders; the centralizing element is the National Constitution because it is applied throughout the territory, which makes it common to all involved; a law of Decentralization, Delimitation, and Transfer of Competencies. The evaluation of the conditions for the approval of Decentralization and Transfer Agreements. Moreover, conditions of the political, economic, human, technical, and social resources would allow its feasibility [3]. Because it is a complex process, it is progressive, requiring learning by the parties involved. Responsibilities and new challenges are assumed [6]. It is not decreed. It is an Intergovernmental Agreement.

The purposes of the Agreement can be summarized as:

• The achievement of efficiency, to reach the objectives, and access to goods and services with equality.
• Citizen participation.
• Prevention of threats and the promotion of social wellbeing.
• Control of corruption, among others.
• Decentralization is a means, not an end. It is a necessary condition to improve access to, quality, and equality of the services intended to provide care to the population.

The objectives to be achieved were clearly defined:

• Strengthen the Central Organs as normative entities, while delegating to the state and local governments the execution of services and benefits. Namely: Regulatory Centralization and Operational Decentralization.
• Strengthen State and Municipal Bodies in planning, programming, management, and service control capabilities.
• Stimulate and organize human, physical, and financial resources.
• Train executive and administrative staff.
• Provide permanent advice to state governments.
• Act with the greatest transparency.
• Conduct technical and administrative actions, adjusted to rules and procedures specifically designed in the Decentralization Agreement.
• Select human resources, curating by merit and public tenders, thus avoiding corrupt patronage.

Likewise, the socio-political, cultural, technical, economic, and administrative benefits, among others, that were expected after its application was:

• A balanced distribution of power, separating it from the Central Power towards the States and Municipalities.
• With decentralization, administrative and functional autonomy was given to the municipalities.
• That autonomy implied breaking with the predominantly Centralist form of the State.
• Promotion of greater efficiency and importance of the regions (States and Municipalities).
• Empower the regions to make appropriate decisions for their benefit.
• Greater ability to obtain, execute, and control local resources.
• Legitimize regional and local leaders.
• Produce favorable changes in the socio-territorial and political structures in the regions and localities.

The implementation of the agreement would lead to the necessity of addressing new challenges [7], for example:

• Modify the redistribution systems to ensure equality and acknowledge regional differences through an adequate combination of social and territorial distribution systems; the social one ensures equal access to public goods and services, and the territorial one takes advantage of collective contributions and local initiatives.
• With decentralization, the states and municipalities assume relevance in the administration of delivery of public services, attending to the specific needs of the localities.
• The central level of government is forced to strengthen its non-competitive powers of stewardship, coordination, governance, control, supervision, and auditing.
• Perform the evaluation, prior diagnosis, monitoring, control, and fulfillment of requirements, of the skills to be transferred, the administrative regulations, and the coordination of services.

The new Constitution establishes that Venezuela is a “Decentralized Federal State,” which implies that its form of organization as a State must inherently include certain elements of a Federal State; one of these elements is decentralization [10].

Decentralization, as it pertains to the form of a State, should bring with it the redistribution and political-territorial reorganization of the powers and decision-making, assigned to the Central Power by the Constitution, towards other political-administrative entities.

In the Statement of Motives, it states: “... are characteristic of the cooperative federal model, in which the authorities and communities of the different territorial political levels participate in the formation of public policies common to the Nation, integrating themselves in a sphere of shared government for the exercise of the competencies in which they concur.” And, in the Preamble, “… with the supreme purpose of re- founding the Republic to establish a democratic, participative, and leading, multiethnic and multicultural society in a federal and decentralized State of justice, that consolidates the values of freedom, independence, peace, solidarity, the common

Constitutional Framework for Decentralization

Although the decentralization processes in Venezuela began in 1989, with the Organic Law of Decentralization, Delimitation, and Transfer of Public Powers (LOD) [8], 10 years later, with the approval of the Constitution of 1999 [9], it was hoped that it would be possible to advance and consolidate the decentralization process; regrettably, this was not the case (Figure 1).

good, territorial integrity, coexistence, and the rule of law for this and future generations...”; here, the existence of the federal and decentralized State is recognized, incorporating society in the functioning of the State to achieve those ends.

In Article 2, a “democratic, social, and legal” State is proposed, for which the Public Power must be decentralized, and then goes on:

In Article 4, “The Bolivarian Republic of Venezuela is a decentralized Federal State in the terms enshrined in this Constitution, and is governed by the principles of territorial integrity, cooperation, solidarity, concurrence, and co- responsibility.” Article 6, “the government is and will always be…. Decentralized;” conceiving decentralization as an essential policy that entails the deepening of democracy and the effectiveness and efficiency of the State, for which it includes political entities in this content, as an integral part of its structure.

To develop this policy, public systems were foreseen: fiscal, judicial, education, health, among other areas; that would guarantee the administrative decentralization of government entities.

Article 157 has an essentially decentralizing content since it states that the Legislative Power, represented in the National Assembly, by majority decision, will attribute to the Municipalities or the States powers that correspond to the National Power, and adds “…to promote decentralization.” Article 158 attributes decentralization as a national public policy and states, among other things, that “... democracy should be deepened, bringing power closer to the population...”, with the idea that the purposes of the State are effective and efficient in their achievement. In Article 185, the Federal Council of Government is defined as: “…body in charge of planning and coordinating policies and actions for the development of the process of decentralization and transfer of powers from the National Power to the States and Municipalities…” “...The Inter-territorial Compensation Fund will depend on the Federal Council of Government, destined to finance public investments aimed at promoting the balanced development of the regions, cooperation and complementation of the development policies and initiatives of the different public entities…” This Body, based on regional imbalances, would annually discuss and approve the resources that would be allocated to the Inter-territorial Compensation Fund and the priority investment areas to which said resources will be applied.

The Federal Power would have Constitutional Guarantees to know [11].

• Federation and decentralization are irreversible characteristics of the Republic and the State.
• The National Power cannot modify the structure of federal power.
• Decentralization must be fiscally sustainable and protect territorial balances.
• Decentralization is progressive and agreed upon by the parties.
• Decentralization is flexible and adaptable to territorial diversity. To guarantee financial security, the Constitution provided for:
• The application of principles of Autonomy and Financial Balance of states and municipalities: Subsidiarity, Inter- territorial Equity, and Coordination.
• The development of state and municipal finances, taxes, fees.
• The creation of the Inter-territorial Compensation Fund, attached to the Federal Council of Government.

Legal Framework of Decentralization

On December 28, 1989, the Organic Law of Decentralization, Delimitation, and Transfer of Powers of Public Power (LOD) was approved [8]. I highlight its content:

• Article 4 established ¨The services will be transferred progressively¨.
• Article 7 defined the procedures to approve transfer and decentralization agreements: When the initiative comes from the National Executive, a proposal is presented to the Senate of the Republic, which will agree or deny the transfer and its modality. If the initiative comes from the State Government, the request is made via the State Legislative Assembly to the National Executive and this to the Senate, which decides.
• And Article 8: Any of the transferred services can be reversed, through a request from the National Executive addressed to the Senate or from the Government, where the incompetence of the region to efficiently comply with the contracted commitment is exposed.
• The projects of Agreements of Decentralization and Transfer of Competencies were carefully analyzed by a High-Level Commission, in particular: Diagnosis of the characteristics of the skills to be transferred.
• An Operational Evaluation, dynamic procedure, during the co-management regime (one year), before the definitive assignment of the transfers.
• The Temporary Assignment (two years), with the annual evaluation of health indicators, and in completed activities. Accountability, evaluation of management capacity, and satisfaction with the quality of services provided.
• The Reversal of the transfer was contemplated in case of breach of commitments.
• The transfer approval process included:
• Evaluation by the High-level Commission for analysis and evaluation of decentralization proposals made up of the Ministry of Health and Social Assistance (MSAS), the Ministry of Internal Affairs, and the State Government.
• Analysis by OCEPRE. (Central Budget Office), OCP (Central Personnel Office), and Ministry of Finance.
• Evaluation of the project and opinion by the National Attorney of the Republic and “Cordiplan” (Ministry of Planning).
• Evaluation and Opinion by the Senate of the Republic of the Republic that finally approved or denied the Co- administration Agreement or the Transfer Agreement.

Consequences of Reversal of Transfers and Recentralization of Health

The decisions of the Executive Power put into practice through presidential decrees, violated the Constitution, concentrated the decisions in the Central Power, undermined the powers of State and Municipal governments [7, 10, 11, 24] and advanced in ways contrary to modern health systems, based on high participation of organized communities, in the Primary Health Care strategy.

We again warned and publicly denounced the consequences of these decisions: ¨Venezuelans have the right to discuss and choose our health system since it is a complex decision, which requires a general agreement, which involves building a new ¨Social Health Contract¨, so it cannot be the result of a hasty decision without consultation, protected by a decree, but by the constitutional principles that guarantee the right to health¨ [28].

Consequences in the political sphere: Such measures had regressive implications for public good guarantees, such as State obligations strengthened through decentralization [24].

They raised the intervention of the National Government in attributions and competencies that belong to the states and municipalities by constitutional mandate.

They regressed towards a model of the centralized organization of the State, which was largely superseded in the 1999 Constitution, in addition to imposing “intervention” and “reversal” measures not contemplated in the Constitution.

They took away from the states and municipalities the means to exercise their powers and competencies. [29]. They affected the fundamental citizen rights, from the very moment that the 1999 Constitution assumed the figure of concurrent powers, in which states and municipalities share responsibilities in all those matters that guarantee a decent life for all its citizens, specifically in timely access to health services, justice and the exercise of the vote.

Regarding the freedoms and citizen rights, the measures to revert powers and recentralize health produced serious consequences both for the democratic political system and for the Human Rights of the Venezuelan population, including the right to health, which is translated into:

• Threats to the fundamental freedoms of citizens through authoritarian practices.
• Social inclusion is limited by the abandonment of public policies.
• The adoption of welfare measures allows greater political control over the population.
• The loss of the right to participation and the means to exercise it, by establishing restrictions on the autonomy of citizens and their organizations.
• Criminalize those who question or do not share the government’s policies and close the instances of participation to those who do not adhere to the socialist ideology.

Specifically, on the Health System, it has been condemned, since then, to a condition of progressive deterioration and extreme precariousness, which makes it unfair, inequitable, inefficient, fragmented, and incapable of satisfying the basic health needs and demands of the population.

The application of legal instruments and decrees contrary to and in violation of the Constitution has had a negative influence on the normative principles of the right to health in Venezuela, namely: universality, equity, promotion and participation, and consequently, the dignified life of the population in a democracy, by affecting the organization of the health system, now centralized, authoritarian and exclusive. Such circumstances make it incapable of responding to the complex and ongoing humanitarian crisis that has affected the country in the last 6 years and efficiently preparing for new threats to collective health [30]; with responsiveness to an epidemic. Venezuela, in 2019, ranked last out of 33 countries in Latin America and the Caribbean and ranked 176th out of a total of 195 countries according to the Global Health Security Index, prepared by a panel of international experts [31]. That was the situation of the health system before the emergency of the COVID-19 pandemic, as of March 2020. What strategic proposals can be developed in a situation of this nature? With an outlaw regime that does not respect the Constitution and democratic norms, which has fraudulently implemented a Communal State, rejected in the Constitutional Referendu [32]. Will decentralization survive “Chavismo-Madurismo”? The actions of municipal weakening and the creation of communal councils only recognized by ideological coincidences, which have been experienced in Venezuela, represent the denial of values and the collapse of the democratic system [33].

In the search to optimize public policies, including the HCS in Venezuela, a set of optimistic proposals stand out, aimed at restoring constitutional mandates, ordering and respecting the powers of the various government levels, and guaranteeing the participation of organized citizens [11].

• That the State and Municipal Governments fully assume the powers and competencies emanating from the Constitution, making the rights of the people prevail above all. Promoting and building an agenda for the development and rescue of Decentralization.
• That political and social agreement be promoted in terms of decentralization linked to the development of exclusive and concurrent powers.
• Promote, extend and deepen the associative links between different sectors of civil society, states, and municipalities of the country, to unite efforts of citizen calls to build alliances and networks to mobilize support.
• Expand the channels of communication and free dissemination of information to citizens, through new strategies and tools.
• Strengthen response capacities in situations of restriction or threat to civil rights and democratic guarantees, recovering public spaces and the civic sense of politics.

In 2014, we proposed the restitution and promotion of the decentralization process in Health Care. To revert re-centralization of Health Care System (HCS) executed by decrees that infringed the Constitution of 2008. To perfect the processes of transference of goods, services, and competencies of the health care services to the states and, in turn, from the states to the municipalities and communities. To set the decentralization process in order, correcting the mistakes and deficiencies of the past, strengthening the governance functions of the National Government in health care, which are substantial and non-delegable, by “regulatory centralization,” and in turn to apply and set in order the “operational and management decentralization” of health services toward other government entities and the communities. To increase the monitoring, comptrollership, and evaluation mechanisms for processes and results, as well as to stimulate the evaluation process for user satisfaction [34].

Conclusion

The progress made during the Health Care Services decentralization that was effectively carried out  in Venezuela between 1989 and 1999, which made it possible to start coverage and care for 89% of the country’s population,  through the application of intergovernmental agreements and the more efficient use of public resources, suffered a notorious setback and paralysis, to the detriment of the health care rights of Venezuelans, from  2007, with the presidential decision to re-centralize health services by decree.  This decision was executed without any prior evaluation of the results of the decentralized management of population health statistics.

Some numbers showed that the decentralized management was more efficient in the use of resources, and overall improvement in health and spending efficiency statistics (Infant Mortality Rate, Maternal Mortality Rate and AARR) were observed during the period of decentralization, when compared with the period before and after the interruption of the constitutional norm, and the recentralization of health care service delivery.

This highlights the discursive contradiction of the government regarding the promotion of citizen participation and protagonism, arranged in the Constitution of 1999 and several other laws, and the contrary actions later applied in the area of health care, which distanced the decision-making and free participation of the communities, and it can be inferred that part of the current low quality and response capacity of the Venezuelan health system is associated with the recentralization process.