DOES PARTICIPATION IMPROVE DEVELOPMENT OUTCOMES?
user fees, or providing oversight over budgets. There was also some disconnect between reports from health facility heads and community members about the extent of community involvement, with health facility heads claiming far greater community engagement in planning and management decisions than community members did. Few if any empirical studies collect this type of qualitative data that could help elucidate the channels through which participation works to improve outcomes and the potential constraints that could limit effective community engagement. Moreover, no careful empirical study has been conducted of the Bamako program that could bring these participation results together with results on service quality and health outcomes.
Decentralization of basic health services to local governments or NGOs. Decentralization of basic health care services to local governments appears to have been successful overall. The evidence suggests substantial gains on a number of child health outcomes as well as on a wider range of health behaviors. Some studies also find improvements in labor market outcomes and decreased fertility. The devolution of health service provision to NGOs appears to have been less successful, although there is evidence of some positive outcomes. In particular, when programs are devolved to NGOs, improvements in health tend to be confined to outcomes specifically targeted by the program. There are also some perverse effects of the imposition of user fees. Much of the evidence on the benefits of decentralized delivery of basic health services comes from a set of studies on Brazil’s family health program, the Programa Saude da Famılia (PSF). The PSF was first rolled out in 1994, as a small pilot initiative covering a few areas. By 2006, it had expanded into a nationwide program; by 2009, the program covered more than 90 percent of Brazilian municipalities. Municipal governments manage the PSF, under the supervision of the Brazilian Ministry of Health. PSF teams—which usually consist of a doctor, a nurse, an assistant nurse, and six community health workers, as well as a dental and a social work professional in some cases—are responsible for monitoring the health status of about 3,000–4,500 people (about 1,000 households). Teams make home visits and perform community-based health promotion activities. All services are delivered free of charge to ensure access by the most disadvantaged. Assessments
Decentralization of basic health care services to local governments appears to have been successful overall.
Devolution of health service provision to NGOs appears to have been less successful, although there is evidence of some positive outcomes.
Assessments of Brazil’s decentralized family health program find positive and economically large effects on health outcomes and behaviors.
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