Delegating Essential Functions to Municipalities as a Collaborative Learning Process

HEP+ started in April 2016, with a new component for health sector reform. Three months later, HEP+ successfully connected all major players, produced consensus about vision, strategic lines, and reform stages. The president and vice president launched the reform process. Only one month later, Ministry of Health (MOH) authorities had resigned, pushed out by the Congress and the Ombudsmen office. The team appointed to lead the MOH stopped the health reform process and devoted most of their 11 months in office trying to expand their own non-governmental organizations' work to six health directorates. Ongoing solutions were frozen, and improvement processes were reversed. The same coalition dismantled coverage extension program, a 17-years initiative to reach the poor, indigenous and rural population.

In such volatile environment, HEP+ decided to pause and reflect. We realized the ultimate determining factor in the health sector decisions was centralization of functions, decisions and resources, as it made institutions and communities vulnerable to political instability. During the last five years there were three presidents, eight health ministries, and tents of deputy minister; however, mayors and municipal officers were stable, accountable and could get reelected.

Our team redefined our theory of change, understanding decentralization as a fundamental reform, a pre-requisite not only for health, but for all ministries and secretaries of state. We saw this not as a gift from central level to municipalities, and not a suitable response for all municipalities, because many were not ready to manage delegated functions. We applied a form of CLA based on measuring capabilities, introducing improvement plans and developing tools to guide delegation of functions, having as allies the Ministry of Finance and the Planning and Executive Coordination Secretariats.