Constructing healthy municipalities: the dogma and dilemmas of decentralization in Mexico.

Publication: Urban Anthropology & Studies of Cultural Systems & World Economic Development

Publication Date: 22-DEC-07

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International health programs have drastically improved health standards throughout the developing world over the last century. Improvements in sanitation, the extended vaccination coverage, increased accessibility of antibiotics, and better health care access have helped to reduce deaths from common infections, decrease infant and maternal mortality rates, and increase the overall lifespan. Yet, despite decades of international health efforts, fundamental health problems that are linked with persistent poverty and a lack of basic sanitation are far from being eradicated.

Anthropologists have long criticized international development efforts not only for failing to improve the health and well-being of populations in southern countries, but also for creating dependencies and deepening the poverty of many living in the south (i.e., Escobar 1995; Simonelli 1987). Scholars have been increasingly vocal about the shortcomings of international health policies that advance the political interests of wealthier countries while failing to address the many real challenges that local populations face. As Castro and Singer (2004) point out, many of these shortcomings reflect the fact that health planning largely occurs from abroad, mirroring economic development strategies that reflect the political agendas of powerful nations rather than the interests, needs, or realities of developing societies. Problematically, while numerous parties are involved in health planning (e.g., international agencies, government officials, pharmaceutical companies, health personnel, NGOs, and civil society organizations), the most influential actors are international donors, international agencies, and national governments, which often leaves local populations with little input (Zaidi 1994).

As scholars have documented, the implementation of health programs in developing countries tends to follow a "one size fits all" prescription, meaning that similar reform packages are applied in countries which have starkly different historical and cultural backgrounds (Whiteford and Manderson 2000). As a result, the local applications of health reform programs by national governments may be mismatched to the realities and needs of their citizens. Neoliberal development agendas (1) that have driven health reforms throughout the developing world over the last three decades have received much attention in light of this mismatch between international agendas and local realities (e.g., Castro and Singer 2004; Kim et al. 2000). The policies advocated through neoliberal reforms have reduced the role of national governments while emphasizing the privatization of public resources, decentralized forms of management, and the incorporation of community residents in taking greater responsibility for existing social and economic problems (Lacey and Ilcan 2005). As these policies deemphasize the role of the state in the distribution of welfare and public services, scholars argue that neoliberal reforms have widened the gap between those who have access to health benefits and services, and those who do not (Laurell 2001).

The Mexican government accepted the terms of neoliberal state reforms to help offset the contraction of public spending after the economic crises of the 1980s and 1990s. As a result, the government has gradually reduced its direct responsibility for the implementation of social assistance programs for the poor, contributed to the commoditization of social services and benefits, and required that families and communities bridge the increasing gap between the retracting state and the inaccessible market (Laurell 2001). The government implemented new participatory initiatives and programs aimed at bridging this gap, specifically in the health and education sectors. Healthy Municipalities is one such program that was introduced to the health sector in the 1990s. Emphasizing "intersectoral collaboration" to facilitate the process of decentralization, Healthy Municipalities expects that municipal governments and residents will collaborate to develop health committees, local projects, and targeted solutions to resolve community health problems. Despite the rhetoric of empowerment that is built into participatory programs like Healthy Municipalities, scholars suggest that such initiatives have been primarily implemented for their utility in reducing government spending, rather than for their democratic of intrinsic values (Zakus 1998).

This paper examines the case of Healthy Municipalities in Morelos, Mexico in light of the growing concern that national governments, carrying out the agendas of international policies, not only ignore the "real" needs of local populations but also create new forms of subjectification as the state divests itself of some of its obligations. I explore the implementation of Healthy Municipalities in the town of San Lucas. (2) I examine the ways in which policy and practice intersect on a local level and how different stakeholders (Ministry of Health administrators, municipal authorities and local residents) respond to the program's opportunities and challenges. This case considers some dilemmas that local populations confront as global health policies, adopted by local governments, define how communities should address their most pressing health problems.

In the first section of the paper, I examine the trajectory of international health policies and explore a series of macroeconomic shifts that have led the Mexican government to accept the terms of neoliberal reform. As participation is an essential component of the neoliberal agenda, I examine participatory approaches in health in historical context and the discursive models that have driven them. I then consider the municipal structure through which health reforms are implemented in Mexico and describe the health problems that Healthy Municipalities seeks to resolve. In the final sections, I describe how Healthy Municipalities is implemented in the town of San Lucas and reflect on the discourses and strategies that guide the program. I conclude the article by reflecting on the mismatches among the vision of the program, the strategies used to implement it, and the interests of local residents. I

suggest that while decentralization strategies are intended to provide a means through which governments increase community participation and intersectoral collaboration, such strategies are ultimately driven by a centralized definition of what needs to be done, who is equipped to do it, and how these goals should be accomplished.

Global Health Policy and Health Reform in Mexico

The global economic crisis of the 1980s deepened many problems that earlier development efforts had been seeking to resolve. Structural adjustment programs (SAPs) were put in place to ensure that poorer nations repaid their debts to lending agencies like the World Bank. Budget austerity and market liberalization involved in adjustment policies resulted in drastic cuts in public services, a reduction of all types of subsidies, and a steep decline of health and education benefits (Rist 1997). As a result, the amount that developing countries could invest in health services began to greatly decrease and the conditions of health care provision deteriorated along with the decline in financial resources (Evers and Juarez 2003).

In Mexico, the debt crisis of the early 1980s required that the national government implement austerity measures that involved radically reducing health spending. As the debt crisis deepened, the government's attempts to increase health care coverage benefits failed. International creditors pressured the Mexican government to reduce unemployment and welfare benefits while multilateral and bilateral agencies (e.g., World Bank, Interamerican Development Bank) pressured the government to reorganize its health system.

Beginning with Miguel de la Madrid's presidency (1982-1988), the government responded to these pressures by embarking upon a process of political and economic decentralization. This process resulted in changes in Article 115 of the Constitution that guaranteed municipalities fixed sources of revenue which would allow them to provide public services and strengthen their political independence (Rodriguez 1997). The health and education sectors were most specifically targeted for decentralization.

Multilateral agencies like the World Bank promoted decentralization strategies as the panacea to address the inequity and inefficiency of health care in developing countries. From this perspective, health sector improvement was possible only if centrist governments better involved diverse social actors in health resource management. The Pan American Health Organization (PAHO) was particularly influential in Latin America in introducing decentralization programs that could help facilitate this goal. For example, in the 1980s, PAHO recommended that governments organize health services into "local health systems" (SILOS, Sistemas Locales de Salud) where local authorities were given greater decision-making power regarding health service operations and the delegation of funding. Municipalities could thus more effectively run community health care and prevention programs, coordinate and mobilize resources, and organize the community to participate in health (Sotelo and Rocabado 1994).

However, funding for Mexico's health programs was in decline by the mid 1990s and the peso devaluation crisis of 1994 required the largest International Monetary Fund (IMF) bailout in Mexican history, with strings of structural adjustment attached. Mexico fell into its most serious depression since the 1930s, requiring a further reduction in social welfare programs to help pay off the growing debt. In response to its economic predicament, Mexico accepted the terms of state reform that accompanied neoliberal globalization as defined by the World Bank and the IMF. These terms, which reflected standardized health sector reforms that were being applied across low- and middle-income countries, required that the government adopt market oriented strategies to offset the contraction of public spending and to improve the nation's competitive position in the world market (Laurell 2001).

To address the growing problems within the national health system, President Ernesto Zedillo set out the objectives of a Health Sector Reform Program 1995-2000 in his national development plan. Zedillo...

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