LOCAL HEALTH-SERVICES - SOME LESSONS FROM THEIR EVOLUTION IN BOLIVIA

For a decade, numerous projects in Bolivia have tried to put in practi ce the concept of local health systems. But, so far, no significant ch anges have been made and local health services still are the 'poor rel ation' of the system. The main components of the projects-expansion of health facilities, training of health personnel and institutional dec entralization-were not designed to respond to the complexity of the pr oblems encountered. Decentralization was implemented at the level of h ealth districts but not accompanied by redefinition of functions at th e central level, and challenged by civil servants' attempts to save th eir jobs. While training activities did introduce new methods and subj ects, they were too often reduced to short workshops or seminars. Heal th facilities were built without regard for their significance beyond health care. A strategic approach is needed to adapt the planning proc ess to the degree of liberty allowed by society.