To decentralize or not to decentralize, is that the question? Nicaraguan health policy under structural adjustment in the 1990s

Since 1990, health. services decentralization in Nicaragua has been accompa nied by structural adjustment, resulting in reduced equity and accountabili ty. Sandinista efforts in the 1980s to extend access to primary care and re duce class and regional disparities in the delivery of health services were accompanied by modest attempts to increase local-level accountability and responsiveness. The escalation of war in the late 1980s transformed this ef fort into greater de facto decentralization. Over the past decade, Nicaragu a has used decentralization policy to restructure the health system through health spending cuts and the favoring of curative over preventive services ; privatization and the promotion of user fees; and confusion of lines of a ccountability. The authors analyze the 1990s' health policies in Nicaragua, paying particular attention to the blending of decentralization policy wit h the fiscal and administrative reforms advanced by the International Monet ary Fund, World Bank, and other international agencies. They conclude that analyzing decentralization as a sector-specific reform that can be ameliora ted through technocratic modifications is insufficient. A full understandin g of the problems and possibilities of decentralization requires an analysi s of the political and economic context th;lt conditions these policies.