The present article proposes an analysis of the USA-Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives--decentralization, fertility and disease control, and maternal and child health--may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti-drugs, political, and economic US interests in Bolivia.

Launching of the the National Rural Health Mission (2005) has brought a sharp policy attention to maternal health with its several initiatives such as (a) cash and material benefits to pregnant women; (b) strengthening health institutions especially of First Referral Units (FRUs); and (c) conducting regular maternal death audits to ensure quality Emergence Obstetric Care (EmOC). In spite of these efforts, the decline in maternal mortality ratio is rather slow and not achieved as per the MDG 5 goal. This study was undertaken to understand why despite infusion of such vast resources into the health system, timely and quality EmOC services have not been implemented.

Evidence shows that eight per cent of maternal mortality in India is caused by unsafe abortions. India was one of the pioneer countries to legalize its abortion services as early as 1971. The Medical Termination of Pregnancy Act (MTP) is an enabling regulation, which allows MTP on both medical and social grounds and thus facilitates access to safe abortion services. However, despite this supposedly progressive law, which has existed for more than four decades, ‘illegal’ and unsafe abortions are still a reality in India particularly in rural areas. There is a large body of research on MTP that examines barriers to access safe abortion services from the users’ perspectives. This paper turns the research gaze from the users to the providers particularly at the primary health care level to examine the persistence of illegal and unsafe abortions in rural Karnataka.

This paper aims at offering alternative methodological perspectives in health systems research, to produce critical, theoretical knowledge in domains such as health policy and management of health care, organization of disease control, political economy of health and medical practice.We first examined the reasons to believe that worldwide economic agents have driven publicly funded schools of public health to adopt their preferred policies and to orient their priority research topics. We then studied whether this hidden leadership has also contributed to shape research methodologies, which we contrasted with the epistemological consequences of a quest for intellectual independence, that is, the researcher’s quest to critically understand the state of health systems and generalize results of related action-research. To do so, we applied concepts of what could be named the ‘French School of Critical Sociology’ to qualitative research methodologies in descriptive health systems research. To do so, we applied concepts of what could be named the ‘French School of Critical Sociology’ to qualitative research methodologies in descriptive health systems research.

This article analyses the influence of the World Bank on reforms of the health sector in Bolivia during the period 1986–2006, and assesses their impact on the health care delivery system to date. The article examines the transformation of health services undertaken by the current socialist government since 2006. A literature review and interviews with decision-makers critically examine the outcome of reforms on criteria linked to health system integration. The study illustrates that Bolivia applied quite comprehensively the WB recommendations. Among others these included indirect privatization through public health services’ restriction of access to a basic package of care and decentralization with devolution. In consequence, the segmentation and fragmentation of the health system was exacerbated, accessibility and quality of care suffered and health status barely improved. The article attempts to locate the relationship between policy, health care delivery and health systems functioning.

In LMICs it is generally acknowledged that access to curative care could be improved if primary care health services were strengthened and new health centres opened when required, if in addition skilled teams are organized in these services and if resource allocation does not discriminate against primary care as has historically been the case in many LMICs. Some publications also focus on the importance of good doctor-patient communication, as highlighted in Chapter 17 of this section, to improve access and to ensure effective integration of health services (Haddad & Fournier, Litvack & Bodart, 1993). There are also important technical dimensions of supporting primary care health services, including sustainable drug supplies in public services (Hanson & Gilson, 1993) (see Part 2 of this chapter).

This paper examines why progress towards Millennium Development Goal 5 on maternal health appears to have stagnated in much of the global south. We contend that besides the widely recognised existence of weak health systems, including weak services, low staffing levels, managerial weaknesses, and lack of infrastructure and information, this stagnation relates to the inability of most countries to meet two essential conditions: to develop access to publicly funded, comprehensive health care, and to provide the not-for-profit sector with needed political, technical and financial support. This paper offers a critical perspective on the past 15 years of international health policies as a possible cofactor of high maternal mortality, because of their emphasis on disease control in public health services at the expense of access to comprehensive health care, and failures of contracting out and public–private partnerships in health care. Health care delivery cannot be an issue both of trade and of right. Without policies to make health systems in the global south more publicly-oriented and accountable, the current standards of maternal and child health care are likely to remain poor, and maternal deaths will continue to affect women and their families at an intolerably high level.