Table Of ContentReshaping Health Care in Latin America
A Comparative Analysis of Health Care Reform
in Argentina, Brazil, and Mexico
Edited by
Sonia Fleury,
Susana Belmartino,
and
Enis Baris
INTERNATIONAL D E V E L O P M E N T RESEARCH CENTRE
Ottawa Cairo Dakar Johannesburg Montevideo » Nairobi * New Delhi • Singapore
Published by the International Development Research Centre
PO Box 8500, Ottawa, ON, Canada K1G 3H9
April 2000
Legal deposit: 2nd quarter 2000
National Library of Canada
ISBN 0-88936-923-2
The views expressed are those of the author(s) and do not necessarily
represent those of the International Development Research Centre. Unless
otherwise stated, copyright for this material is held by the authors. Mention
of a proprietary name does not constitute endorsement of the product and
is given only for information. A microfiche edition is available.
The catalogue of IDRC Books and this publication may be consulted online
at http://www.idrc.ca/booktique.
Contents
Foreword — Maureen O'Neil v
Preface vii
Section I. Introduction
Chapter 1. Reforming Health Care in Latin America:
Challenges and Options — Son/a Fleury 3
The Social Protection Model in Latin America 3
After a Decade of Reforms in Latin America 7
Some Issues in Comparative Analysis 12
Methodological Options 20
Section II. Analysis of Health Care Policies
Chapter 2. The Context and Process of Health Care
Reform in Argentina — Susana Belmartino 27
Introduction 27
Background Influences 29
The Reform Process 31
Implementation 35
Reform of the Public Subsystem: Decentralization of the Hospital System 38
Evaluation 40
Conclusion 44
Chapter 3. Reorganizing the Health Care
System in Argentina — Susana Belmartino 47
Introduction 47
Structural Features 47
Transformations in the Health Service Systems — Organizational Models 59
Health Service System Regulation 71
Discussion 75
Chapter 4. The Context and Process of Health Care
Reform In Brazil — Lenaura Lobato and Luciene Burlandy 79
Introduction 79
Background Influences 82
The Reform Process 88
The Reform Implementation 92
Evaluation 98
Conclusion 101
Chapter 5. Reorganizing the Health Care System in Brazil — Lenaura Lobato 103
Introduction 103
Structural Features 103
Transformations in the Health Care System 115
Conclusion 130
Chapter 6. The Context and Process of Health Care
Reform In Mexico — Silvia Tamez and Nancy Molina 133
Introduction 133
Background Influences 135
Reform Process 137
Conclusions 150
iii
iv CONTENTS
Chapter 7. Reorganizing the Health Care
System in Mexico —Silvia Tamez and Nancy Molina 153
Introduction 153
Structural Features 153
Changes in the Health Service System 169
Section III. Determinants of Utilization of Health Care Services
Chapter 8. A Population-based Survey in Three Cities of
Latin America — Enis Baris, Stella Sanchez,
Mauricio de Vasconcellos, and Moises Balassiano 185
Introduction 185
Determinants of the Use of Health Care Services in Argentina, Brazil and Mexico 192
Discussion 207
Appendix 1. Operational Definitions of the Variables in the Model 211
Appendix 2. Path Diagrams 213
Section IV. Conclusions
Chapter 9. Reshaping Health Care Systems in Latin America:
Toward Fairness? — Sonia Fleury 225
Major Economic and Social Tendencies 225
The Health Reform Process 231
Comparative Analysis of the Health Care Reforms 238
The Make-up of a Reformed Health Care System 246
Lessons from the experience 256
Acronyms and Abbreviations..... 263
Contributing Authors 267
Bibliography 269
Foreword
This book assesses the health care reforms of the past decade in Argentina,
Brazil and Mexico. The authors are in agreement that reform in the governance,
management and financing of the provision of health services was essential.
However, they criticize the outcomes of the reform process not only for the
anticipated exacerbation of social and economic inequalities, but also because of
inattention paid to human resources as well as much-needed development of
science and technology.
The country studies are set within the political and economic context of the
reform period and strive to assess outcomes for people at different levels of
income. The methodology illustrates the approach for which IDRC strives in the
work it supports. IDRC operates on the belief that no "problem" — in this case
accessible, affordable and appropriate health care — can be viewed in isolation
from its context. As well, "solutions" must be judged by identifying exactly
whose lives have improved.
Sadly, the ultimate conclusion of the researchers is not a hopeful one. The
reforms are likely to leave many citizens with inadequate care and pit the middle
class against the poor, both culturally and politically. Social solidarity will
remain elusive. Indeed, if governments continue their implementation of reforms,
the health sector could well be modernized without any reduction in the
economic inequities fracturing the region.
This study should be a flashing red light to policymakers and the public: a
signal to stop and confirm direction. Through their quality, accessibility and
governance, health services demonstrate a democracy's effectiveness in meeting
the critical needs of its citizens, just like education does.
Traditionally, the state in Latin America has been strong in its ability to
control its citizens but not in creating the social solidarity (and services) that
citizens need. Failure of the new democracies to strengthen the social state could
have dire consequences. The reality is that so far, at least in the three countries
studied, governments have not kept social fairness as the "bottom line" in the
design of health reforms.
This study makes an important contribution to re-thinking policy
directions. Its conclusions should inspire politicians and the public to take a
second look.
Maureen O'Neil
President
International Development Research Centre
V
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Preface
Since the early 1990s, several national and international research institutions and
policy think-tanks in Latin America have been preoccupied with social sector
reforms and their equity implications. This book draws on and expands earlier
efforts with the overall goal of investigating in a comparative manner
transformations in the modes of health care financing and delivery resulting from
the last two decades of social reform in three Latin American countries —
Argentina, Brazil and Mexico. Such earlier efforts included regional meetings
organized by the Asociacion Latinoamericana de Medicina Social (ALAMES,
Latin American association of social medicine) and national or multi-country
gatherings spearheaded by the Fundagao Oswaldo Cruz (FIOCRUZ, Oswaldo
Cruz foundation) and Fundagao Getulio Vargas (FGV) in Brazil, the Centro de
Estudios Sanitarios y Sociales (CESS, centre for health and social studies) in
Argentina, and the Universidad Autonoma Metropolitana - Xochimilco (UAM-
X, autonomous university of Mexico - Xochimilco) in Mexico.
IDRC shared the preoccupations of these institutions and was willing to
collaborate with FIOCRUZ, FGV, CESS, and UAM-X on a comparative
research project that posed particular challenges from both a methodological and
organizational point of view. First, comparability required the use of a similar
underlying conceptual model, study design and methods of data collection. At
the same time, an overly rigid approach had to be avoided to allow the specific
characteristics of each country to emerge. Second, a balanced approach was
needed to make best use of the strengths of both quantitative and qualitative
methods of inquiry. This was deemed crucial for a combined study of the larger
political context and household health services utilization. The third was the
daunting logistics of project implementation in three large countries, including
sampling frame and strategy, and questionnaire development and testing in two
languages. Lack of comparable baseline data on service use further complicated
the task.
By the same token, this comparative study is unique in the way it combines
and integrates both qualitative and quantitative analyses of health care across
three countries at various stages in the implementation of their own health sector
reforms. It not only sheds light on important issues pertaining to accessibility and
equity in the three countries, but also sets a precedent and provides
methodological and theoretical guidelines for further comparative work in this
area.
vii
viii PREFACE
The book is divided in four sections. Section I (Chapter 1) sets the scene
with a historical narrative, identifies key commonalities and differences between
the three systems, raises several socio-political issues of the last decade for
contextual analysis, and discusses various conceptual models used in the health
care literature before introducing the methodological approach used in this study.
Section II comprises three sub-sections, each including two chapters per
country. Thus, chapters 2,4 and 6 introduce the reader to the context and process
of health care reform in Argentina, Brazil and Mexico, respectively. The
emphasis is on political analysis of the main stakeholders and various processes
followed during implementation, including setbacks and compromises. These
chapters reveal how important and influential political traditions, degree of
transparency and pluralism, devolution of power, and democratization and
governance are in reforming the health care system.
Chapters 3, 5 and 7 take the reader to the heart of the matter. First, the
authors describe, both in narration and numbers and figures, the main health and
health care issues in each country. Using a similar format, they present a detailed
analysis of the relationships between the patients/population, providers and
payers in both the pre- and post-reform era. They go on to elucidate changes in
the roles and responsibilities of, and ultimately the power shift between, the
stake-holders in this tripartite relationship. The emphasis is placed on the main
health care functions of regulation, organization, financing, and service delivery.
Section IH (Chapter 8) provides a snapshot of the current status of health
services utilization in the three countries. The analysis is quantitative and
household-based, and is intended to complement the more qualitative and
sectoral (macro level) analyses of the previous section. Using a behavioural
model as its theoretical background, it presents the findings of a survey with a
representative sampling scheme that was carried out in Rosario, Rio de Janeiro,
and Mexico City to explore whether system- or patient-related factors play a
predominant role in access to and use of health care services. Obviously, such a
study cannot differentiate causes from effects, nor can it attribute observed
effects to health care reforms because of its cross-sectional nature and lack of
pre-reform baseline data. It proved useful, however, in providing a new baseline
for future utilization studies. More importantly, perhaps, it revealed — and to a
certain extent exposed — some of the inherent inequities in the three health care
systems. It did so by showing associations between income, out-of-pocket
payment, having a regular source of care, and entitlement, on the one hand, and
service use, on the other, at least for the three tracers of hypertension, prenatal
care and diarrhea.
PREFACE ix
Section IV (Chapter 9) provides a thorough discussion and synthesis of the
health care reforms in the three countries, draws on lessons from the recent
experience, and elaborates possible scenarios for the way forward.
The author notes the crucial roles of the timing of the reform with respect
to the economic crisis and the process of democratization; the process of
decentralization; and the instruments used to fulfill the key functions of
organizing, financing, regulating, planning, and participating in the reform
process.
The transformation of the social security system, either by incorporating it
into the public health care system or by opening it to competition from private
insurers and providers, is at the core of the reform process. On the other hand,
the trend toward decentralization appears to be the key issue for the public health
care system, although its modalities vary largely from one country to another.
The most important change, however, and the one affecting the entire dynamic of
the health care sector, is the role of the competitive market in health care
insurance and provision.
Possible combinations of the three sub-systems — public, social security
and market— suggest three possible scenarios for the future, namely,
competitive, dual, or specialized.
Under the competitive scenario, market competition becomes the prevalent
modality of organizing the health care system, subordinating or even replacing
the public integrated and compulsory models. The dual scenario occurs when
both the voluntary and the public system — compulsory or contracted — are
strong enough to maintain their own forms in parallel. The specialized scenario is
one in which all providing institutions are defined according to the package of
health care services they offer to each segment of the population.
Analyzing the feasibility and consequences of the three scenarios yields
some lessons from the experience of reform in the three countries and suggests
some measures to avoid segmenting the population along socio-economic lines
with respect to their degree of access to health care.
Noting that no special mechanism has so far been designed as part of the
reform in any of the three countries to promote solidarity across various socio-
economic layers of citizenry, the authors believe that the reform processes are
likely to deepen inequality in a region already well known for having the worst
distribution of wealth in the world.
Health care reform is necessary and important, not only because of the
significant improvements it can achieve in terms of access to health care and,
subsequently, better health, but also because it is often predictive of the direction
