COMMERCIALLY ORIENTED HEALTH SYSTEMS: A MODEL?

Transcription

1 Round table 2 COMMERCIALLY ORIENTED HEALTH SYSTEMS: A MODEL? Evidence from Latin America 16:00-16:10 16:10-16:20 16:20-16:30 16:30-16:40 Introduction PROF. RUBEN DARÍO GOMEZ ARIAS, University of Antoquia, Medellín, Colombia DR. EDUARDO ESPINOZA, Vice Minister for Health Policies, El Salvador PROF. ALICIA STOLKINER University of Buenos Aires PROF. LIGIA GIOVANELLA FIOCRUZ Reforms of first and second generation in Colombia Socially oriented reforms of the El Salvador health system lessons for Europe The impact on health of the 90 s neo liberal reform and the 2001 crisis in Argentina A comparison between Latin America and Europe: the organization of first line services, with special emphasis on the role of nurses 16:40-17:00 PANEL: Mariza Matías, European Parliamentary Ivonne Cisneros, University of Vera Cruz María Luiza Vásquez Hospitals Consortium of Catalonia

2 Round table 3 COMMERCIALLY ORIENTED HEALTH SYSTEMS: A MODEL? Evidence from Latin America First and second generation reforms in Colombia Executive Secretary. Colombian Network of Research on Health Policy and Systems Professor of Epidemiology. National School of Public Health University of Antioquia. Medellin

3 The health reforms that began at the end of the 80's in LA were not the result of internal consensus nor of endogenous analysis, but of foreign interests and pressures that were imposed on the domestic political systems with the support of local elites. The case of Colombia may illustrate the dynamics and consequences of these reforms.

4 Much of our social, economic and political history has been marked by the history of other countries and other contexts. So have health policies and reforms The deep crisis caused in Europe by the Second World War also affected our countries.

5 The great crisis of the postwar In Europe, to address the crisis, Keynesian models propose Welfare States John Meynard Keynes Social investment is channeled to basic needs 2. The low cost production is pushed 3. It invests in public services for people 4. Consumption capacity is improved The State is the protagonist of social development

6 Latin America copied Welfare States Latin America, also faces its crisis Ruthless exploitation Corruption Relations of economic dependence Fragile democracies Threatened in their legitimacy and sustainability, Latin American governments seek refuge in the 'welfare states' Welfare State principles were expanded throughout the region as the alternative to chaos Fotos: Sebastián Salgado.

7 Colombia, like the majority of the countries in the region, installed National Health Systems installed NHS Model: State system of public assistance Target population: Claim for universal coverage Financing: State (National and departmental revenues) Central and governmental control of resources Functional integration through affiliation and links agreements with public and private institutions. Single statewide network organized by levels of complexity Focused on Local Hospital as provider and health authority Integration of care to environment and people Subsystems of information, planning and investment Consistent legislation with the system health (Law 9 of 1979)

8 The National Health System (NHS) of Colombia Coverage 1993 Access to health care GDP Health investment 1,3% of GDP Not covered 37% NHS 33% Private 10% Social Security 20% Limitations 1. Underfunding 2. Mismanagement 3. Concentration of resources in third level 4. Low coverages Achievements 1. Control of tuberculosis 2. Leprosy Control MINISTERIO DE SALUD 3. Control of epidemics 4. Reduction of Maternal Mortality DIRECCIONES SECCIONALES DE SALUD 5. Reduction of Infant Mortality 6. Emergency 7. environmental sanitation

9 But one thing are Welfare States in Europe and quite another in Latin America Tasas ajustadas por 100 mil habitantes Achievements TBC Incidence Avoidable Mortality by prevention Tuberculosis control 2. Leprosy Control 3. Control of epidemics 4. Maternal Mortality 5. Infant mortality 6. Emergencies 7. Environmental sanitation Obstetric mortality MORTALIDAD MATERNA. COLOMBIA ANALISIS DE JOINPOINT Perinatal. Mortality Intra and Interinstitutional articulation 2. Health planning 3. Information Systems 4. Community Participation DB MA AÑO

10 The 80s: Markets recover and generate the "crisis" of the welfare state Milton Friedman New York 1912 Sn Fco : Golden years of capitalism. The market recognizes public goods and services as a source of untapped income The Welfare State, owner of public goods, is no longer the savior, but the big competitor Investors take on the Welfare State Thomas Hobbes ( ) Technological development Concentration of wealth Concentration of power Recovery of the principles of economic liberalism First generation reforms

11 Birds of a feather flock together : The Washington Consensus Guidelines for LA and the rest of the World John Williamson Herford-England 1937 Peterson Institute for international economics 1. Fiscal discipline in spending 2. Reordering of spending priorities 3. Broad-based tax reforms 4. Liberalization of interest rates 5. Competitive exchange rates 6. Liberalization of international trade 7. Liberalization of inward foreign direct investment 8. Privatization of public goods and services 9. Deregulation of transactions 10. Protection of private property rights 1. Williamson, John: What Washington Means by Policy Reform. Conference. Institute for International Economics Williamson, John: What Washington Means by Policy Reform, in: Williamson, John (ed.): Latin American Readjustment: How Much has Happened, Washington: Institute for International Economics Williamson, John; A Short History of the Washington Consensus, Barcelona, 2004

12 The Washington Consensus causes two types of policies First generation reforms Addressed to dismantle welfare states and trade controls. In Colombia beginning in the late '80s and propose decentralization as a strategy to overcome poverty Law 14 of 1983: Fiscal strengthening the regions Law 12 of 1986: VAT to municipalities Legislative Act No. 1 of 1986: Popular Election of Mayors Law 60 of 1993 of competences and resources In less than 10 years these policies fragmented and weakened the precarious institutions of the Colombian State 12

13 1990 Second generation reforms Designed to ensure the appropriation of public resources by private investors. Are proposed by international banking and political elite, supported on the model of first generation reforms. Law 60. Decentralization of public administration Strengthening the financial sector to make it attractive to the private sector 1990 Law 10 dismantling the NHS 1993 Investing in Health Policy. World Bank Strengthen investment in the sector Organize services under market principles Promote competition Approval of Law Regulation of transition Desde 1996 Proceso de implementación 2007 Ley 1122 Consolidates the model 13

14 Although Law 100 of 1993 tripled the financial resources Health indicators deteriorated Public expenditure on health, and health insurance coverage ( ). Colombia. (1995 Pesos) Incidence of TBC Avoidable Mortalidad Obstetric Mortalit y Perinatal. Mortality Jramillo I En dónde está el dinero de la salud? El Pulso. Medellín. No 104; Mayo Barón Gilberto. Gasto Nacional en Salud de Colombia : Composición y Tendencias Rev. salud pública. 9 (2): ,

15 After 20 years of law Healthcare market was established in one of the most lucrative areas of business 2. The public services network passed to the private sector 3. Insurers consolidated as a one of the major economic and political power of the country 1. Public health indicators deteriorated Health authority weakened Drug and services costs increased Health service network became fragmented Health activities were disassembled Information system was dismantled Planning system was dismantled The crisis of the state hospitals was generated Popular protests have increased Arbeláez M, Gaviria M, Franco A, Restrepo R, Hincapié D, Blas E. Tuberculosis control and managed competition in Colombia. Int J Health Plann Mgmt 2004; 2004(19):S25-S43 Gómez-Arias RD. La mortalidad evitable como indicador de impacto de la reforma sanitaria. Colombia Revista Facultad Nacional de Salud Pública. Universidad de Antioquia. Medellín. 2008

16 La historia nos da lecciones Each country should decide the course of its history... But since we do not have time to learn from our mistakes, history teaches us lessons. We should at least learn from the mistakes of others...