Health and social security reforms in Latin America: the convergence of the World Health Organization, the World Bank, and transnational corporations.

International financial institutions have played an increasing role in the formation of social policy in Latin American countries over the last two decades, particularly in health and pension programs. World Bank loans and their attached policy conditions have promoted several social security reforms within a neoliberal framework that privileges the role of the market in the provision of health and pensions. Moreover, by endorsing the privatization of health services in Latin America, the World Health Organization has converged with these policies. The privatization of social security has benefited international corporations that become partners with local business elites. Thus the World Health Organization, international financial institutions, and transnational corporations have converged in the neoliberal reforms of social security in Latin America. Overall, the process represents a mechanism of resource transfer from labor to capital and sheds light on one of the ways in which neoliberalism may affect the health of Latin American populations.     

Why neoliberal health reforms have failed in Latin America

This paper reviews Latin American neoliberal health reforms sponsored by the IMF and the World Bank, and analyzes the impact on the region of decentralization and privatization, the two basic components of the reforms. The second part of the paper examines in some detail the Chilean and Colombian reforms, the two countries that have implemented closely the principles of the neoliberal reform. The two case studies confirm that neoliberal reforms do not improve quality of care, equity, and efficiency. In the discussion the authors identify the beneficiaries of the reforms: transnational corporations, consultant firms, and the World Bank's staff. The recognition of the beneficiaries helps to explain some of the reasons behind the Word Bank continuing pressures to implement neoliberal health reforms in spite the growing evidence of their failures.     

Neoliberal health sector reforms in Latin America: unprepared managers and unhappy workers]

This work analyzes the neoliberal health sector reforms that have taken place in Latin America, the preparation of health care workers for the reforms, the reforms' impacts on the workers, and the consequences that the reforms have had on efficiency and quality in the health sector. The piece also looks at the process of formulating and implementing the reforms. The piece utilizes secondary sources and in-depth interviews with health sector managers in Bolivia, Colombia, Costa Rica, the Dominican Republic, Ecuador, El Salvador, and Mexico. Neoliberal reforms have not solved the human resources problems that health sector evaluations and academic studies had identified as the leading causes of health system inefficiency and low-quality services that existed before the reforms. The reforms worsened the situation by putting new pressures on health personnel, in terms of both the lack of necessary training to face the challenges that came with the reforms and efforts to take away from workers the rights and benefits that they had gained during years of struggles by unions, and to replace them with temporary contracts, reduced job security, and lower benefits. The secrecy with which the reforms were developed and applied made workers even more unified. In response, unions opposed the reforms, and in some countries they were able to delay the reforms. The neoliberal reforms have not improved the efficiency or quality of health systems in Latin America despite the resources that have been invested. Nor have the neoliberal reforms supported specific changes that have been applied in the public sector and that have demonstrated their ability to solve important health problems. These specific changes have produced better results than the neoliberal reforms, and at a lower cost.     

Gender equity in health sector reform policies in Latin America and the Caribbean]

Gender equity is increasingly being acknowledged as an essential aspect of sustainable development and more specifically, of health development. The Pan American Health Organization's Program for Women, Health, and Development has been piloting for a year now a project known as Equidad de género en las políticas de reforma del sector de salud, whose objective is to promote gender equity in the health sector reform efforts in the Region. The first stage of the project is being conducted in Chile and Peru, along with some activities throughout the Region. The core of the project is the production and use of information as a tool for introducing changes geared toward achieving greater gender equity in health, particularly in connection with malefemale disparities that are unnecessary, avoidable, and unfair in health status, access to health care, and participation in decision-making within the health system. We expect that in three years the project will have brought about changes in the production of information and knowledge, advocacy, and information dissemination, as well as in the development, appropriation, and identification of intersectoral mechanisms that will make it possible for key figures in government and civil society to work together in setting and surveying policy on gender equity in health.     

Women, household and health in Latin America

Although recent studies have identified some of the links in Latin America between uneven capitalist economic development and health, the impact of development on either the health of women or on household health is still largely unknown. This account identifies several areas of needed research. It focuses on how changing women's roles and patterns of domestic production affect women's reproductive behavior, and the consequences of these changes for the health of women and other members of their households.     

Water privatization and public health in Latin America.

OBJECTIVES: This study had two objectives: (1) to determine what the public health and development literature has found regarding the public health outcomes of water privatization in Latin America and (2) to evaluate whether the benefits of water privatization, if any, outweigh the equity and justice concerns that privatization raises. METHODS: Using a standard set of terms to search several databases, the authors identified and reviewed articles and other materials from public health and development sources that were published between 1995 and 2005 and that evaluated the public health effects of water privatizations in Latin America from 1989 to 2000, based on (1) access to water by the poor and/or (2) improvements in public health. Next, the authors examined the experiences of three cities in Bolivia (Cochabamba, El Alto, and La Paz) in order to illuminate further the challenges of water privatization. Finally, the authors considered the equity and justice issues raised by the privatization of water. RESULTS: The literature review raised persistent concerns regarding access to water by the poor under privatization. The review also suggested that the public sector could deliver public health outcomes comparable to those of the private sector, as measured by access rates and decreasing child mortality rates. In terms of social equity and justice, privatization marked a troubling shift away from the conception of water as a "social good" and toward the conception of water--and water management services--as commodities. CONCLUSIONS: Our results indicated there is no compelling case for privatizing existing public water utilities based on public health grounds. From the perspective of equity and justice, water privatization may encourage a minimalist conception of social responsibility for public health that may hinder the development of public health capacities in the long run.     

Demographic growth and health needs in Latin America.

The net effect of the rapid population growth in Latin American countries is an increase in the needs for health services. Nevertheless, the demographic factor is not the only nor the most important consideration in determining how to satisfy these demands in the region. The main contradiction lies between the magnitude of needs for services generated by the adverse living conditions prevalling among the majority of the population, together with a restricted supply of health services, the availability of which varies according to social class. The problem of the increasing demand for medical care, generated by the rapid population growth, should be recognized as originating in the socioeconomic structural conditions prevailing in Latin American countries today which determine, simultaneously, low health levels, deficiencies in the provision of health services, and rapid population growth.     

Impact of sustainability policies on sterilization services in Latin America.

The Association for Voluntary Surgical Contraception retrospectively examined the impact of funding decreases on access to sterilization services at 20 nongovernmental family planning clinics in Mexico, the Dominican Republic, and Brazil. Clinic staff were asked questions about client fees, caseloads, availability of comparable low-cost or free services nearby, cost-recovery activities, and the socioeconomic profile of clients before, during the time, and after subsidies were lowered or eliminated. Funding reductions were followed by decreased caseloads at 14 of the 20 sites studied. Of the six others, four experienced an increase in caseloads, one saw no perceptible change, and one experienced a decrease only as a result of management policy to cut the caseload to improve quality. The most common response to the decrease in funding (shared by 17 sites) was an increase in client fees. In all but three of the 17 clinics, the increase in fees was met with a decline in caseloads. Moreover, at nine of these 17 sites, the fee increase effected a change in client mix; anecdotal evidence suggests that more middle-income and fewer lower-income clients were using sterilization services. Four lessons can be drawn from this study: Donors need to plan funding phase-outs carefully, in conjunction with grantees; grantees need to assess the costs of the procedure realistically, and assign fees accordingly; management needs to seek alternative funding sources in lieu of, or in addition to, increasing fees; and caseloads can be increased and costs recovered by diversifying services.     

Decentralization of health systems in Latin America.

Decentralization is often a major part of health reform policies. However, there have been few attempts to comparatively study the degree of decentralization and the effects of decentralization on equity of allocations to health, so we do not know how best to implement this reform. This article uses an innovative comparative analysis of the "decision space" that was allowed to local municipalities in the health reforms of Bolivia and Chile, two countries that have had several years of experience in implementing decentralization. The studies found that relatively little decision space was allowed to local authorities over key functions of health care systems. The studies also found that central authorities often reduce the decision space in order to direct more resources to health or to restrict local choice over human resources issues. The studies found that more equitable allocations of health funding were achieved through a common equalization fund for the municipalities in Chile and by forcing the assignment to health of a specific percentage of the central government transfers to municipalities in Bolivia.     

Governance and political economy of PHC policies in Latin America

The development of implementation processes of PHC policies in Latin America, is a challenge yet to be tackled. It is necessary to acknowledge the political economy related to the implementation processes of PHC policies in Latin America from a governance perspective, characterized by the regulatory strategies used and the political processes. The promotion of social values, organizational policies or the introduction of new financial incentives are components of different forms of governance used in health system reforms. The institutional factors of social protection systems in Latin America are considered. Their potential, redistribution limitations and the political economy disputes of the reform strategies are explained by the conflict between the economic and related interests and values of the actors involved. This dynamic of the political process influences regulatory modes inherent in the processes of implementation of PHC policies. The State's governing capacity and levels of health system segmentation impinge on the effectiveness of reform strategies for resolving the conflicts in the policies implemented.     

Neoliberal reforms in health services in Latin America: a critical view from two case studies]

Neoliberal reforms have promoted privatization and decentralization as strategies to improve equity, efficiency, and the quality of health services. In this piece the impact of these reforms in Latin America is critically analyzed, and the impacts of privatization in Colombia and of decentralization in Mexico are detailed. These two cases show that after 10 years of privatization in Colombia and 20 years of decentralization in Mexico the reforms have had the opposite of the desired effect: They have not improved equity, have increased health expenditures, have not increased efficiency, and have not shown a positive impact on quality. Public health programs in Colombia have deteriorated, while decentralization in Mexico has had a very high cost, without achieving the proposed objectives. It is officially accepted that decentralization in Mexico has increased inequity, and that new reforms implemented in 2003 promote vertical programs. Health systems based on regulated competition are not the most suitable ones for Latin America. Latin American countries should improve their health systems in line with the principles stated in the Declaration of Alma Ata and according to their own national experiences.