Managed care in Latin America: transnationalization of the health sector in the context of reform

This article presents the results of the comparative research project "Managed Care in Latin America: Its Role in Health Reform". The project was conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States. The study's objective was to analyze the process by which managed care is exported, especially from the United States, and how managed care is adopted in Latin American countries. Our research methods included qualitative and quantitative techniques. Adoption of managed care reflects transnationalization of the health sector. Our findings demonstrate the entrance of large multinational financial capital into the private insurance and health services sectors and their intention of participating in the administration of government institutions and medical/social security funds. We conclude that this basic change involving the slow adoption of managed care is facilitated by ideological changes with discourses accepting the inexorable nature of public sector reform.     

Quality and health care reform in Latin America and the Caribbean]

Improving the quality of basic health services, together with the search for equity, efficiency, sustainability, and social participation, has been one of the guiding principles of health sector reform initiatives ever since the I Summit of the Americas was held in 1994. This article addresses some basic concepts, examines the status of quality control within health systems and services in Latin America and the Caribbean, and analyzes the most important trends observed in the Region in the establishment of quality assurance programs. Finally, ways of improving and monitoring quality continuously and sustainable are recommended.     

Regional initiative on health care reform in Latin America and the Caribbean]

Many countries throughout Latin America and the Caribbean are introducing reforms that can profoundly influence how health services are provided and who receives them. Governments in the region identified the need for a network to support health reform by building capacity in analysis and training, both at the Summit of the Americas in 1994 and at the Special Meeting on Health Sector Reform, which was convened in 1995 by an interagency committee of the Pan American Health Organization/World Health Organization, the Inter-American Development Bank, the World Bank, and other multilateral and bilateral agencies. In response, in 1997 the Pan American Health Organization and the United States Agency for the International Development launched the Latin America and Caribbean Regional Health Sector Reform Initiative. The Initiative has approximately US$ 10 million in funding through the year 2002 to support activities in Bolivia, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Paraguay, and Peru. Now in its third year of implementation, the Initiative supports regional activities seeking to promote more equitable and effective delivery of basic health services.     

Mental health policy developments in Latin America

New assessment guidelines for measuring the overall impact of mental health problems in Latin America have served as a catalyst for countries to review their mental health policies. Latin American countries have taken various steps to address long-standing problems such as structural difficulties, scarce financial and human resources, and social, political, and cultural obstacles in the implementation of mental health policies and legislation. These policy developments, however, have had uneven results. Policies must reflect the desire, determination, and commitment of policy-makers to take mental health seriously and look after people's mental health needs. This paper describes the development of mental health policies in Latin American countries, focusing on published data in peer-reviewed journals, and legislative change and its implementation. It presents a brief history of mental health policy developments, and analyzes the basis and practicalities of current practice.     

Equity and health systems reform in Latin America

The aim of any health care system is to help improve the people's health, and to do so as efficiently as possible. In order to improve the efficiency and equity of health services provision, many countries around the world have implemented reforms, including several Latin American nations. However similar the objectives may appear, the various ways societies implement such reforms reflect different values and concepts. This article analyzes the egalitarian and neoliberal values underlying different concepts of equity in health care. The authors develop criteria to interpret selected health services funding and provision strategies in Latin American health system reforms. These criteria are then applied to health care financing and delivery policies under the reforms currently being implemented in Colombia and Costa Rica.     

Family health care spending in Latin America

Household budget data from surveys in six Latin American countries, 1966-75, are used to estimate income elasticities of private health care spending. For ten cities in five countries the elasticity is constant at 1.5; for metropolitan, other urban, and rural areas of Brazil it is constant at 1.17. The Brazilian data also show 30 percent higher spending in small than in large cities, and 50 percent higher in the countryside. These results are consistent with supposing that private care is a luxury compared to public care, and that more is spent on the former when the latter is not available. Geographic differences may be exaggerated by differences in payment mechanisms, since reported out-of-pocket expenditure is not net of public reimbursement. Different components of spending such as drugs and hospitalization show very different behavior from the total.     

Latin American health policy and additive reform: the case of Guatemala

Until the mid-1960s, the market-based, dependent-development-conditioned structure of Latin American health systems reflected the skewed distribution of wealth in the region: most (including government) health resources were found in curative care medicine and were concentrated in the capital cities, where they primarily served the needs of the elite. But for many countries of the area, the 1964 PAHO-led efforts to introduce health planning, intended as a first step in rationalizing the health sector, marked a fundamental turning point in the structural development of their delivery systems. Since then, this commitment has been reaffirmed in the Latin American Ministers of Health's 1973 adoption of the primary care approach as the cornerstone of their national health plans, and their ongoing endorsement and pursuit of "Health For All by 2000." Guatemala, however, was and remains an exception. Guatemalan technocrats have proven unable to plan effectively. But, far more fundamentally, the Guatemalan oligarchy has proven unwilling to appropriate the resources necessary to effect change. The reforms that have been made have been the products of bilateral and multilateral agencies, which have conceptualized, promoted, designed, built, and underwritten them. Those changes have not altered the fundamental structure of the system, but instead have been tacked onto it, and exemplify what may be termed "additive reform." Evidence suggests that without the continued sponsorship, support, and guidance of the bilateral and multilateral agencies, even these "reforms" will prove evanescent.     

Managed behavioral health care provider practice patterns: a new item for the public policy agenda

Managed care is a dominating issue on the public policy agenda. Difficulties in defining and operationalizing it continue to have ramifications for the nation. It is often assumed that the care being reimbursed by managed care organizations is for clients whose psychiatric conditions have been appropriately diagnosed and treated. Based on the responses of a randomly-selected group from the major behavioral health care disciplines, not all care reimbursed is for care which has been appropriately diagnosed and treated. The cost implications of managed care and the ramifications for public health policy are discussed.     

The reform process and social participation in health in Latin America

Currently, many countries throughout the world are reforming their health services. Even though these reforms differ according to the country's characteristics, they share many policies, one of which is the promotion of social participation in health-related matters. This policy, however, is not new in the field of health service organization. Throughout the last century, individual or collective collaboration between the population and health services has been promoted by several philosophies and concepts with different aims: from the search for collaboration with the general public to broaden public health system coverage to the promotion of the creation of mechanisms that would allow society to exercise control over these services' performance. Nevertheless, for the public to be involved with these services, several factors concerning both the services themselves and the population, need to converge. Although the theoretical frameworks that have encouraged social participation throughout the history of the development of health systems differ considerably, their practical implementation shares many common elements in all periods, from participation as a means of obtaining certain objectives to being an end in itself, as a democratic process. This can also be applied to the current promotion of social participation policies in the context of health care reforms, which are analyzed using Colombia and Brazil as examples.     

Understanding health care service quality in developing Latin America

Researchers have overlooked how poor consumers judge service quality in health care settings in Latin America. This research addresses this void by exploring how vulnerable consumers evaluate quality in a public hospital. The results show that vulnerable consumers evaluate hospitals on service delivery process, physician–patient relationship, and medical service reliability. Vulnerable consumers judge health care quality foremost on a provider’s ability to provide them with fairness. The results also show that vulnerable consumers view the quality of their relationship with a physician just as important as reliability. Hospitals that serve vulnerable patients should strive to emphasize fairness and empathy.     

新医改背景下社区卫生服务若干政策问题的探讨

在新医改政策精神的指导下,医药卫生体制改革进入新阶段,社区卫生服务也面临着新的机遇和挑战。本文从理论层面探讨了社区卫生服务中国家基本药物、信息化建设、绩效考核和人员编制、人才培养以及城乡医疗卫生服务均等化等几大核心问题,对其现有的政策逻辑、面临的问题挑战以及相应的对策建议进行了思考。     

Structured pluralism: towards an innovative model for health system reform in Latin America

Health systems throughout the world are searching for better ways of responding to present and future challenges. Latin America is no exception in this innovative process. Health systems in this region have to face a dual challenge: on the one hand, they must deal with a backlog of accumulated problems characteristic of underdeveloped societies; on the other hand, they are already facing a set of emerging problems characteristic of industrialized countries. This paper aims at analyzing the performance of current health systems in Latin America, while proposing an innovative model to promote equity, quality, and efficiency. We first develop a conceptualization of health systems in terms of the relationships between populations and institutions. In order to meet population needs, health systems must perform four basic functions. Two of these-financing and delivery-are conventional functions performed by every health system. The other two have often been carried out only in an implicit way or not at all. These neglected functions are 'modulation' (a broader concept than regulation, which involves setting transparent and fair rules of the game) and 'articulation' (which makes it possible to organize and manage a series of transactions among members of the population, financing agencies, and providers so that resources can flow into the production and consumption of services). Based on this conceptual framework, the paper offers a classification of current health system models in Latin America. The most frequent one, the segmented model, is criticized because it segregates the different social groups into three segments: the ministry of health, the social security institute(s), and the private sector. Each of these is vertically integrated, so that it performs all functions but only for a particular group. As an alternative, we propose a model of 'structured pluralism', which would turn the current system around by organizing it according to functions rather than social groups. In this model, modulation would become the central mission of the ministry of health, which would move out of the direct provision of personal health services. Financing would be the main function of social security institutes, which would be gradually extended to protect the entire population. The articulation function would be made explicit by fostering the establishment of 'organizations for health services articulation', which would perform a series of crucial activities, including the competitive enrollment of populations into health plans in exchange for a risk-adjusted capitation, the specification of explicit packages of benefits or interventions, the organization of networks of providers so as to structure consumer choices, the design and implementation of incentives to providers through payment mechanisms, and the management of quality of care. Finally, the delivery function would be open to pluralism that would be adapted to differential needs of urban and rural populations. After examining the convergence of various reform initiatives towards elements of the structured pluralism model, the paper reviews both the technical instruments and the political strategies for implementing changes. The worldwide health reform movement needs to sustain a systematic sharing of the unique learning opportunity that each reform experience represents.     

Health sector reform and reproductive health in Latin America and the Caribbean: strengthening the links

Many countries in Latin America and the Caribbean (LAC) are currently reforming their national health sectors and also implementing a comprehensive approach to reproductive health care. Three regional workshops to explore how health sector reform could improve reproductive health services have revealed the inherently complex, competing, and political nature of health sector reform and reproductive health. The objectives of reproductive health care can run parallel to those of health sector reform in that both are concerned with promoting equitable access to high quality care by means of integrated approaches to primary health care, and by the involvement of the public in setting health sector priorities. However, there is a serious risk that health reforms will be driven mainly by financial and/or political considerations and not by the need to improve the quality of health services as a basic human right. With only limited changes to the health systems in many Latin American and Caribbean countries and a handful of examples of positive progress resulting from reforms, the gap between rhetoric and practice remains wide.     

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.     

CFOs: cost-shift pressures will spur health care policy reform

Hospitals are "on the verge of self-destruction" because they are finding it more difficult to shift costs to those few payers who pay full charges, say CFOs. In fact, the inability to continue shifting costs will lead to national health care reform, say members of a panel of CFOs hosted by Hospitals.