Document(s) 2 of 14

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 Asociación Latinoamericana de Medicina Social (ALAMES, Latin American association of social medicine) and national or multi-country gatherings spearheaded by the Fundação Oswaldo Cruz (FIOCRUZ, Oswaldo Cruz foundation) and Fundação Getúlio Vargas (FGV) in Brazil, the Centro de Estudios Sanitarios y Sociales (CESS, centre for health and social studies) in Argentina, and the Universidad Autónoma 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.

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 III (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.

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 that other social and economic reforms will take since it reveals changes in the underlying value system. Depending on the direction it takes, health reform will either reinforce social cohesiveness or decrease it by aggravating existing inequalities — a crucial issue for the three countries in this study. It could also prove a precursor of changes in governance yet to come.

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Document(s) 2 of 14