Rubén Darío Gómez-Arias [email protected]
Round table 2 COMMERCIALLY ORIENTED HEALTH SYSTEMS: A
MODEL?
Evidence from Latin America
16:00-16:10
Introduction
PROF. RUBEN DARÍO GOMEZ ARIAS, University of Antoquia, Medellín, Colombia
Reforms of first and second generation in Colombia
16:10-16:20 DR. EDUARDO ESPINOZA, Vice Minister for Health Policies, El
Salvador
Socially oriented reforms of the El Salvador health system –
lessons for Europe
16:20-16:30 PROF. ALICIA STOLKINER University of Buenos Aires
The impact on health of the 90’s neo liberal reform and the 2001
crisis in Argentina
16:30-16:40 PROF. LIGIA GIOVANELLA FIOCRUZ
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
Rubén Darío Gómez-Arias [email protected]
Round table 3
COMMERCIALLY ORIENTED HEALTH SYSTEMS: A MODEL?
Evidence from Latin America
Rubén Darío Gómez-Arias
Executive Secretary. Colombian Network of Research on Health Policy and Systems Professor of Epidemiology. National School of Public Health University of Antioquia. Medellin [email protected]
First and second generation reforms
in Colombia
Rubén Darío Gómez-Arias [email protected]
The case of Colombia may illustrate the dynamics and consequences of these reforms.
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.
Rubén Darío Gómez-Arias [email protected]
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.
Rubén Darío Gómez-Arias [email protected]
1. 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 great crisis of the postwar
In Europe, to address the crisis, Keynesian models propose Welfare States
John Meynard Keynes 1883-1946
The State is the protagonist of social development
Rubén Darío Gómez-Arias [email protected]
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. http://www.revistafuturos.info/futuros_8/pobreza1.htm
http://www.lr21.com.uy/comunidad/229164-la-pobreza-en-latinoamerica-se-ubico-por-debajo-del-40-su-nivel-mas-bajo-en-25-anos
Rubén Darío Gómez-Arias [email protected]
Colombia, like the majority of the countries in the region, installed National Health Systems installed
• 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)
NHS 1975-1990
Rubén Darío Gómez-Arias [email protected]
GDP
The National Health System (NHS) of Colombia
MINISTERIO DE SALUD
DIRECCIONES SECCIONALES DE SALUD
1. Control of tuberculosis 2. Leprosy Control 3. Control of epidemics 4. Reduction of Maternal
Mortality 5. Reduction of Infant Mortality 6. Emergency 7. environmental sanitation
Achievements
1. Underfunding 2. Mismanagement 3. Concentration of resources in
third level 4. Low coverages
Limitations
NHS 33%
Social Security
20% Private
10%
Not covered
37%
Coverage 1993 Access to health care
Health investment
1,3% of GDP
Rubén Darío Gómez-Arias [email protected]
But one thing are Welfare States in Europe and quite another in Latin America
TBC Incidence 1983-1993 Avoidable Mortality by prevention 1985-1993
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
DB 157 135 134 109 115 105 100 101 100 91 78 82 81 99 126 138 114
MA 139 134 128 122 117 111 105 100 94 89 83 77 88 99 110 121 132
60
70
80
90
100
110
120
130
140
150
160
Ta
sa
s a
justa
da
s p
or
10
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il h
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ita
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s
AÑO
MORTALIDAD MATERNA. COLOMBIA 1985-2001 ANALISIS DE JOINPOINT
Obstetric mortality
1985-1993
Perinatal. Mortality
1985-1993
1. Tuberculosis control 2. Leprosy Control 3. Control of epidemics 4. Maternal Mortality 5. Infant mortality 6. Emergencies 7. Environmental sanitation
Achievements
1. Intra and Interinstitutional
articulation 2. Health planning 3. Information Systems 4. Community Participation
Rubén Darío Gómez-Arias [email protected]
1945-1973: 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
The 80s: Markets recover and generate the "crisis" of the welfare state
• Recovery of the principles of economic liberalism
• First generation reforms
Milton Friedman New York 1912 –Sn Fco 2006
Thomas Hobbes (1588-1679)
Concentration of wealth
Concentration of power
Technological development
Rubén Darío Gómez-Arias [email protected]
1. Williamson, John: What Washington Means by Policy Reform. Conference. Institute for International Economics. 1989. 2. Williamson, John: What Washington Means by Policy Reform, in: Williamson, John (ed.): Latin American Readjustment: How Much has
Happened, Washington: Institute for International Economics 1989. 3. Williamson, John; A Short History of the Washington Consensus, Barcelona, 2004
1980: The Washington Consensus Guidelines for LA and the rest of the World
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
John Williamson Herford-England
1937
Peterson Institute for international economics
Birds of a feather flock together ...
Rubén Darío Gómez-Arias [email protected]
12
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
The Washington Consensus causes two types of policies
• 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
Rubén Darío Gómez-Arias [email protected]
13
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 100
1994-1995. Regulation of transition
Desde 1996 Proceso de implementación 2007 Ley 1122 Consolidates the model
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.
Rubén Darío Gómez-Arias [email protected]
Incidence of TBC 1983 – 2001
Obstetric Mortalit y 1985-2001
Avoidable Mortalidad. 1985-
2001
Perinatal. Mortality 1985-2001
14
Although Law 100 of
1993 tripled the
financial resources
1. Jramillo I ¿En dónde está el dinero de la salud? El Pulso. Medellín . No 104; Mayo 2007
2. Barón Gilberto. Gasto Nacional en Salud de Colombia 1993-2003: Composición y Tendencias Rev. salud pública. 9 (2):167-
179, 2007
Public expenditure on health, and health insurance coverage (1980-2004). Colombia. (1995 Pesos)
Health indicators deteriorated
Rubén Darío Gómez-Arias [email protected]
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 1985 – 2001. Revista Facultad Nacional de Salud Pública.
Universidad de Antioquia. Medellín. 2008
After 20 years of law 100
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
1. 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
Rubén Darío Gómez-Arias [email protected]
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 ....