Les auteurs (Stephen Isaacs, J. D., et Giorgio Solimano, M. D.) rappellent la relation de l'économie avec la santé et le bien-être de la population. La nouvelle donne véhiculée par la mondialisation, facilitée par la chute de l'URSS, ouvre la porte à la décentralisation et à la privatisation du monde de la santé, ce qui signifie la fin de l'aide de l'État.
Four related elements have converged during the last decade and a half that are affecting the health and well-being of individuals and on a larger scale, the socioeconomic development of Latin America. The first is the widespread acceptance of an economic theory of growth based on open, market-based economy driven by private for-profit companies. The second is the arrival of a global economy where goods and services cross national boundaries with ease (and, some fear, threaten to erase those national boundaries). The third - reflecting the logic of the first two - is a dramatic shift towards privatized, for-profit managed care systems as the providers of health services. The fourth is a reduced and increasingly decentralized governmental role in the provision of health services.
These elements are skewing health services away from those most in need to those who most can pay; are shifting the focus from community-oriented preventative care to individually oriented curative care; and are exacerbating the inequalities in health and health care services that have long characterized Latin America. The time is right to reconsider health reform and to move towards a more equitable system of health services delivery. Thanks to a fifth convergent element - the rise of democracies in Latin America - civil society has become a significant force in shaping public policies and can play an important leadership role in reforming the region’s health reforms.
Globalization and Market Economics
The collapse of the Soviet Union removed the last countervailing force to the international acceptance of the economic theories adopted by the United States in the 1980s during the presidency of Ronald Reagan and followed, with modest adaptations, in the 1990s during the presidency of Bill Clinton. These theories posited that for development - measured by growth of the gross domestic product - to occur, inflation must be held in check and a number of structural elements must be in place: The size of government must be reduced and services previously provided by governments shifted elsewhere, largely to the private sector. The private sector must be unleashed and constraints - such as legal and regulatory restrictions - minimized. To the extent that government continues to provide social and other services, they must be decentralized, i.e., provided by state and local governments rather than the central government.
These ideas were adopted during the 1980s by international and bilateral aid agencies who, thanks to a deteriorating financial situation in the region, exercised tremendous power over nations’ economic policy. As debt-ridden nations - from Argentina to Mexico - sought loans and grants from international donors, structural adjustments based on these ideas were the price of debt relief imposed by the World Bank, the International Monetary Fund, the Inter American Bank, and the U.S. Agency for International Development.
Health Reform in Latin America
Although international agencies talk with one voice in Latin America, the World Bank has played a particularly important role in the region’s health reform. Its 1987 publication, Financing Health Services in Developing Countries, set an agenda for reform for those countries that wanted to have access to World Bank funds.1 In essence, this publication conceived the problem as one of runaway expenditures in the health sector and proposed four steps to bring costs under control: (1) increase the amount patients pay for their own health care; (2) develop health insurance mechanisms (3) expand the participation of the private sector, and (4) decentralize governmental health care services. Its influential 1993 World Development Report, Investing in Health, reinforced this approach to health reform and articulated the rationale for it.2
Under the influence of international financial and aid agencies - and their own ministries of finance - most Latin American countries reformed their health care systems in accordance with the principles enunciated by the World Bank. They opened their health sectors to for-profit multinational managed care corporations, most of whom are based in the United States.
The example of Chile is illustrative. In the 1960s and 1970s, Chile had a national health system that provided for the basic health care needs of nearly all of the country’s citizenry. Under the government of General Augusto Pinochet, Chile dismantled its widely admired system. The 1980 constitution, for example, permitted government health care and social security funds to be used for privatized managed care entities called “ISAPREs” (Instituciones de Salud Previsional) that could be bought by multinational insurance companies. Aetna, a United States-based insurance company, for example, covers 60,000 members through its Chilean subsidiary, and CIGNA, another U.S.-based insurance company, provides managed care coverage to about 100,000 people through its Chilean subsidiary3. Health care services for those who could not or did not subscribe to an ISAPRE are provided, increasingly, by underfunded and strained local hospitals and clinics.
Similar patterns of for-profit multinational managed care penetration have been seen throughout the hemisphere. Aetna acquired a 49 percent interest in Sul America Seguros, the largest insurance company in Brazil with 1.6 million managed care enrollees. CIGNA has initiated managed care operations throughout Latin America: for example, in Brazil it manages the care of 2.5 million enrollees through a joint venture with a large bank and a prepaid health plan and in Guatemala, it covers 40,000 enrollees through its managed care system. The Principal Financial Group, the American International Group, and the EXXEL Group are some of the large multinational companies competing to secure a place in the burgeoning Latin American managed care market.
Although health reforms in Latin America were justified on the grounds that they would improve both efficiency and equity, in practice, the former has been favored over the latter. Managed care organizations in Latin America attempt to attract members who are young, relatively healthy, and make few claims. This leaves underfunded local governments to cover the older, sicker, and more expensive patients, inducing what Argentine political scientist Eduardo Bustelo calls “a dual form of health services - with the state for the poor and the market for the rich”5. These trends raise a number if basic considerations, among them:
1. The kind and extent of health care that society is willing to guarantee and finance for its citizens
Although it has never been put into practice adequately, Latin American constitutions, by and large, contain a provision guaranteeing a right to health care. Now, for the first time, the societal guarantee of health care is undercut by a development model that posits Growth first, Then distribution and a health reform model where cost control takes precedence over disease control.
The current health care reforms signal a retreat from the principle of “Health for All” adopted at Alma Ata over two decades ago. Without a basic package of services guaranteed for all citizens, it retreats even from the limited interventions suggested by the GOBI approach.
Moreover, health reforms have weakened long established national health services and replaced them with a dynamic in which profit maximization is the major guide to health policies6. With government budgets being slashed at all levels, the effect is felt most strongly at local levels where sufficient resources do not exist to offer basic services to vulnerable populations. Although bringing services closer to the people is desirable, without adequate funding it remains an empty promise.
Health reforms have also led to an emphasis on curative services - which are more profitable in the short run - over preventative and public health services whose benefits take longer to manifest themselves. The health profile of Latin America is a curious one. On the one hand, it is characterized by infectious diseases, high infant and maternal mortality, and other illnesses associated with poverty - particularly rural poverty. On the other hand, Latin America is rapidly urbanizing and the health of many of its residents is characterized by cancers, cardiovascular diseases, stress, and other conditions more common in the United States and Western Europe. People living in or around urban areas die or become ill increasingly from diseases ultimately traceable to tobacco, bad diet, lack of exercise, or environmental contamination. However, because the market tends to favor highly technical treatments, preventive services such as basic nutrition, reproductive health, smoking cessation, are neglected. And because markets look for those who can afford to pay, people living in rural or urban poverty tend to be ignored.
2. The Role of Government, the Commercial Sector, and Civil Society
The 1980s and 1990s can be characterized by a widespread revolution in the way the respective roles of government, business, and civil society are perceived. Put simply, as the role of government - especially central government - diminishes, the roles of business and civil society tend to increase. Health care business in Latin America has boomed recently. With privatization, and agreements such as GATT easing trade restrictions, for-profit managed care corporations have jumped into Latin American markets. As the president of the Association of Latin American Pre-paid Health Plans has stated, “By the year 2000, it is estimated that 80 percent of the total U.S. population will be insured by some sort of managed care organization. Since 70 percent of all American managed care organizations are for-profit enterprises, new markets are needed to sustain growth and return on investment.”7
Similarly, the role of civil society is increasing. It is expected to fill at least some of the gaps caused by government’s abandoning its traditional role as the provider of “safety net” services. However, the resources that would enable civil society organizations to play a larger role in providing services and information have not kept up with the need.
While nobody favors bloated government and unresponsive bureaucrats, it is appropriate to ask whether the pendulum has swung too far and whether the roles of government, business, and civil society should not be reconsidered again? In particular, it is timely to ask whether the role of the government should be something more than a croupier in an international game of economic roulette?
3. Efficiency and Equity in Health Reform
Health reform in Latin America has been justified on the grounds that it will bring about more efficiency in the delivery of health care services and that it will lead to more equitable distribution of health care services8. However, in practice, the health reforms and the economic adjustments which they are part of have led to unprecedented inequality. The 1996 United Nations Human Development Report notes that the world’s 358 richest individuals control economic assets equivalent to the combined annual incomes of the poor countries that are home to 45 percent of the world’s population9. According to health policy analyst Vicente Navarro, this situation is the primary cause of the slowdown in the health improvements that occurred worldwide in the previous decades, “causing stagnation and even declines in the level of health and well-being in many regions of the world”10. Certainly, there is mounting evidence that income inequality itself - rather than poverty - affects health. That is, income inequality per se predicts excess mortality even after median income, poverty rates, smoking prevalence, and race are taken into account.11
The negative effect on health of income disparity is reinforced by the region’s health reforms with their incentives to enroll younger, healthier people of means and avoid those who are older, sicker, or with chronic illnesses. In Chile, for example, every year approximately 24 percent of those covered by ISAPRE managed care organizations go to public health clinics and hospitals for medical care because they cannot afford the co-payments (i.e., the amount they themselves must pay out-of-pocket for the services the receive)12. Similar situations have been reported elsewhere.
The Role of Civil Society
Globalization and an international market economy have led to unparalleled prosperity in many parts of the world. It is not likely to be reversed, nor would we suggest that it should be reversed. However, as we have noted earlier, globalization has a darker side whose negative effects should be tempered. In the case of health reforms, for-profit managed care offered by multinational insurance companies and their subsidiaries can reduce costs and, in the best of cases, lead to more coordinated care, but they can also result in inequitable access to services, avoidance of more costly patients, dismantling public health systems, tearing of safety nets, and lower priority to preventive services.
Civil society in Latin America can play an important role in creating the conditions that will bring about more equity in health care. Prior to the breakup of the Soviet Union and the democratization of Eastern Europe, the term “civil society” was not used frequently. Although begun in the context of Eastern Europe, it has meaning in Latin America which, too, has embraced democracy as it has turned away from dictatorships.
In Latin America, civil society is largely considered to encompass those organizations that pursue social welfare goals, such as human rights, environment, health, and women’s rights. (These organizations are sometimes referred to as “nongovernmental organizations,” or NGOs. We prefer the term “civil society organizations” on the grounds that is preferable to describe an organization in terms of what it is rather than what it is not.) Civil society is sometimes considered to include groups such as labor unions and ecclesiastic organizations as well.
Generally speaking, civil society organizations are weak and fragmented, competing with each other for limited resources. Often, their members talk only to others with similar interests - women’s groups talk to other women’s groups; environmentalists talk to other environmentalists, and so forth. Despite these drawbacks, civil society organizations have had a demonstrated impact in improving social policy. In a number of countries, environmental groups were instrumental in securing the passage of legislation and in seeing that laws were enforced. Women’s organizations, in combination with civil society organizations from other fields, came together at the International Conference on Population and Development held in Cairo in 1994 to advance the reproductive health agenda that has been dominant since that time. Human rights organizations have played effective roles in challenging dictatorships and bringing about a return to democracy.
The potential for civil society to bolster new democracies and to affect social policy has not gone unnoticed. For example, the Civil Society Forum of the Americas is bringing together leaders of civil society organizations from different fields and providing a space for them to develop common strategies that address pressing issues of social concern. The Civil Society Forum of the Americas organized a meeting in March, 1999, to examine health reform in Latin America, its effect on vulnerable populations, and the appropriate role of government, the commercial sector, and civil society. Held in Santiago, Chile, and attended by 75 prominent health care experts and leaders of civil society organizations from diverse fields, the conference participants took one of the first hard analytical looks at health reform. They concluded that it is now necessary to “reform the health reforms” to ensure equity as well as cut costs; that the state should be play a more active role than that of a croupier, and that a more integrated, prevention-oriented view of health should be emphasized. The participants strongly recommended that civil society should play a more active role in promoting progressive health policies.”
This recommendation should set the stage for new collaborations between representatives of diverse civil society organizations and health professionals in an effort to examine the effects of health reforms and to bring about fairer and more equitable health policies that address today’s pressing health needs.
1) World Bank, Financing Health Services in Developing Countries: An Agenda for Reform (World Bank, 1990).
2) World Bank, World Development Report 1993: Investing in Health (World Bank, 1993).
3) Karen Stocker, Howard Waitzkin, and Celia Iriart, "The Exportation of Managed Care to Latin America", New England Journal of Medicine, 340:1131-1136, April 8, 1999.
5) Eduardo S. Bustelo, "Salud y Ciudadanía", paper presented at the Conference on Health Reform in Latin America, Santiago, Chile, March, 1999.
6) Vicente Navarro, "Comment: Whose Globalization?" American Journal of Public Health, 88: 742-743, May, 1998.
7) J.C. Lewis, "Latin American Managed Care Partnering Opportunities", presented at the Eighth Congress of the Association of Latin American Pre-paid Health Plans, Sao Paulo, Brazil, November 8, 1996.
8) Carlyle Gerra de Macedo, "Modelos de Gestión y Eficacia de las Reformas de Salud en América Latina", presented at the Conference on Health Reform in Latin America, Santiago, Chile, 1999. See also, Cristian Baeza, "Taking Stock of health Sector Reform in Latin America: Trends and Challenges for Health Reform", Centro Latinoamericano de Investigación en Sistemas de Salud, 1998.
9) United Nations, Human Development Report 1996, Oxford University Press, 1996.
10) V. Navarro, op. cit., note 6.
11) Ichiro Kawachi and Bruce P. Kennedy, "Health and Social Cohesion: Why Care about Income Inequality?" British Medical Journal 314:1037-1040, April 5, 1997.
12) Karen Stocker et al., op cit., note 3.
13) "Síntesis Propositiva", Conference on Health Reforms in Latin America, Santiago, Chile, 1999.