Argentina The Health Sector in Argentina

78 Pages·2003·5.62 MB·English

R Report No. 26144-AR
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. The Health Sector in Argentina
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4 Current Situation and Options for Improvement
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July 21, 2003
Human Development Department
Argentina, Chile, Paraguay, and Uruguay Country Managament Unit
Latin America and the Caribbean Region
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Document of the World Bank
CURRENCY EQUIVALENTS
Currency Unit : The Argentine Peso
EXCHANGE RATE
July 21,2003
USD $l=ARS $2.78
WEIGHTS AND MEASURES: Metric System
FISCAL YEAR: January 1 - December 3 1
ABBREVIATIONS AND ACRONYMS
AFIP Administracibn Federal de Ingresos Pu'blicos, Federal Public Income Administration
ANMAT Administracibn Nacional de Medicamentos, Alimentos y Tecnologia, National Drug,
Food and Technology Administration
APE Administracio'n de Programas Especiales, Special Programs Administration
ANSES Administracibn Nacional de la Seguridad Social, National Social Security Administration
COFESA Consejo Federal de Salud, Federal Health Council
FSR Fondo Solidario de Redistribucibn, Solidarity Redistribution Fund
GDP Gross Domestic Product
HIV/AIDS Human Immuno-deficiency Virus I Acquired Immuno-deficiency Syndrome
HPA Hospital Pu'blico de Autogestibn, Autonomous Public Hospital
HPGD Hospital Pu'blico de Gestibn Descentralizada, Public Hospital with Decentralized
Management
IMR Infant Mortality Rate
INSSJyP Instituto Nacional de Seguridad Social de Jubilados y Pensionados, National Institute of
Social Security for Retired Persons and Pensioners (or PAMI)
MCI Maternal and Child Health Insurance
MMR Maternal Mortality Rate
MoE National Ministry of Economy
MoH National Ministry of Health
Obras Sociales Social Security Health Insurers
OSN Obras sociales nacionales, National Social Security Health Insurers
OSP Obras sociales provinciales, Provincial Social Security Health Insurers
PMoH Provincial Ministry of Health
PAHO Pan-American Health Organization
PA1 Programa Ampliado de Inmunizaciones, Expanded Program of Immunizations
PAMI Programa de Asistencia Mkdica Integral (or INSSJyP), Program of Integrated Medical
Assistance
PMO Plan Mkdico Obligatorio, Mandatory Health Benefits Package
PRESSAL Proyecto de Desarrollo del Sector Salud en las Provincias, Project for the Development
of the Health Sector in the Provinces
PROFE Programa Federal de Salud, Federal Health Program
SNSS Sistema Nacional de Seguro de Salud, National Health Insurance System
sss Superintendencia de Sewicios de Salud, Superintendency of Health Services
STI Sexually Transmitted Infection
TB Tuberculosis
TGN Tesoro General de la Nacio'n, National Treasury
UBN Unsatisfied Basic Needs
WHO World Health Organization
YPLL Years of Potential Life Lost
Vice President : David de Ferranti
Country Director: Axel van Trotsenburg
Sector Director: Ana Maria Arriagada
Sector Manager : Evangeline Javier
Country Sector Leader: Ariel Fiszbein
Task Team Leader: Juan Pablo Uribe
TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS ........................................................................................ 2
ACKNOWLEDGEMENTS. ............................................................................................................ 4
EXECUTIVE SUMMARY ............................................................................................................. 5
INTRODUCTION. ........................................................................................................................ 10
CHAPTER 1. SECTOR ANALYSIS ................................................................................... 12
1.1. The Health Status of the Argentine Population ......................................................... 12
1.2. Access to Health Services .......................................................................................... 15
1.3. Structure, Functioning and Challenges of the Argentine Health Sector .................... 19
1.4. Public Health and National Programs ........................................................................ 34
CHAPTER 2. THE PAST AND FUTURE OF HEALTH REFORMS IN ARGENTINA ... 37
2.1. Reforms of the 1990s and Lessons Learned .............................................................. 37
2.2. Essential Public Health Functions ............................................................................. 43
2.3. Mechanisms for Health-RelatedF ederal Articulation ............................................... 45
CHAPTER 3 . OPTIONS FOR IMPROVING THE PERFORMANCE OF THE HEALTH
SECTOR ....................................................................................................................... 46
3.1. Framework of Options to Improve the Health Sector ................................................ 46
3.2. Options at the Provincial Level ................................................................................. 48
3.3. Options at the National Level .................................................................................... 51
3.4. Complementary Social Security Reforms. ................................................................. 54
3.5. Regulatory Framework and Sector Dialogue. ............................................................ 55
CONCLUSIONS ........................................................................................................................... 57
ANNEX I:P UBLIC SPENDING ON HEALTH. ........................................................................ 59
ANNEX 11: HETEROGENEITY AMONG PROVINCES .......................................................... 62
ANNEX 111: PRIVATE SPENDING ON HEALTH. ................................................................... 65
ANNEX IV: MATERNAL AND CHILD HEALTH INSURANCE ........................................... 68
ANNEX V: NATIONAL INSTITUTE FOR SOCIAL SERVICES FOR RETIRED PERSONS
AND PENSIONERS - PAM1. ....................................................................................................... 70
ANNEX VI: THE FEDERAL HEALTH PROGRAM (PROFE) ................................................. 73
REFERENCES .............................................................................................................................. 75

ACKNOWLEDGEMENTS
This report was prepared by Juan Pablo Uribe (LCSHH, task team leader), Nicole Schwab
(LCSHH), Isabella Anna Dane1 (LCSHH), Luis PCrez (Mendoza, Argentina) and Natalia
Moncada (LCSHH). During the preparation of this document, the team benefited from valuable
support from Ariel Fiszbein, Cristian Baeza, Alexandre Abrantes, Pablo Gottret, Daniel Dulitzky,
Evangeline Javier, Fernando Lavadenz, Marcel0 Becerra, Maria Paula Giovagnoli and Ariadna
Garcia-Prado.
The Center for State and Society Studies (CEDES; Buenos Aires, Argentina) and the Center for
Institutional Development Studies (CEDI; Buenos Aires, Argentina) contributed to the
development of this paper through important sector studies and their planning and participation in
various workshops. This paper also benefited immensely from the permanent availability and
openness to dialogue and debate regarding options for health sector development in Argentina on
the part of the Ministry of Health and the Superintendence of Health Services, as well as different
actors in the Health sector who decisively strengthened the report. The World Bank team thanks
all participants for their valuable input.

EXECUTIVE SUMMARY
Introduction
Despite various reform efforts during the 1990s, the Argentine health sector still faces the
challenge to improve its performance in response to the expectations and needs of the population.
The Argentine health sector presents serious structural flaws that result in interhntra provincial
inequities (in terms of health status and access, as well as health service financing), high levels of
fragmentation, inefficiency and a weak regulatory framework. The recent economic, political and
social crisis exacerbated these problems, affecting the poorest sectors of the population most.
Specifically, the crisis resulted in a sharp decrease in health insurance coverage and access to
services and medications. In turn, this led to an increase in demand in the public hospital network,
often beyond the public hospitals’ capacity and resource availability. The crisis also threatened
the effectiveness of priority public health programs, and worsened the already precarious
economic and financial situation of many insurers and service providers, thus increasing the
levels of debt prevailing in the sector.
This document presents options for improving the performance of the Argentine health sector,
especially in terms of increasing the health status of the poorest and most vulnerable populations.
To this end, the document first analyzes the health sector, including the health status of the
population, its access to health services, the structure and functioning of the sector and the public
health programs. The document then reviews the lessons learned through recent reforms and
highlights the central role of the provinces. The next section discusses a series of alternatives for
improving the health sector, with a focus on the poor. The document ends with some brief
conclusions. Through this document, the World Bank hopes to contribute to the debate and
development of health sector policies in Argentina, especially at the current time when the need
to improve the health sector’s performance has become a priority on the political agenda.
Chapter 1. Sector Analysis
Health status of the population. Despite an advanced demographic and epidemiological
transition, and the positive trends observed in national averages of key health status indicators,
Argentina continues to display concerning health outcomes. Although Argentina’s level of
spending on health is high, and the supply of services is broad and sophisticated, there are marked
differences in the health status of populations within and between different regions and provinces.
Maternal and child health are of particular concern. The national averages of maternal and infant
mortality remain very high in relation to the rates seen in neighboring countries with similar
levels of development and lower health sector spending. There are large (and in some cases
rising) differences between provinces in terms of the risk factors for maternal andor infant death.
The majority of these deaths are avoidable through timely prevention, diagnosis and treatment.
For example, in 2000,60 percent of the more than 7,600 neonatal deaths could have been avoided
through better prenatal care. Similarly, a significant percentage of maternal deaths could have
been prevented through access to sexual and reproductive health services, antenatal care and
skilled birth attendance. The persistence of these avoidable maternal and infant deaths highlights
the need to carefully analyze the population’s access to health services.
Access to health services. In Argentina, access to health services largely depends on an
individual’s income level. The public hospital network is the main source of health care for more
than 45 percent of the population, particularly for those in the poorest income quintile. The
richest quintile of the population usually receives health care from health social security or, more
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often, from private insurers. Provinces where the population has limited health insurance
coverage and depends mostly on the public hospital network tend to be those with the poorest
health outcomes, less spending on health per capita and a greater proportion of the population
living in poverty.
There are significant barriers to accessing health services and medications, both for the uninsured
as well as the insured populations. The primary barrier to access, in both cases, is the lack of
money to buy medications, or to pay the co-payments necessary to receive care; The second most
common barrier to access is a lack of insurance coverage, followed by a lack of service
availability. Due to the difficulties in accessing both health services and insurance, Argentina
continues to report high levels of out-of-pocket spending on health care. As would be expected,
this spending is regressive and represents close to 9.4 percent of the poorest households’ income.
The current crisis worsened the access to health services, especially for the poorest, who have
suffered a decrease in health insurance coverage three times greater that of the non-poor.
Consequently, demand for some services has been displaced to the public assistance network. At
the same time, the utilization of public health services decreased. From the end of 2001 to the
middle of 2002, preventive health care for children dropped 38 percent in the general population
and 57 percent in the poorest households. Similar patterns seem to be found in other maternal
and child health services, apparently affecting the timeliness, quality and frequency of prenatal
check-ups.
Structure, Functioning and Challenges of the Health Sector. The current structure and
functioning of the health sector does not guarantee effective access to quality health services for
the entire population. The high level of fragmentation and complexity of the sector and its
limited internal articulation make it difficult to improve health outcomes. In addition, each of the
large sub-systems that comprise the health sector (national and provincial social security insurers,
public providers and private insurers) face serious challenges.
Health sector financing is complex. Private out-of-pocket spending is the primary source of
funding (43 percent of the total in the year 2000), followed by mandatory employee-employer
contributions to national and provincial health social security (34 percent of the total), and public
financing, primarily at the provincial level for the public assistance network (23 percent of the
total). Despite the economic crisis, public health spending remained high, reflecting the national
government’s efforts to protect key national programs. However, this is not the case for social
security spending, which dropped substantially between 2001 and 2002, as a result of the
decrease in employment and salary levels.
Health services are provided through public and private providers, with significant variations
between provinces. The management and financing of the public hospital network is largely the
responsibility of the provinces, with minimal national participation. However, contrary to what
would be expected, the distribution of public supply of health services does not correspond to the
proportion of the population without health insurance in each province. National social security
insurers (OSN and PAMI) primarily contract with private providers for health services. In
general, health services are concentrated in large urban centers and focus on highly specialized
care.
Under the current structure for financing and supplying services, the Argentine health sector faces
three major challenges: (i)in equity, (ii)in efficiency, and (iii)a weak regulatory framework. All
provinces share these challenges, albeit in different degrees and with significant differences
between urban and rural areas. This results in a complex framework for articulating efforts and
policies, as well as building consensus.
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Inequity is reflected in the substantial differences between and within provinces in health status,
spending per capita, access to services and level of financial protection. These disparities are the
result of (i)a public provision model that does not guarantee access to services for the poor and
uninsured; (ii)a n organizational model for national and provincial social security insurers that
constrains their expansion to cover unprotected sectors of the population and presents chronic
internal inefficiencies and limited financial redistribution mechanisms; and (iii)p ersistence of
regressive cross-subsidies between public assistance and social security sub-sectors.
Inefficiency in the health sector manifests itself in different ways, such as the rigidity and lack of
performance incentives in the provision of public health services and the focus on high
complexity care. Primary care generally accounts for less than 10 percent of provincial health
budgets. Social security is highly fragmented with a growing numbers of intermediaries and
chronic recurrent deficits despite multiple attempts to financially “rescue” certain insurers (Le.
PAMI). In addition, recently launched reforms that would increase the efficiency of specific
entities, such as the Special Programs Administration (APE), still need to be completed.
Finally, there are gaps in the sector’s regulatory framework and the compliance with existing
regulations. The federal nature of the health sector and the complexity of its current structure
largely account for these regulatory gaps. Priority issues that should be addressed include: (i)th e
role of the Superintendence of Health Services (SSS), (ii)qu ality assurance, and (iii)th e absence
of an effective forum for dialogue and consensus-building around health policies.
Public Health and National Programs. The recent crisis highlighted the need to evaluate
national programs that respond to collective health interests to avoid backtracking on health status
achievements. The national government responded to the crisis by maintaining adequate levels of
financing for priority programs, including maternal and child health, immunizations, provision of
essential medications, infectious disease control and, more recently, sexual and reproductive
health. The main challenges in public health involve the articulation of these programs within the
complex federal structure, as well as overcoming the inertia in allocating and managing limited
resources at the national level.
Chapter 2. The Past and Future of Health Sector Reforms in Argentina
Reforms of the 1990s and Lessons Learned. The reforms undertaken during the 1990s,
especially those related to social security at the national level and the management of public
hospitals, provide useful lessons for the future. A first lesson is that the central role of the
provinces must be recognized in order to improve services for the poor. In practical terms, the
provinces are the leaders of the health sector’s response to the needs of low-income populations.
Past experiences also highlight the health sector characteristics that determine reform outcomes,
namely the sector’s federal nature, its complex political economy and heterogeneity.
Federalism in the Argentine health sector is the framework within which the sector must progress.
Within this framework, the dominant role of the provinces cannot be overlooked, as they control
about 25 percent of health spending (including public provincial and OSP spending) and more
than 60 percent of the public provision of insurance and medical services. At the same time, the
national government plays an important role in terms of stewardship and coordination, including
the regulation and control of national social security insurers (OSN and PAMI), leadership of
national public health programs and coordination of international sources of financial and
technical assistance. However, despite the importance of national-provincial relations in the
development of health sector policies and practices, there is currently no forum to promote
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dialogue and regularly and effectively coordinate activities. The main instrument for such a
forum, the Federal Health Council (COFESA), lacks the necessary legal, technical and functional
attributes. The impulse given to COFESA during 2002 confirms the importance and current
opportunity to advance in its restructuring.
The complex political economy of the sector is another challenge that must be addressed.
Reforms have high transaction costs. This may explain why Argentina has tended to prefer slow,
gradual transformations. The apparent lack of transparency and in some cases, corruption, are
possible derivations of the complex structure of the sector that lead to high costs and make it
difficult to reach consensus.
Finally, the Argentine health sector is very heterogeneous. This includes, for instance, differences
among and within provinces in terms of epidemiological profile, regulatory frameworks, sector
structure, institutional capacity and level of spending. Therefore, it is not practical to think of
rigid reforms implemented from the national level, or of the generalized application of certain
models and instruments. Rather, any changes must be locally adapted.
Essential Public Health Functions. The achievements and progress in the health sector, as well
as its problems and gaps, reflect the effectiveness of the government’s stewardship functions. To
this end, it is important to examine the level of development of these functions (termed “essential
public health functions”) and to strengthen weak areas. At the national and provincial government
levels, recent evaluations highlight the need to focus efforts on (a) planning and development of
sector policies; (b) regulation and control; (c) quality assurance; and (d) social participation.
Chapter 3. Options to Improve Health Sector Performance
The primary challenge facing the health sector is to improve the health status of the population,
especially the poorest and most vulnerable, thus reducing existing inequalities. To achieve this,
all provinces have a central role to play in the introduction of changes to the current structure and
functioning of the health sector. Although the challenge is common for all provinces, the options
for reform are diverse. However, it is possible to identify some immediate alternatives that stand
out for their viability and potential to improve health sector articulation.
Options at the Provincial Level. A number of interventions would help provinces improve their
purchasing of health services for the poorest and align incentives with providers’ performance.
The development of “public provincial health insurance” schemes is a key alternative, as it could
strengthen the provincial government’s purchasing function and target resources to the most
needy (for example, the maternal and child population). A second complementary intervention is
the expansion of agreements or contracts linked to the performance of public providers. Another
possibility is to increase the available public financing by eliminating regressive cross-subsidies
in favor of third party payers. Broad collaboration between national and provincial authorities is.
necessary to successfully implement these alternatives.
Options at the National Level. The national government can collaborate in a decisive way to
facilitate provincial reforms. The national government’s stewardship and leadership is necessary
for the definition, implementation and articulation of sector policies. The generation of national-
provincial agreements on health goals would be an excellent instrument for guiding health sector
improvements. These goals could serve as the parameters for the national government to confer
corresponding incentives. The national government could also lead complementary initiatives at
the national level, such as the definition and establishment of an insurance for high cost, low
incidence health events. Finally, by maintaining effective national public health programs, the
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