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Can Insurance Guarantee Universal Access to Health Services?

It is now 15 years since the publication of Investing in Health (World Bank, 1993), a report which set the course for health care system reform in Latin America and around of the world. Since that time a great many studies about the reforms have been published and new reforms have been launched to “correct” the defects of the earlier ones. The objective of this paper is to call into question the entire current political debate over health care, as well as to clarify key concepts and practices. To this end I will analyze the current vogue of interrelated proposals for a second reform of the state. I will examine debates over insurance as a way of grant universal coverage; the separation between the regulation, financing and provision of health services; and the public private partnerships for the construction, financing, and management of hospitals. This paper will also examine the development of a new scientific discourse around “evidence-based policies” and academic referral networks. The goal of this paper is not to offer a comprehensive treatment of these issues, but rather to question some assumptions and contribute to the larger debate.

This Medicina Social/Social Medicine issue includes, among others, two articles critical of so-called Universal Health Coverage (UHC), one by Mishra and Seshadri and another by Waitzkin. The debate surrounding UHC has been around for a while in Latin America, where progressive governments have worked towards guaranteeing the universal right to health through a single, free, public health system, whilst neoliberal governments have implemented policies based on public-private insurance schemes and competition between public and private health service providers. The debate therefore swings between two different and opposing perspectives based on different views of the world and society where the competition between public and private insurance forms part of the neoliberal doctrine and the single, free, public health system is linked to the welfare state. The doctrinal and ideological nature of the neoliberal approach is demonstrated by the fact that it is modeled on the most expensive and inefficient health system in the world: that of the US. ...

Desde la salud pública, los programas de detección para diabetes mellitus tipo 2 son un recurso para su vigilancia. La Secretaría de Salud Nacional implementó como estrategia de tamizaje el Programa de Acción Diabetes Mellitus (PADM-2), el cual se basa en dos pruebas secuenciales: Cuestionario de Factores de Riesgo y medición de glucemia capilar. En este trabajo, se exploró la capacidad del PADM-2 como estrategia de tamizaje. El estudio se efectuó en el año 2005, participaron 1.562 individuos que asistieron a seis unidades del primer nivel de atención de la Secretaría de Salud del Gobierno del Distrito. Se consideró como el estándar de oro a la glucosa sérica en ayuno. Al valorar las dos pruebas en serie, la sensibilidad fue de 98%, la especificidad de 58,7%, y el valor predictivo positivo de 16,6%. El valor predictivo positivo apunta a que una alta proporción del gasto se destina a detectar falsos positivos, lo cual hace necesario replantearse los criterios utilizados en el PADM-2, de tal manera que se obtenga un mayor beneficio económico y social.From the public health perspective, programs to detect type 2 diabetes mellitus are a prime resource for surveillance of the disease. As a screening strategy, the Mexican Ministry of Health implemented the Diabetes Mellitus Action Program (PADM-2), based on two sequential tests: the Risk Factor Questionnaire and capillary blood glucose test. This study explored the Program's capacity as a screening strategy. The study was carried out in the year 2005, with a sample of 1,562 that attended six primary care units under the Health Secretariat of the Federal District. Fasting serum glucose was defined as the gold standard. When assessing the two tests sequentially, sensitivity was 98%, specificity 58.7%, and positive predictive value 16.6%. The positive predictive values indicates that a high proportion of the expenditure still goes to detecting false-positives, thus requiring reconsideration of the Program's criteria to obtain a greater economic and social benefit.

Os determinantes políticos e econômicos para um novo Estado de bem estar social na América Latina e os desafios que essa tarefa propõe são discutidos com base no exame da políticas sociais no contexto do ajuste estrutural em curso nas economias latinoamericanos.The political and economic determinants of a new welfare state in Latin America and the challenges put forward by this task are discussed on the basis of an analysis of the social policies in the context of the context of the ongoing structural adjustment of latinoamerican economies

A política social mexicana recente já foi apontada por organismos multilaterias como o Banco Mundial como um programa bem sucedido de combate à pobreza. O artigo mostra que essa avaliação é inteiramente equivocada e mostra como e porque a pobreza aumentou substancialmente no país no período 1983-1994. Quanto aos recursos destinados ao programa de combate à pobreza extrema, o PRONASOL, se foram ínfimos em face das carências sociais, foram no entanto suficientes para fazer do programa um instrumento bastante útil aos propósitos , clientelístas e de controle político do Partido Revolucionário Institucional (PRI).Mexico's recent social policies have benn pointed out by multilateral organs like the World Bank as a successfull program against poverty. This papers claims that this evaluation is utterly mistaken and shows how and why poverty has grown substancially in the country during the period 1983-1994. As to the resourses alloted to the program against extreme poverty, PRONASOL, it is shown that they, although insignificant as compared to the social needs, were large enough to make the program an useful instrumental for the clientelistic and political controling interests of the PRI

With the goal of fully guaranteeing the constitutional right to health protection, Mexico City’s leftist administration (2000-2006) undertook a reform to provide health services to people without insurance. The reform had four components: free medicine and health services; the introduction of a new service model (MAS); the strengthening, expansion, and improvement of services, and legislation to ensure that the city government become guarantor of this constitutional right. The reform resulted in 95% of eligible families being enrolled in free care; expansion of health care infrastructure with the construction of five new health care centers and a 1/3 increase in the number of public hospital beds in impoverished and disadvantaged areas; increased access to and use of health services particularly by the poor and for expensive interventions; and the legal guarantee of the continuity of this policy. The implementation of this new policy was made possible through an 80% budget increase, improvements in efficiency, and a successful fight against corruption. The health impact of the reform was seen in decline of mortality rates in all age groups between 1997 and 2005 (22% for child mortality, 11% for economically active age groups, and 7.9% for retired age groups) and by a 16% decline in AIDS related mortality between 2000 and 2005. This reform contrasts with the health care reform promoted by the right wing Federal government in the rest of the country; the latter was based on voluntary health insurance, cost-sharing by families, access to a limited package of services, and gradual enrollment of the population

El texto utiliza el enfoque de la contradicción entre la acumulación capitalista y la legitimación del orden social para examinar los sistemas de salud de América Latina. Analiza, por un lado, los nuevos campos y estrategias de acumulación en salud en la globalización neoliberal y, por el otro, la recuperación del campo de salud por los gobiernos progresistas como ámbito público y garantía universal del derecho de la salud. Observa cómo la garantía de este derecho lo ha convertido en un campo de lucha política donde se enfrentan los agentes económicos privados y los gobiernos progresista y cómo la ofensiva ideológica neoliberal ha apropiado el discurso progresista pero cambiando en su contenido.