Proyectos políticos y opciones de salud en América Latina (Ideología, discurso y realidades) / Political projects and health actions in Latin America (Ideology, discourse and realities)

En prácticamente todo el continente americano la crisis ha servido para imponer bajo una u otra forma proyectos neoliberales. Conviene recordar que estos proyectos van más allá de una serie de medidas económicas y significan una radical redefinición de las relaciones entre las naciones, pero ante todo, entre el Capital y el Trabajo que se sintetiza en los conceptos de globalización, liberalización y desregulación. Abarcan así, el conjunto de los procesos económicos, políticos y sociales y se expresan en una ideología definida. Los valores de fondo de esta ideología son el mercado, la competencia y la desigualdad.1 Contra todas las demostraciones de la inexistencia hoy del libre mercado,2 sostiene que este es el motor del progreso, ya que promueve la competencia entre los individuos movilizando al máximo sus capacidades e inventiva. Pero para que ello ocurra es preciso garantizar la desigualdad porque con igualdad no hay competencia. En el terreno de la política social la centralidad del valor de la desigualdad significa una decisión básica, porque implica el rechazo al concepto de los derechos sociales, máxime cuando su contraparte explícita es la obligación del Estado de garantizarlos para todos los ciudadanos. En la visión neoliberal, la universalidad de los derechos y la igualdad en su goce resultan inaceptables porque violan los principios del mercado y la competencia. Plantea entonces que el bienestar social pertenece al ámbito de lo privado -a la familia o a la iniciativa privada- y solo debe ser tarea pública cuando los privados fallan. Por ello, sostiene que el Estado debe proporcionar una asistencia social mínima únicamente a aquellos que fracasaron en satisfacer sus necesidades básicas,3 eso es, a los más pobres. De esta manera, en oposición a una política social basada en la noción de los derechos sociales universales, el neoliberalismo propone otra, selectiva y asistencialista; en vez de propugnar la universalización de la seguridad social y la ampliación de sus beneficios, formula una política restrictiva y discrecional de caridad pública. Que se presente a esta política como de combate a la pobreza o, incluso, solidaria no cambia en nada su esencia. Sin embargo, la aparición...(AU)

THE MEXICAN POPULAR HEALTH INSURANCE: MYTHS AND REALITIES.

Universal health coverage (UHC) is today a dominant issue in the global health policy debate. The hegemonic proposal is UHC that recommends universal health insurance with an explicit service package and a payer-provider split with public and private managers. The Mexican Popular Health Insurance (PHI) is widely presented as a UHC success case to be followed. This article reviews critically its achievements after a decade of implementation. It shows that universal coverage has not been reached and about 30 million Mexicans are uninsured. Access to needed services is quite limited for PHI affiliates given the restrictions of the service package, which excludes common high-cost diseases, and the lack of health facilities. Public health expenditure has increased 0.36 percent of Gross National Product, favoring the PHI at the expense of public social security. These funds are, however, lower than legal specifications and the service package under-priced. Private health expenditure as a percentage of total expenditure has not varied much and PHI affiliates' out-of-pocket payment is larger than the whole PHI budget. There is no evidence of health impact. The Mexican health reform corresponds to neoclassic-neoliberal reorganization of society on the market principle. Although some of the PHI problems are particular to Mexico, it illustrates some of the overall flaws of the UHC model.

Three decades of neoliberalism in Mexico: the destruction of society.

Neoliberalism has been implemented in Latin America for about three decades. This article reviews Mexico's neoliberal trajectory to illustrate the political, economic, and social alterations that have resulted from this process. It finds that representative democracy has been perverted through fear, putting central political decisions in the hands of power groups with special interests. The border between the state of law and the state of exception is blurred. Economic structural adjustment with liberalization and privatization has provoked recurrent crisis, but has been maintained, leading to the destruction of the national productive structure in favor of supranational corporations, particularly financial capital. The association between criminal economy and economic criminality is also discussed. The privatization of social benefits and services requires state subsidies and allows the privatization of profits and the socialization of losses. The social impact of this process has been devastating, with a polarized income distribution, falling wages, increased precarious jobs, rising inequality, and extreme violence. Health conditions have also deteriorated and disorders associated with violence, chronic stress, and a changing nutritional culture have become dominating. However, in Latin America, massive, organized political and social mobilization has broken the vicious neoliberal circle and elected progressive governments that are struggling to reverse social and economic devastation.

Contradicciones en salud: sobre acumulación y legitimidad en los gobiernos neoliberales y sociales de derecho en América Latina / Contradictions in health: on acumulation and legitimation in Latin American neoliberal and social states

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.

This text uses the perspective of the contradiction between capital accumulation and legitimation of the social order to examine Latin American health systems. Analyzes, on one hand, the new areas and strategies of accumulation in health under neoliberal globalization and, on the other, the recovery of health as a public domain to assure the universal right to health by progressive governments. It observes how the guarantee of this right has turned it into a field of political struggle where private economic agents and progressive governments clash and how the neoliberal offensive has appropriated ideologically the progressive discourse but changing its content.

[Mexican health insurance: uncertain universal coverage]. / Los seguros de salud mexicanos: cobertura universal incierta.

The Mexican health system is comprised of the Department of Health, state labor social security and the private sector. It is undergoing a reform process initiated in 1995 to achieve universal coverage and separate the regulation, financing and service functions; a reform that after fifteen years is incomplete and problematic. The scope of this paper is to assess the problems that underlie the successive reforms. Special emphasis is given to the last reform stage with the introduction of the "Insurance of the People" aimed at the population without labor social security. In the analysis, health reform is seen as part of the Reform of the State in the context of neoliberal reorganization of society. Unlike other Latin American countries, this process did not include a new Constitution. The study is based on official documents and a systematic review of the process of the implementation of the System of Social Health Protection and its impact on coverage and access to health services. The analysis concludes that it is unlikely that universal population coverage will be accomplished much less universal access to services. However, reforms are leading to the commodification of the health system even in the context of a weak private sector.

Los seguros de salud mexicanos: cobertura universal incierta / Mexican health insurance: uncertain universal coverage

El sistema de salud mexicano se compone de la Secretaría de Salud (rectora del sector y prestador de algunos servicios), la seguridad social laboral pública, y el sector privado. Transita por un proceso de reforma iniciado en 1995 para universalizar la cobertura y separar las funciones regulación-financiamiento-prestación de servicios; reforma que después de quince años sigue inacabada y problemática. Este texto analiza crítica- y propositivamente la problemática surgida a raíz de las sucesivas reformas. El énfasis se pone en su última etapa con la introducción del "Seguro Popular" para la población sin seguridad social laboral. El análisis concibe la reforma de salud como parte de la Reforma del Estado en el marco de la reorganización neoliberal de la sociedad. A diferencia de otros países latinoamericanos este proceso no pasó por una nueva Constitución. El análisis se basa en documentos oficiales y un seguimiento sistemático de la instrumentación del Sistema de Protección Social en Salud y su impacto sobre la cobertura y acceso a los servicios. Se concluye que es improbable que se universalice la cobertura poblacional y menos el acceso a los servicios. Empero las reformas están forzando la mercantilización del sistema aún en presencia de un sector privado débil.

The Mexican health system is comprised of the Department of Health, state labor social security and the private sector. It is undergoing a reform process initiated in 1995 to achieve universal coverage and separate the regulation, financing and service functions; a reform that after fifteen years is incomplete and problematic. The scope of this paper is to assess the problems that underlie the successive reforms. Special emphasis is given to the last reform stage with the introduction of the "Insurance of the People" aimed at the population without labor social security. In the analysis, health reform is seen as part of the Reform of the State in the context of neoliberal reorganization of society. Unlike other Latin American countries, this process did not include a new Constitution. The study is based on official documents and a systematic review of the process of the implementation of the System of Social Health Protection and its impact on coverage and access to health services. The analysis concludes that it is unlikely that universal population coverage will be accomplished much less universal access to services. However, reforms are leading to the commodification of the health system even in the context of a weak private sector.

La Segunda Reforma de Salud: aseguramiento y compra-venta de servicios / The Second Health Reform: insurance and payer-provider split

El aseguramiento en salud es la propuesta de varios gobiernos latinoamericanos para lograr la cobertura universal en salud. Surge a raíz de la Segunda Reforma Social. Para conocer los resultados de los seguros de salud se analizan Chile, Colombia y México que tienen distintas formas y diversos tiempos de implantación. Se examinan los mismos aspectos para conocer si los seguros han cumplido sus objetivos. Los seguros no han alcanzado cobertura universal poblacional y la cobertura médica está limitada. Persiste el acceso inequitativo y se tiende a una nueva pauta de inclusión-exclusión. La separación entre administración de fondos y prestación de servicios ha llevado a la mercantilización y ha creado nuevos actores económicos en el sector con acceso a los fondos públicos de salud. La administración de estos fondos tiene una creciente complejidad y aumento de los costos y pese a los incrementos en el presupuesto público de salud los costos sobrepasan los recursos. La lógica dominante del seguro es la económica y no la de satisfacción de necesidades de salud.

Health insurance is proposed by several Latin American governments to reach universal health coverage. This is a part of the Second Social Reform. Chile, Colombia and Mexico, that have different models and times of implantation, are analyzed to know the results of health insurance implementation. The three examples are examined to know if they have reached their objectives. Health insurance has not reached universal population coverage and the medical coverage is limited. Unequal access still persists and tends to a new pattern of inclusionexclusion. The split between funds administration and service provision has led to the commodification of both and has created new economic actors with access to public health funds. The administration of these funds is increasingly complex and expensive. Despite the increase in public health expenditure costs exceed resources. The dominant logic of health insurance is economic and not the satisfaction of health needs.

[Analysis of the diabetes mellitus screening program in the Federal District, Mexico]. / Consideraciones sobre el programa de detección de diabetes mellitus en población mexicana: el caso del Distrito Federal.

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.

Consideraciones sobre el programa de detección de diabetes mellitus en población mexicana: el caso del Distrito Federal / Analysis of the diabetes mellitus screening program in the Federal District, Mexico

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 por ciento, la especificidad de 58,7 por ciento, y el valor predictivo positivo de 16,6 por ciento. 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 percent, specificity 58.7 percent, and positive predictive value 16.6 percent. 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.

Health system reform in Mexico: a critical review.

Last year Lancet published a series of articles on Mexico's 2004 health system reform. This article reviews the reform and its presentation in the Lancet series. The author sees the 2004 reform as a continuation of those initiated in 1995 at the largest public social security institute and in 1996 at the Ministry of Health, following the same conceptual design: "managed competition". The cornerstone of the 2004 reform-the voluntary Popular Health Insurance (PHI)--will not resolve the problems of the public health care system. The author assesses the robustness and validity of the evidence on which the 2004 reform is based, noting some inconsistencies and methodological errors in the data analysis and in the construction of the "effective coverage" index. Finally, some predictions about the future of PHI are outlined, given its intrinsic weaknesses. The next two or three years are critical for the viability of PHI: both families and states will face increasing difficulties in paying the insurance premium; health infrastructure and staff are insufficient to guarantee the health package services; and the private service contracting will further strain state health ministries' ability to strengthen service supply. Moreover, redistribution of federal health expenditure favoring PHI at the cost of the Social Security Institute will further endanger public health care delivery.