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Country Health Profile.
Data updated for 2001Argentina Health Situation Analysis and Trends Summary Country Chapter Summary from Health in the Americas, 1998. ARGENTINAGENERAL SITUATION AND TRENDSSocioeconomic, Political, and Demographic Overview The Argentine Republic is a federal democracy and, accordingly, all powers not expressly vested in the national government are attributed to the provinces. It has an area of 3,761,274 km2 and shares borders with five other countries. It is divided into 23 provinces and a federal district, the Capital Federal. Since taking office in 1989, the present administration has implemented three economic stabilization plans. The most recent one—the Convertibility Plan—was unveiled in early 1991. It tied the local currency to the United States dollar and set a course for structural adjustment based on export-driven growth. As a result, the Government has been able to shore up the country’s fiscal accounts and generate surpluses to pay its financial commitments. The prospect of broader regional integration under the economic integration treaty signed by Argentina, Brazil, Paraguay, and Uruguay, MERCOSUR, makes economic stability all the more important. Economic indicators for the 1991–1996 period confirm the success of the Convertibility Plan and other adjustment efforts in strengthening the country’s macroeconomic situation: inflation was reined in and the gross domestic product (GDP), exports, and capital flows all improved. Following a jump of 84.00% in 1991, the consumer price index (CPI) rose only 10.3% in 1992. As inflation continued falling, so did shifts in the CPI, which stood at 3.9% in 1994 and only 1.5% in 1995. By 1996, the CPI rise was only 0.4%, and investment rates had returned to positive figures. GDP growth from 1990 to 1994 showed a cumulative rate of 35.0%. The 1991 National Population and Housing Census projected a total population of 35,219,612 for 1996. The average annual growth rate was expected to be 1.26%, lower than in previous periods. The total fertility rate continued declining, going from 3.15 children per woman in 1980 to a projected 2.82 for the period 1990–1995 and 2.62 for 1995–2000. The birth rate declined slightly, but steadily, from 19.8 per 1,000 population in 1993, to 19.7 per 1,000 in 1994, and 18.9 per 1,000 in 1995. Life expectancy at birth for the total population was estimated at 71.93 years for the period 1990–1992 (75.69 years for women and 68.44 years for men) and 75.59 years for the period 1995–2000 (75.75 years for women and 69.55 years for men). Looking at the country’s age distribution, children under 15 years old accounted for less than 30% of the overall population, while persons over 60 years represented 13% of the total. The population’s median age in 1985 was 27.6 years, and was projected to rise to 28.4 years by the year 2000. The population over 65 years of age represented 9.0% of the total in 1990, is currently estimated at 9.5%, and is expected to reach 9.8% by the year 2000, with a strong predominance of women.
Mortality and Morbidity Profile Argentina’s mortality profile improved over the 1990–1995 period. A total of 268,997 deaths were reported in 1995, of which 9,708 (3.6% of the total) were due to ill-defined causes. The total mortality rate was 7.7 per 1,000 population. Maternal mortality, which had risen between 1994 (3.9 per 10,000 live births) and 1995 (4.4 per 10,000 live births), experienced a decrease of close to 14.0% in 1995. Infant mortality fell 15.7% between 1990 and 1995, reaching a level of 22.2 per 1,000 live births. Between 1990 and 1995, the percentage of newborns weighing less than 2,500 g increased from 6.1% to 6.6% nationwide. An analysis of mortality by leading cause of death and by sex reveals that the number of deaths attributable to heart disease nationwide fell 10.9% between 1990 (252.6 per 100,000 population) and 1995 (227.7 per 100,000 population). Over the same period, mortality from cerebrovascular diseases and accidents also decreased significantly, by 16.7% (from 80.8 to 69.2 per 100,000 population) and 16.4% (from 32.6 to 28.0 per 100,000), respectively. Deaths from malignant tumors registered a smaller decline, falling from 143.7 per 100,000 population in 1990 to 141.6 per 100,000 in 1996. Heart disease, malignant tumors, and cerebrovascular diseases were the leading causes of death among both sexes. For men, the death rate from heart disease in 1995 was 244.5 per 100,000 population, while for women it was somewhat lower, 206.4 per 100,000. The male death rate was also higher for malignant tumors (157.6 per 100,000, compared with 124.1 per 100,000 for women) and cerebrovascular diseases (70.4 per 100,000, compared with 66.5 per 100,000 for women). Accidents were the fourth most common cause of death among men, with 6,766 of the total 9,740 accidents ending in death (39.7 per 100,000 population); the specific mortality rate from this cause among women was 16.1 per 100,000 population. Conditions originating in the perinatal period were the leading cause of infant mortality (7,125 deaths), accounting for 50% of deaths from all causes in children under 1 year old. The specific mortality rate from this cause dropped 17.1% between 1990 and 1995 (from 1,267.2 to 1,081.6 per 100,000 population). Congenital abnormalities were the second most common cause (396.8 per 100,000). Deaths from pneumonia and influenza (690 in 1995) declined 5.7% between 1990 and 1995, and intestinal infectious diseases moved from fourth to sixth place. Among children 1–4 years old, accidents were the leading cause of death by a wide margin (16.9 per 100,000 population). Although the 1990–1995 period saw a 28.9 % drop in mortality from accidents, this cause still claimed 458 lives in 1995 (21.4% of all deaths), of which approximately 45% were traffic accidents or accidents in the home. The risk of dying from pneumonia and influenza dropped nearly 22.0% in 1995, moving this group of causes into fourth place. Mortality from intestinal infectious diseases also declined, and these diseases no longer rank among the five leading causes of death. Accidents were also the leading cause of death in the age group 5–14 years old, with 571 deaths in 1995 (8.6 per 100,000 population). Nevertheless, mortality from this cause dropped 26.7% between 1990 and 1995. Malignant tumors were the second most common cause of death (3.7 per 100,000 population). In the population aged 15 to 49, heart diseases and malignant tumors represented the first and second most common causes of death in 1990, at rates of 33.8 and 33.7 per 100,000 population, respectively. In 1995, there was a decline in mortality from heart diseases (27.9 per 100,000), leaving malignant tumors as the leading cause that year (31.1 per 100,000 population). Accidents continued to be the third most common cause of death in this cohort (25.1 per 100,000). In the age group 50–64 years old, mortality from heart diseases and malignant tumors exhibited patterns similar to the previous age group. The number of deaths attributable to heart diseases declined considerably between 1990 and 1995, dropping from 340.8 to 289.3 per 100,000 population. Mortality from malignant neoplasms fell slightly, and malignant tumors came to rank as the leading cause of death. In the population 65 years of age and older, heart disease continued to be the leading cause of death in the 1990–1995 period. Tumors and cerebrovascular diseases ranked second and third; mortality from pneumonia and influenza increased 21.0%.
SPECIFIC HEALTH PROBLEMSAnalysis by Population Group Morbidity data for this analysis were difficult to collect, because in Argentina records are not generally kept on patient visits, nor are periodic health surveys conducted. Health of Children Of the 14,606 deaths among children under 1 year of age reported in 1995, 56.2% were males. Although mortality from conditions originating in the perinatal period declined 17.1%, they continued to be the leading cause of death between 1990 and 1995, accounting for 48.8% of the total. Deaths from pneumonia and influenza rose nearly 6.0%, while those caused by intestinal infections dropped. The apparent increase in deaths attributed to congenital abnormalities may be due to the relative decrease in the other causes. Accidents climbed from the fifth most common cause in 1990 to fourth in 1995. Although accidents were responsible for only 4.0% of all deaths, their risk to children under 1 year of age rose considerably. Data collected from records of discharges from public-sector hospitals give an idea, albeit partial, of morbidity in this age group. Conditions originating in the perinatal period, intestinal infectious diseases, and pneumonia accounted for 60.3% of hospitalizations. A total of 2,142 deaths were reported in children between 1 and 4 years of age; 54.3% in males. The specific mortality of this cohort fell from 1.2 per 1,000 population in 1990 to 0.8 per 1,000 in 1995. The high number of deaths from preventable causes underscores the need for a more comprehensive approach to health care for this group. Morbidity data based on discharge records from public hospitals show that, in 1992, 43% of hospital visits were due to diseases of the respiratory system and intestinal infections. A 1994 survey covering eight major cities found that more than two-thirds of Argentina’s children had presented with episodes of upper respiratory infections. In the age group 5–9 years old, accidents continued to be the leading cause of death, although their actual number was much lower than for other childhood age groups. A significantly higher number of cases occurred among boys. The 251 accidents reported in 1995 accounted for 28.6% of all deaths in this age group; over one-third were from traffic accidents. Malignant neoplasms, especially those of lymphatic and hemopoietic tissue, constituted the second cause of death (147 cases in 1995). Health of Adolescents (10 to 19 Years Old) A total of 1,064 adolescents between the ages of 10 and 14 died in 1995. The risk of dying from an accident—especially traffic accidents (130 deaths in 1995)—was much higher in this age group than it was for children. The general profile of mortality and morbidity was similar to that of the 5–9-year-old age group, except that suicides (32 deaths) and homicides (14 deaths) begin to gather importance as causes of death in this age group. Sexual initiation occurred between the ages of 15 and 19 years for 50% of the population, and this was a factor in sexually transmitted diseases (STDs), AIDS, and unwanted pregnancies. External causes were the most frequent cause of death among adolescents in 1995. Specific mortality from traffic accidents was 23.8 per 100,000 population; from suicide, 10.3 per 100,000; and from homicide, 8.8 per 100,000. With a male-to-female ratio of 3:1, these three causes accounted for 29.7% of all deaths in this age group. Malignant neoplasms and cardiovascular diseases ranked second and third. Mortality from obstetric causes was less than 3.0 per 10,000 live births. Hospital admissions of adolescents at public-sector facilities were attributed, in order of importance, to obstetric causes, abortions, and diseases of the digestive system. Health of Adults (15 to 60 Years) Cardiovascular diseases, malignant tumors, and accidents were the leading causes of death among adults. Accidents were the most prevalent external cause of death among persons 30 years and younger, followed by suicide (574 deaths in 1995). From age 30 on, the leading cause of death shifted toward cardiovascular diseases and malignant tumors. The scant information available on contraceptive use was based on a survey conducted in Buenos Aires and six other cities. Roughly 60% of Argentine women used some form of family planning. Among adolescents under age 20, that percentage dropped to levels as low as 30% and 50%, and was indirectly proportional to the individual’s level of formal education and directly proportional to the level of unmet basic needs. The ratio between normal deliveries and cesarean sections ranged from 1.8 to 4.4 in the areas studied. Of the 290 maternal deaths reported in 1995, two-thirds were due to direct obstetric causes in which the preventable risk factor was greater than 80%. For indirect obstetric causes, the preventable risk factor was over 50%. However, these figures do not reflect the true seriousness of the situation, since underreporting is estimated in more than half of these cases. Maternal mortality fell from 5.9 per 10,000 live births in 1985 to 4.4 per 10,000 in 1995, a decline of 34.1%. According to data from public hospital records, morbidity in this group presented a pattern similar to that of the 15-to-24 age group, with a clear predominance of obstetric causes and abortions (20.8% of all diagnoses). The third most common cause of morbidity were diseases of the digestive system, e.g., ulcers of the stomach and duodenum, appendicitis, disorders of the gallbladder, and cirrhosis of the liver. Health of the Elderly (60 and Older) Heart diseases, malignant tumors, and cerebrovascular diseases were the three leading causes of death in this age group, although mortality had declined considerably. In 1995, the mortality profile underwent a marked change as deaths from heart disease and cerebrovascular diseases fell 10.9 % and 16.9%, respectively, between 1990 and 1995, and malignant tumors became the leading cause of death (922.3 per 100,000 population). Morbidity data were collected from statistics compiled by the National Social Services Administration for Retirees and Pensioners (INSSJyP) under its Comprehensive Health Care Plan (the PAMI plan). Based on a sample of 500,000 beneficiaries from the three sectors that provide health care (public sector, obras sociales plans, and private sector), an examination of the principal diagnoses indicated that diseases of the digestive system, cardiopulmonary diseases, and respiratory diseases accounted for 29% of all hospitalizations. In outpatient services, the most common causes of morbidity reported were cardiovascular diseases, followed by diseases of the musculoskeletal system and connective tissue, and endocrine and metabolic diseases. Family Health The National Council on Children and the Family—an agency of the Secretariat for Social Development, which reports directly to the Office of the President of the Republic—provides assistance for teenage mothers nationwide. Between 1985 and 1993, the percentage of children born to mothers under the age of 19 rose from 13.3% to 15.7%. The provinces with the highest percentages of adolescent mothers (>20%) were Catamarca, Chaco, Corrientes, and Misiones. Of these young mothers, 1.1% were illiterate and 11.8% had not finished primary school. Workers’ Health Data compiled by the Ministry of Labor from a broad sample of companies showed that most work-related accidents between 1991 and 1993 occurred in the food and metallurgical industries. During that period, the accident rate rose 5%. This apparent increase in the risk of accidents in all industries (except textile and nonmetallic mineral) was attributed to better reporting by the companies. Among the so-called "occupational diseases," psychiatric disorders were especially prevalent in the transportation sector, where workers are exposed to highly stressful conditions; construction workers, on the other hand, suffered mainly from joint-related ailments, respiratory conditions, and alcohol addiction. The food and metallurgical industries accounted for 47.1% of all occupational diseases, and incidence rates were high. Health of Indigenous People Since health statistics for Argentina are not broken down by ethnic group, the necessary data are not available to accurately diagnose the health situation of the indigenous population. Nevertheless, the experience of local programs—such as those for the prevention of cholera and Chagas’ disease, environmental sanitation, and maternal and child health—points to generally poor health conditions in this population group. In the wake of the cholera epidemic, which hit indigenous communities particularly hard, an agreement was signed by the Ministry of Health and Social Action, the Ministry of Labor, the social security system, the provincial governments, and indigenous organizations, setting up the Health Program for Indigenous Peoples. The program was launched in the northern provinces in January 1994 and has thus far trained and outfitted 250 indigenous health agents who provide primary health care in their communities; gradually, these agents have been incorporated into the local health teams.
Analysis by Type of Disease or Health Impairment Communicable Diseases Vector-Borne Diseases. The risk of infection by Triatoma infestans was present across 86% of continental Argentina. Serological prevalence among the general population was less than 8%. Thirteen percent of the infected population was under 20 years of age, while persons over age 60 presented the highest rates (>10%). In 1996, the serological prevalence as detected at blood banks stood at 3.7%. The incidence of Argentine hemorrhagic fever, which had been declining since 1988, experienced an increase in 1990, with 727 cases reported (2.2 per 100,000 population). In 1995, only 65 cases were reported (0.3 per 100,000 population). The downward trend observed in malaria incidence since 1989 was reversed in 1993, and by 1995 annual case reports had risen to 1,065. Given the steady decline in the number of autochthonous cases, the increase in the overall level (incidence of 3.3 per 100,000 population in 1995) was mainly due to imported cases associated with the steady migration into the country from southern Bolivia. In 1996, 2,020 cases were reported, with the proportion of native cases remaining the same (44.0%). Salta—the province with the most cases—continued to display residual endemic conditions. All reported cases of malaria involved Plasmodium vivax infection. Vaccine-Preventable Diseases. From 1991 on, the highest number of cases of diphtheria reported in any single year was five; no cases were reported in 1996. The incidence of whooping cough declined over the five-year period, with 737 cases reported in 1996 (2.2 per 100,000 population). Twenty-six cases of neonatal tetanus were reported between 1993 and 1996; a program to eradicate this disease was unveiled in July 1994. A serious measles epidemic swept Argentina in 1991, striking at a rate of 129.1 per 100,000 population. A mass vaccination campaign was launched in 1993, targeting all children under age 15. Nationwide coverage reached 97% among children under 1 year old, and new cases fell back sharply, with only 655 cases reported in 1995 (2.0 per 100,000 population). The last reported case of wild poliovirus occurred in 1984. In June 1994, the health authorities declared the disease eradicated in Argentina. Cholera and Other Intestinal Infectious Diseases. The first cases of cholera in the 1992 epidemic were reported in January among indigenous communities in the province of Salta, along the Bolivian border. The pathogen isolated was Vibrio cholerae O1 biotype El Tor. Subsequent epidemic outbreaks of cholera occurred in 1993 and 1994, striking mainly the population over 15 years old (56.5%) and children 1 to 4 years old (23%–25%). Incidence peaked in 1993 at 2,080 cases (6.5 per 100,000 population) and a case fatality rate of 1.6%; in 1995, incidence dropped to 188 (0.6 per 100,000 population), only to rise again to 474 cases in 1996 (1.4 per 100,000). The case fatality rate remained stable at 1.1% in 1995 and 1996. The steady increase observed in the number of reported cases of diarrheal diseases since 1992 was attributed to better reporting practices. Acute Respiratory Infections. A total of 561,189 cases of influenza (161.4 per 10,000 population) were reported in 1996. The influenza virus, type A (H3N2) was isolated in 1993, followed later by the influenza B virus, involving a strain similar to B/Panama/90. The incidence of pneumonia was much lower and stood at 91,740 cases in 1996 (26.4 per 10,000 population), although improved reporting had contributed to a general upward trend. Here too, the highest incidence was found in the northern part of the country. Rabies. Human rabies is now a controlled disease thanks to the success of prevention and animal vaccination programs that have reduced the incidence of animal rabies by 99%. In 1994, a single case of human rabies was reported, the first one since 1985. AIDS and Other STDs. AIDS was first reported in 1982 and incidence has grown with each passing year. From 720 cases in 1991, the number rose to 1,624 in 1995. Underreporting is thought to be very high, with the actual number of cases estimated to be at least 40% higher than the reported level. The serological prevalence of the human immunodeficiency virus (HIV) was calculated at 0.3% among blood bank donors. As of 1992, the pattern of distribution by sex began to shift, dropping from 4.1 male cases for each female case that year to 3.5 in 1996. Sixty-one percent of all AIDS patients were between 20 and 34 years of age. Before 1989, though, the age group with the most cases had been the 30–49 age group. This shift toward a younger age group is attributed to an increase in intravenous transmission associated with drug use. The average age was 33 years among males and 28 years among females. The epidemic’s profile has changed not only in terms of the higher number of women infected (rising from 0 cases in 1985 to 21.9% of cases in 1996), but also because of the gradual spread of intravenous drug addiction as a means of transmission. Sexual transmission, which accounted for 100 % of cases between 1982 and 1985, dropped to roughly 50% of cases in 1996; 40% to 45% of cases were transmitted by way of blood, and from 5% to 10% were cases of perinatal transmission. For the 1992–1996 period, a full 68.5% of the cases were associated with heterosexual transmission, an HIV-positive mother, or intravenous drug addiction. Other STDs (including syphilis and gonorrhea) remained relatively stable over the period, although the incidence of syphilis was lower. Widespread underreporting continues to distort the true picture of the health situation with regard to these diseases. Provisional figures on incidence for 1996 indicated 1,339 cases of primary and secondary syphilis, 3,246 cases of unspecified syphilis, and 6,620 cases of gonorrhea. Congenital syphilis was first reported as a separate category in 1994; 275 cases were reported in 1996. Emerging and Re-emerging Diseases. Reported cases of meningococcal encephalitis started to show an increase as of 1989. A total of 3,793 episodes were reported for the country as a whole (11.2 per 100,000 population). Children under 5 years old were the age group most severely affected (56.3%). Hantavirus pulmonary syndrome was first reported in 1981. Of the 81 cases confirmed as of early 1997, 39 of them (48.1%) occurred in 1996 and presented a case fatality rate of 55%. Hepatitis case reporting has improved since 1993. The serological prevalence of hepatitis B and C was 0.6% and 0.7%, respectively, based on donors screened at blood banks. In 1993, reported cases of hepatitis A began to show an increase; by 1994, the disease had assumed epidemic proportions, with an incidence of 28,488 cases (87.4 per 100,000 population) that climbed even further to 32,880 cases in 1995 (100.8 per 100,000). Chronic Communicable Diseases. A total of 12,185 cases of tuberculosis were reported in 1991, the year with the lowest incidence in the 1991–1995 period (37.3 per 100,000 population). From that year on, reported cases increased and, in 1993, they reached a total of 13,914 (41.3 per 100,000 population). Some 13,450 cases were reported in 1995, representing a decline of 1.7% over 1994 and 3.4% over 1993. Underreporting is suspected to be high. The association between tuberculosis and AIDS continued to grow: tuberculosis was present in 17% of AIDS patients in 1996. The incidence of leprosy changed very little, with 500 new cases were reported each year (1.5 per 100,000 population). Noncommunicable Diseases and Other Health-Related Problems Nutritional Diseases and Diseases of Metabolism. The studies conducted in this area present partial or limited data, making it difficult to draw comparisons and estimate indicators at the national level. Iodine deficiency and, even more so, iron deficiency were reported in the age group 1–6 years old. The prevalence of iron deficiency anemia in children ranged from 24% to 47%, depending on the province; there was a strong correlation with socioeconomic level. The most frequent nutritional disorder among pre-school and school-aged children was growth retardation (i.e., below normal height-for-age) owing to chronic malnutrition. The prevalence of chronic malnutrition as measured by body mass index (BMI < 18.5) was calculated at 4.2%, with the highest levels being recorded, once again, in the northwestern and northeastern areas of the country. At the same time, 19.5% of the population was classified as overweight (BMI > 25) and 4.1% as obese (BMI > 30). Cardiovascular Diseases. Aside from nutrition-related factors, arterial hypertension also plays a role in cardiovascular risk. Among adults 18 to 59 years of age, 13% of males and 7% of females suffered from high blood pressure. Smoking—to cite another contributing factor—had a prevalence of 40% among men and 32% among women. Malignant Tumors. Mortality from malignant tumors remained relatively stable over the 10-year period ending in 1995. The overall rate was 141.6 per 100,000 population in 1995, making malignant tumors the second leading cause of death that year. The mortality rate from malignant tumors was calculated at 157.6 per 100,000 population among men and 124.1 per 100,000 population among women. Accidents and Violence. Accidents were the fourth leading cause of death. Despite a drop from 32.6 per 100,000 population in 1990 to 28.0 per 100,000 in 1995, accidents remained a serious health problem and were responsible for the loss of considerable years of life potential lost (estimated total YPLL of 522,966). Behavioral Disorders. Information on the prevalence of mental illness is very scant. Data from public-sector establishments are incomplete, but indicate that 2.5% of all hospitalizations were related to this category of diseases. Mental illness was more predominant among males and among the 30-to-55 age group. Mental disorders accounted for an estimated 5% of all hospital admissions nationwide. Different studies placed the prevalence of smoking at somewhere between 40% and 50% for males and between 25% and 35% for females. An increasing percentage of adolescents were becoming addicted. Studies on the prevalence of alcoholism do not provide full data, but they do indicate a high percentage of alcoholics among economically active males (between 30 % and 50%). Recently, there has been a trend toward alcohol use at younger ages. Industrial Accidents and Natural Disasters. Twenty-nine industrial accidents were reported in 1995, resulting in 15 deaths. In 1996, a total of 24 accidents were reported in the chemical industry: 85% were chemical spills, 8.3% involved leaks, and 4.2% were fires. Of these accidents, 62.5% occurred during transport operations and 37.5% at fixed installations, leading to the exposure of 1,035 persons and chemical intoxication of 19. Periodic flooding is another source of growing concern, given the vulnerability of many residents in at-risk areas. The danger of flooding and the damage it wreaks is exacerbated by improper land use, deforestation, and inappropriate building practices.
RESPONSE OF THE HEALTH SYSTEMNational Health Plans and Policies The national health policies adopted in July 1992 were designed to ensure the population’s right to health on the basis of the principles of equity, solidarity, efficiency, effectiveness, and quality; enhance the accessibility, efficiency, and quality of health care; strengthen health promotion and protection by targeting specific population groups; and redefine the role of the State in line with federalization and decentralization efforts. Steps were taken to revamp the health care system—including reform of the obras sociales employee-benefit plans—and a series of new initiatives were unveiled, such as the National Program for Quality Assurance in Medical Care, the Self-Managing Public Hospitals Program, and the Compulsory Health Plan. The changes in the health sector were preceded by broad-based reform in the country’s retirement and pension system, which now combines compulsory and voluntary coverage modalities. The compulsory portion has two components: the government-administered component is financed through tax revenue (on a pay-as-you-go basis) and guarantees a standard minimum benefit according to principles of redistribution and insurance; the private component is geared toward savings and security, and takes the form of individual member-capitalized savings plans or company-managed plans that are funded by joint employee and employer contributions, fully and individually capitalized and regulated by the government (i.e., fully funded plans). The voluntary plans are identical in all respects to the fully funded plans with the exception that they are capitalized exclusively by the beneficiary. Health Sector Reform Current health reforms respond to the macroeconomic objective of paring back the costs of productive activity. Change is also sweeping the health sector at the microeconomic level, as it learns to work with new actors (i.e., insurance companies) and other intermediaries, as well as with new forms of contracting that are redefining its relationship with the private sector. The system shifted from a fee-for-service basis to a capitation-based system that concentrated the risk in the provider organization. The private subsector took on a greater role in providing health care services, as the role of the obras sociales and public subsectors shrank in the face of fiscal constraints, lower wage levels, unemployment, and lower employer contributions. Reform of the obras sociales plans led to the formulation of the Compulsory Health Plan (PMO). To develop, negotiate, and implement this proposal, a commission was set up that included the Ministry of Health, ANSSAL, and Argentina’s largest labor union, the Confederación General del Trabajo. The approved PMO opened the way in late 1996 for full beneficiary mobility in choosing an obras sociales plan. In January 1997, Law 24,754 (governing private-sector activity in this area) made it compulsory for voluntary insurance plans to offer PMO coverage as well. This legislation supersedes and overrides all existing agreements; any user may demand the coverage established in the PMO, which encompasses transplants, dental care, services for hemophiliacs, dialysis for chronic patients, and psychological care. The PMO is the cornerstone of compulsory insurance reform, since it defines the product that the obras sociales plans will compete with each other to supply. ANSSAL, the National Obras Sociales Board (INOS), and the National Obras Sociales Directorate (DINOS) were merged to create the National Heath Services Superintendency, a decentralized agency under the Ministry of Health and Social Action. The agency enjoys administrative, economic, and financial autonomy, and is responsible for supervising, inspecting, and overseeing all the players in the National Health Insurance System. The superintendency will focus its action on monitoring the PMO and the National Program for Quality Assurance in Health Care at service providers throughout the system, enforcing guidelines pertaining to self-managed public hospitals, and ensuring the exercise of people’s right to freely select the obras sociales plan of their choice. Organization of the Health Sector Institutional Organization The health services system is composed of three main subsectors: the public subsector (i.e., government-provided financing and services), the obras sociales (employee-benefit plans formerly run by unions and now organized by professional category), and the private subsector (prepaid voluntary insurance plans based on actuarial risk). There is a strong bias toward curative care, with emphasis on hospital services. Although national, provincial, and municipal policies all define primary health care as their basic strategy, most of the jurisdictions that have adopted this strategy approach it in the form of "programs" to be carried out at the primary care level. The public subsector provides care services through the public network. After a prolonged process, hospitals were decentralized in 1991 and directors were given administrative flexibility. In December 1996, the Ministry of Health and Social Action was reorganized into two separate units: the Health Policy and Regulations Secretariat and the Health Programs Secretariat. The obras sociales plans are a system of compulsory social insurance that includes other benefits in addition to health care. Their financing comes from employer and employee contributions. The Government is expediting deregulation of the sector in order to foster competition between the obras sociales plans and private (prepaid) health insurance companies, encourage beneficiaries to take an active role in choosing their obras sociales plan, and guarantee that all plans afford the basic benefits package of main services, diagnoses, and treatments (PMO) as required by law. In the private subsector, the two main subgroups are: professionals who provide independent care services to members of obras sociales or private, prepaid plans; and health care facilities that are contracted by obras sociales plans. Organization of Health Regulatory Activities The current reform process called for new legislation on sector organization, regulation, oversight, and control. Statutes, decrees, resolutions, and ordinances were enacted in such areas as health policy approval, organizational changes in the Ministry of Health, the creation of agencies to oversee new programs or perform supervisory, oversight, or control functions, the operation of various health-sector entities (self-managed public hospitals, obras sociales plans, the PAMI plan, and the private subsector), food and drug regulations, and environmental protection. In some instances, however, enabling regulations are lacking, enforcement structures are fragmented, and overlapping responsibilities create conflict with other jurisdictional levels. Coordination is still at an incipient stage, bearing in mind that under the country’s federal system of government not all subnational jurisdictions have to adopt the norms and procedures generated at the national level. The National Program for Quality Assurance in Health Care oversees the exercise of professional activity in this sector and, accordingly, examines the health team’s overall professional performance as well as specializations, registration, certification, and recertification. The National Food, Drug, and Medical Technology Administration (ANMAT) is a decentralized agency that serves as a national reference center and training site for specialized human resources. Its mandate includes quality control, and it is the highest authority for matters pertaining to the control and inspection of the safety and quality of all products likely to have an impact on human health. Organization of Services for Care of the Population Health Promotion. Reform of the State has led not only to the aforementioned technical and political restructuring of the Ministry of Health and Social Action but also to a reorientation of strategies and programs in several core technical units, such as the Maternal and Child Health Program. In 1994, an initiative entitled "Commitment to Women and Children" was formulated, national strategies and targets were set, and substantial central-government funding was re-allocated for the implementation of provincial programs (whose management responsibilities have increased). The Ministry of Health stepped up its health promotion and protection efforts by establishing programs for public awareness, health education, and tobacco and health, and encouraging a shift in service networks’ care focus. Disease Prevention and Control Programs. Argentina’s Program for the Prevention and Control of Communicable Diseases merits special mention. The national vaccination program seeks to increase levels of vaccine coverage and surveillance under the Expanded Program on Immunization and to enhance coordination with provincial programs; as a specific initiative, a campaign to eliminate measles has also been launched. In 1996, coverage stood at 89.7% for polio vaccine, 82.8% for DTP, 100% for BCG, and 100% for measles vaccine. The system for communicable disease surveillance has also been upgraded, resulting in an increase in case reportings. Epidemiological Surveillance and Public Health Laboratories. The National Epidemiological Surveillance System dates back to the 1950s, when monthly data were already reported for communicable diseases by jurisdiction. The system was reformulated in 1993 under the auspices of the National Epidemiology Directorate of the Ministry of Health and Social Action, and case reportings subsequently increased by around 174% between 1993 and 1996. Almost all data came from the public subsector and referred to morbidity as recorded by outpatient, emergency, and inpatient services. In 1996, the National Network of Argentine Public Health Laboratories (RELAS) was created, linking various networks of laboratories. Water Supply and Sewerage Systems. The service infrastructure in this subsector presents large inequalities. Urban growth over recent decades did not benefit from proper planning and, as a result, the problems of major urban centers progressively worsened. Inadequate water supply and excreta disposal generate high-risk conditions that especially endanger the country’s poorer areas. Municipal Solid Waste Disposal (Including Hospital Waste). No reliable data were available on municipal solid waste. A study on hazardous waste carried out by the province of Buenos Aires in late 1991 estimated that the chemical, petrochemical, and oil and gas industries produced roughly 29.9% of all waste. Prevention and Control of Air Pollution. Environmental quality suffered from a wide range of problems. Generally speaking, though, environmental conditions were poor in marginal urban areas and in regions undergoing rapid economic development. The monitoring system continued to be deficient. Many of the stations included in the Global Environment Monitoring System did not have permanent monitoring systems in place, making it impossible to undertake a specific analysis. Food Assistance Programs. Food assistance is one of the specific components of the Social Plan. Revenue share-outs are used to distribute powdered whole milk to at-risk children and pregnant women as a way of preventing malnutrition. The Children’s Food and Nutrition Program of the Social Development Secretariat provides food supplements as part of the actions geared toward improving living conditions and access to appropriate and adequate food for children between the ages of 2 and 14. Organization and Operation of Personal Health Care Services Insurance Schemes and Coverage. Given the overlapping of categories and coverage levels, the exact extent of health insurance coverage is hard to estimate. According to the 1991 National Population and Housing Census, 62.2% of the population had some kind of insurance coverage. Outpatient, Hospital, and Emergency Services. Public hospitals provide care services for the poor and, on a reimbursable basis, for members of obras sociales plans. They also cover demand from social sectors having greater ability to pay, they provide emergency and accident care, and they perform the functions of a medical school. The public subsector continues to be the principal provider of emergency and psychiatric services and of care for the chronically ill. The number of available beds rose from 145,690 in 1980 to 155,749 in 1995, for a 1995 rate of 4.5 beds per 1,000 population. This indicator represented a drop from the 1980 level; in other words, the number of beds increased at a slower rate than the population did. Bed availability in 1995 broke down as follows: 54% in the public subsector (62.5% in 1980), 2.8% in the obras sociales subsector (5.5% in 1980), 43.1% in the private subsector (32% in 1980), and 0.1% at mixed-administration establishments (which did not exist in 1980). In 1996, there were 824 self-managing public hospitals, offering a total of 62,402 beds (almost 75.3% of the country’s public beds). Auxiliary Diagnostic Services and Blood Banks. Plans have been under way since 1996 to institute laboratory control procedures aimed at guaranteeing high-quality diagnoses. Argentina has 776 registered hemotherapy services and blood banks, some of which serve as compilation points for data from various centers. Included in this number are 536 laboratories that screen blood for transfusions and perform other blood control functions for various institutions. Currently, serological testing is done for hepatitis B and C, Trypanosoma cruzi, HIV, and syphilis. All donors in both the public and private subsectors are screened. Specialized Services. The public subsector has 40 mental health establishments, including 35 residential care facilities for chronic patients. These facilities account for the highest percentage (98%) of the total 15,069 beds available. The private subsector operates 187 establishments, including residential care facilities for cases classified as acute, chronic, acute chronic, or of undetermined duration; these are the most common type of private facility (139) and account for the highest percentage of available beds (80% of the total 9,047 beds for mental health care in the private subsector). From these data it can be seen that virtually all the resources for chronic patient care are located in the public subsector. Twenty-four establishments with a total of 953 beds provide physical rehabilitation services. Nine of these establishments (532 beds) are in the public subsector and ten (421 beds) are in the private subsector. Inputs for Health Drug prices were deregulated near the end of 1991, along with the legal mark-up limits that retail pharmacies may charge. Drug registration procedures were streamlined in 1993, resulting in considerable time savings; drug surveillance and inspections were stepped up as well. The private pharmaceutical sector instituted new drug distribution, administration, and dispensing systems that are used by obras sociales plans and prepaid systems for which specific regulations are not yet in place. Following prolonged parliamentary debate on the issue, the new Patent Act was passed into law in late 1995. Except for those included under special programs, the public subsector does not cover drugs for outpatient care. The public-sector obras sociales plans defray a percentage of members’ drug costs and fully subsidize all the uncommon, high-cost drugs included in the PMO. Prepaid medicine companies also cover about 50% of beneficiaries’ drug costs. Human Resources Work Force Size. The current size of the health work force cannot be determined accurately in view of the fact that no comprehensive studies have been done since 1980. That year, the health sector employed some 210,000 persons, equivalent to approximately 2.9% of the national work force. Total personnel in the various nursing categories was estimated at 85,000 (on the basis of figures from 1988 and 1994): 1,000 graduate nurses (1.2%), 25,000 tertiary-level nurses (29.4%), 49,000 nursing auxiliaries (57.6%), and 10,000 lay nurses (11.7%). Many lay nurses were receiving training to become nursing auxiliaries. Training. The training of health human resources exhibits some very specific characteristics owing to the medical model’s hegemony over the sector. There are seven public and seven private medical schools, which together form the Argentine Association of Schools of Medical Sciences (AFACIMERA). The country has two other private medical schools that are not members of the association. Universities train some 3,500 physicians each year. Labor Market for Health Professionals. Many areas of the labor market need to be studied in greater detail, data need to be updated, and points of consensus need to be established. In 1992, there was an average of only one physician for every 367 residents, although the level ranged from one physician per 113 people in Buenos Aires to one per 911 in Formosa. At a ratio of 1 nurse for every 4 physicians, and 5.4 nurses per 10,000 population (with broad regional variations), levels in this category, too, were considered insufficient. Research and Technology Organization and Financing of Scientific Activity and Training of Human Resources. Reorganization of the science and technology sector began with the transfer of the Science and Technology Secretariat (SCyT) to the Ministry of Culture and Education. The SCyT formulates sector policy, draws up the National Multiyear Plan for Science and Technology, prepares the national budget for the sector, and sets sector priorities. A 1996 survey conducted by the National Health Sciences Information Network identified 250 individually-operated health science libraries, most of which lacked appropriate infrastructure, specialized staff, and the necessary resources for proper knowledge dissemination. Expenditures and Sectoral Financing Expenditures. Most of the country’s health spending is financed by the State and by the obras sociales plans through payroll deductions. Spending by these two subsectors as a percentage of GDP grew between 1980 and 1994 from 3.6% to 4.4%. According to data from the Ministry of Health and Social Action, health spending by these two subsectors in 1994 accounted for 16.49% of all public spending, for a per capita level of US$ 388 in public health expenditure that year. Total health spending in 1995 was calculated at US$ 20,147 million, broken down as follows: public sector (i.e., national, provincial, and municipal governments) US$ 4,676 million; obras sociales plans (national and provincial schemes, and the PAMI plan) US$ 7,055 million; and private sector (prepaid and out-of-pocket) US$ 8,416 million. Despite some intermediate oscillations, public health spending as a percentage of GDP climbed from 1.24% in 1980 to 1.71% in 1994. Private-sector spending as a percentage of GDP declined from 4.5% in 1970 to 2.7% in 1993. External Technical and Financial Cooperation. According to data from the Ministry of Health and Social Action, the main projects benefiting from external financial cooperation were: The Maternal and Child Health and Nutrition Program (PROMIN). This program is targeted at the poor population and assigns top priority to the strategies of primary health care, child development centers (as a referral level), food supplements, and institutional strengthening of the sectors responsible for program activities. The program has a budget of US$ 160 million, toward which the International Bank for Reconstruction and Development (IBRD) is providing US$ 100 million; disbursements are scheduled through 1999. The rest of the budget is covered by the federal government (US$ 40 million) and the provincial and municipal governments (US$ 20 million). The Health Sector Reform Project (PRESAL). The PRESAL project is bolstering reform in the three subsectors (public, private, and obras sociales) by redefining implementation arrangements and relationships and promoting cooperative and competitive synergy among them, with an eye to efficient, equitable, and high-quality medical care. The project has three components: countrywide studies, pilot experiments with self-managed hospitals, and nationwide implementation of the reform, including self-managed public hospitals and training. The budget of US$ 144.65 million is funded in part by the IBRD. The Obras Sociales Reform Program. Negotiations have been concluded for an IBRD loan to finance the reform program as well as institutional strengthening. The program will seek to shore up the financial positions of the obras sociales and PAMI plans and, as part of a gradual restructuring effort, to adjust staffing levels in line with the profiles best suited to achieving the stated objectives. The program has a total budget of US$ 375 million. The Health Infrastructure Rehabilitation Program. Financed by the Inter-American Development Bank (IDB), this US$ 64.09-million program will build four highly complex provincial hospitals.
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