Pan American Health Organization

Health system transformations toward universal health

  • Introduction
  • Health policies as components of systems for social protection in health
  • Health Reforms
  • The challenges of moving toward systems with universal access to health and universal health coverage
  • References
  • Full Article
Page 1 of 5

Introduction

The right to health, equity, and solidarity are values that have guided health system transformations in the Region of the Americas. However, health inequities and social and economic inequality in the Region continue to pose challenges that health systems must confront. New pressures have arisen from the emergence and influence of new health problems, such as the growing burden of noncommunicable diseases, increasing violence and road injuries, and demographic changes reflected in the rapid aging of the population ().

In order to advance toward universal health, health systems must take these transformations further by strengthening the stewardship of the health authorities, boosting regulatory mechanisms, and investing more public funds in health (including efficient and equitable financing). Efforts should also be made to increase and better allocate human resources in line with a people-centered and community-centered health care model ().

At the same time, it is essential for health to be understood as a key component of the social development agenda and, consequently, of countries’ social protection systems. Health inequities are an expression of social problems, determined largely by the structure of existing social protection systems in the countries. For this reason, the transformation of health systems should be viewed through the lens of the new social protection systems being developed and the commitments countries have made through the 2030 Agenda for Sustainable Development ().

This topic presents the key characteristics for describing and evaluating the various ways in which health systems are transforming. It examines the content of health policies as well as aspects of economic policy associated with the formulation and implementation of health policy. This framework helps describe health system transformation processes in the Region these past few years. It also offers a forward-looking analysis whose reference point is the strategy for universal access to health and universal health coverage.

Health policies as components of systems for social protection in health

The right to health, equity, and solidarity are the core values of the strategy for universal access to health and universal coverage (universal health). They also serve as the basis for development of systems for social protection in health ().

The United Nations’ Commission for Social Development defines social protection as “a set of public and private policies and programs undertaken by societies in response to various contingencies in order to offset the absence or substantial reduction of income from work; provide assistance for families with children; and provide people with health care and housing” ( p. 3). According to the Commission, these measures address the need for coverage and promotion of those living in poverty and extreme poverty, as well as the insurance needs of those who, while not necessarily poor, need to feel safe when facing adverse circumstances or certain stages of the life course ().

The rationale behind the strategy for universal access to health and universal health coverag requires an understanding of social protection that is explicitly aligned with the right to health. This means the focus must remain on people and communities in all stages of the life course, and social determinants of health must be an indispensable component ().

Within this framework, stronger social protection helps create more inclusive and just societies in which all people can exercise their health-related rights. This occurs in a context of respect for all economic, political, social, and cultural rights, promoted by public policies that favor sustainable human development ().

Problems and challenges

One of the main challenges faced by health systems is the persistence of inequities1 in income and in health outcomes. As was mentioned previously under inequities and barriers in health systems, these are important issues for social protection systems and, therefore, must be addressed if conditions of inequity in the Region are to be reversed ().

This perspective assumes that conditions of economic growth do not suffice to address the challenges of inequity. On the contrary, far-reaching changes must be made in the institutional structures of the health systems (the financing model, how health services are organized, human resources, technology, and social determinants of health) to ensure that they have an impact on health equity.

Definitions, history, and evolution of social protection systems

The ways that social issues are addressed by government, as well as the priorities established, have evolved over time in the Region of the Americas. This is the result of different approaches to social policy at different times in history, as well as the dynamics of power among the parties involved in decision-making ().

Although they manifest differently in the various countries, the evolution of social protection systems can be grouped into four main stages. In each of these we recognize certain unique features linked to development and to contributory social protection policies (social security), and to the main directives governing non-contributory social protection. In each case, these models give rise to specific concepts regarding the role of the State and of social protection ().

In the first stage, prior to the Great Depression of 1929, social policy tended not to be based in sectors or institutions. When social protection institutions first began to play a leading role in the community, they were contributory in nature, particularly for health in some countries of the Region. This was done through mutual societies and collective insurance, primarily for urban wage-earners and with little State regulation. During the second stage, with greater industrialization and more government planning, the main social policy issues were related to justice, social order, and social security, applied universally, albeit in a fragmented or stratified fashion (). However, there were serious limitations on coverage with marked differences between those who earned formal wages and those who did not. The challenges of adopting a comprehensive approach to include both contributory and non-contributory interventions yielded a lack of coordination, preventing comprehensive interventions. Funding for non-contributory social policy came primarily from the State and resource distribution basically involved subsidizing supply. This allowed the State to extend its presence in service delivery, with scant participation from the private sector.

The third stage, during the last two decades of the 20th century, was marked by economic adjustment processes and a diminished State role in social policies (). These changes had an impact on both the contributory and noncontributory components. Changes to the contributory component took place through privatization and deregulation of health social security systems. New private actors were allowed to manage social security resources through competitive frameworks. The noncontributory component underwent reforms to introduce economic incentives for health service providers. There were innovative funding models which sought to move from funding supply to funding demand by separating funding from health service delivery. This same logic was promoted in other social policies, targeting the population living in poverty ().

At present, a new paradigm of social protection has emerged, based on protection of human and social rights, in keeping with the values and principles established in Chapter 1, which underpin the strategy for universal access to health and universal health coverage ().
Access and coverage have particular relevance in transformation initiatives, with differential consequences for the contributory and noncontributory components. In some countries, these initiatives have focused on strengthening the contributory schemes, with innovations in insurance coverage systems aimed at expanding coverage to the entire population, including those not formally employed. In other countries, initiatives have focused on strengthening the public, noncontributory system. These efforts are geared to strengthening and transforming health services by expanding access and promoting intersectoral policies. But these processes have not been uniform across countries.

Health reforms

Health reforms can be defined as processes aimed at introducing substantive changes to health systems through their various entities, levels, and functions. Changes are achieved through strategies and actions, with the ultimate goal of better meeting the health needs of the population (). Thus, we should define what we mean by health system. The World Health Organization (WHO) states that a health system “consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health”; in other words, a group of actors that carry out health-related activities, understood as any action in the sphere of personal or collective health, public health services, or intersectoral initiatives whose main goal is to improve the standard of health of individuals, communities, or populations ().

Reform processes have affected health systems in most regions and countries of the world since the 1990s. Reform proposals and processes based on the unique characteristics of each region and country have developed in accordance with each specific political, economic, and social context. Still we can identify features of reform that are common to different regions and countries, essentially responding to the social protection models implemented and the prevailing ideas during certain periods, promoted by international organizations. The reform proposals have combined population health objectives (including access to services, expansion of coverage, and improved health service performance) with objectives for changing conditions within institutions (such as segmenting health systems according to different insurance systems and organizational changes associated with the fragmentation of health services).

Plans and strategies for reform are based on one or all of the main elements of health systems: the funding, organization, and delivery of health services, and institutional frameworks. Through this approach, reform processes set strategies associated with the most relevant variables, such as equity, access, efficiency, quality, effectiveness, financial protection, expectations of the population, solidarity, sustainability, and participation.

Two of the most interesting aspects are access and equitable access, considered to be among the central objectives of transformation processes. Access is the capacity to use health services when they are needed. It includes activities targeting the entire population as well as individuals. Access also includes the diverse array of conditions in which the population lives, and the differentiated needs of individuals and population groups. It entails activities to promote health and prevent disease, and to provide whatever health care is needed. Access to health is related to the health needs of populations and the conditions under which the system is used. This is determined by various individual, community, and sociocultural factors, as well as by the characteristics of the health system itself. In other words, access is determined by the interaction between people and their health needs, and the health system ().

Health equity is the absence of unjust differences in one’s health status, in access to health care, and to healthy environments, and in the treatment received in the health system and other social services ().

Equity in financial coverage requires an equitable funding model, with special attention to financial coverage. This is reflected in differences in the allocation of resources (per capital spending) that are not justified by different health needs, but rather by a different ability to contribute, with different parts of the system having differentiated resources to respond to different needs, but inversely—i.e., more resources for groups that likely have fewer health needs (the wealthiest) and fewer resources for those who might fall ill more often and more seriously (the poorest).

Contents and processes of health system transformations

Health system transformations can generally be evaluated in light of two complementary aspects: the content of the reforms and the processes by which they are formulated and implemented.

When examining content, we look at the objectives, tools, and strategies used and how they are applied. This allows us to recognize two types of reforms discussed under the topic of stewardship and governance in Chapter 1 of this publication: i) reforms promoted through innovation in how health systems are organized and the model of care; and ii) reforms through changes to the population’s health insurance mechanism. The objectives of these two kinds of reform are easily differentiated: the former is a matter of increasing access to health services, while the latter increases financial coverage for health services. There is also differentiation in how they are applied, because the first kind of reforms focus on the public sector, while the second kind takes place within the social security system.

An analysis of the processes whereby reforms are formulated and implemented includes an examination of the actors involved, in light of their interests, values, and understanding. This analysis must be conducted to address issues of political economy that underlie the strategies for universal access to health and universal health coverage. The approach includes three interrelated dimensions: i) creation of new institutional frameworks making it possible to establish systems for universal access and coverage; ii) the stakeholders who should participate in the social dialogue; and iii) challenges to the transformation process. This analysis should consider the fragmentation and segmentation of health systems to be key challenges ().

Achieving universal coverage and universal access requires relevant institutional innovations, rather than just maintaining structures that perpetuate the status quo in the Region’s health systems. A political economy analysis requires the identification and description of the institutional arrangements involved in transformation processes, namely: those related to the funding model, how the health services are organized, and how social determinants are addressed. Only by identifying and describing each of these components can the underlying stakeholders, interests, and conflicts be acknowledged ().

When considering the players involved in creating a system to ensure universal access and universal coverage, we must consider the types of actors, the relationships between them, and their technical and political capacity (). As for the kinds of actors involved in these processes of change, a distinction must be drawn between those in the health system and those in the area of finance or other sectors or social contexts. It is also essential to acknowledge their unique interests, perspectives on the problems, and positions regarding the measures promoted to move toward universal health. As for the relationships between the actors, we can imagine a scale going from full cooperation to outright conflict.

Technical and political capacities should acknowledge the conditions needed to build and sustain a universal health agenda. Political capacity is related to the inclusion of new players within a framework of collective leadership with partnership agreements (). Technical capacity is related to the ability of actors to interpret the challenges and prepare interventions.

Finally, conflicts () among the stakeholders must be analyzed when designing transformation strategies. This transcends a financial, organizational, or technical analysis and underscores the political nature of the transformation process involved in moving toward universal health.

Although there are sufficient social values and arguments for promoting universal health, many decisions and measures may be perceived as threats or as contrary to the interests of certain social groups. If these issues are analyzed, it may be possible to enhance the effectiveness of policy formulation and implementation processes. These disputes do not manifest themselves uniformly across the health system’s institutions (). The different types of political economy issues should be recognized according to the type of institutional arrangements in play during the processes of transforming health systems.

Analysis of transformation processes

The processes of transforming health systems can be characterized in terms of two core areas: equitable access and fragmentation of health services; and equitable financial coverage and segmentation of health systems. These core areas allow us to conduct a dynamic analysis of the countries of the Region through the following diagram.

Figure 1 lays out four scenarios. The graph has a horizontal axis indicating higher to lower segmentation of health systems, while the vertical axis indicates higher to lower fragmentation of health services. Each of these scenarios makes it possible to describe different transformation processes, in different countries at different times. Both axes incorporate an analysis of equity conditions. While reduced fragmentation brings improvements in equitable access, reduced segmentation brings more equity in financial coverage.

Figure 1. Health systems transformations

The two extremes are reflected in scenario one (upper-right quadrant of Figure 1) called integral reforms, and scenario three (lower-left quadrant of Figure 1) corresponding to adjustment reforms. While the upper-right quadrant depicts scenarios of less fragmentation simultaneous with less segmentation, the lower-left quadrant depicts reforms that have increased both fragmentation and segmentation.

Structural adjustment policies

The lower-left quadrant of Figure 1 depicts structural adjustment policies. It encompasses reforms to health systems that occurred within the structural adjustment policies implemented during the last two decades of the 20th century. Public sector transformations–including policies that targeted those living in extreme poverty with a limited set of services–had negative effects and increased both segmentation and fragmentation. Segmentation was exacerbated by multiple coverage systems for different populations groups, defined by their own targeting criteria. Fragmentation in the organization of services was a result of initiatives limited to sets of limited services, without a comprehensive health service perspective ().

These kinds of reforms are characterized by a reduced role for the State, with the weak participation of social actors; they are vulnerable to pressure exerted by private actors who stand to benefit from the changes ().

21st century transformations

Changes over the past decade are characterized by two types of reforms: those geared to expanding access and those focused on expanding coverage. Reforms geared to expanding access (upper-left quadrant of Figure 1) focused on developing service systems centered on people, families, and communities. The platform for these transformations has been the public sector, but there has been limited coordination with social security and the private insurance sector. These reforms did not achieve significant progress in terms of universal coverage with reduced segmentation of health systems, and they were limited to the public sector.

This type of reform was characterized by the emergence of new social actors who acquired greater influence on health policy decision-making and implementation. There are three groups of actors. First, health professionals (family doctors and general practitioners, psychologists, social workers) changed the way the health services are organized by playing an important role in forming new health teams and, therefore, direct service delivery. Second, social movements also provided new actors, particularly those making their own demands to improve access to health services. Both the professionals and social movements contributed ideas, values, and interests associated with these initiatives. They were complemented by the presence of actors with academic traditions and reputations, who influenced the decision-making processes and the formulation and implementation of reform policies. Finally, some of these transformations included coordination with other sectors and social policies. Multi-sectoral governance has played an essential role in coordinating implementation of reform policies throughout each country’s territory, and therefore, addressing social determinants of health ().

Reforms geared to expanding coverage (lower-right quadrant of Figure 1) are characterized by efforts to move toward universal coverage by reducing segmentation in the health systems. These include innovations in funding, particularly for insurance. A common feature of these processes is to encourage the convergence, or at least harmonization, of social security and the public sector. However, these reforms have still not made enough progress to sustain transformations in how services are organized, with a people- and community-centered model of care, since the market mechanisms have not been effective enough and provider incentives have not yet achieved the desired results.

Formulating and implementing these kinds of reforms brought in new strategic actors, either through the development of new State structures, or through greater coordination with academic institutions capable of influencing health policy-making.

The challenges of moving toward systems with universal access to health and universal health coverage

Figure 1 can be explained with the following selected cases. Starting with the structural adjustment reforms of the 1990s, the following countries promoted reforms to improve their health systems. In Bolivia, Ecuador, and El Salvador, reform processes that prioritized primary care moved them closer to comprehensive care (). However, convergence of the contributory and noncontributory subsystems still needs to be addressed. Chile may also be included in this group, but with a different strategy, starting with the development of explicit health guarantees (GES) (). Colombia, the United States, and Uruguay took a different approach and made progress in reducing segmentation (). However, the variable of equity must be included so that within each group there are cases that promote greater equity and others that still face challenges in reducing levels of inequity.

In the countries that managed to move toward a scenario of less segmentation (lower-right quadrant of Figure 1), significant progress was made in terms of greater financial coverage. However, several challenges remain on the path to equity in financing and in access to health services (). As regards equitable financing, two types of challenges remain. Progress with coverage does not necessarily mean improved equity in financing, because different population groups have coverage systems with very different levels of financial protection. In order to reduce this gap, additional fiscal resources must be invested in the public sector.2 In addition, some transformation processes geared to changing the insurance model are still facing major problems in terms of pooling social security resources. Progress along these lines requires changes to the mechanisms for regulating risk management in the private organizations that manage social security resources.

The greatest weakness of these reforms is the scant progress made in transforming the model under which the health services are organized. Therefore, this kind of reform requires strategies to introduce regulatory mechanisms for new health service delivery models, with appropriate incentives in the forms of payment and explicit targets in terms of equitable access to health services. Furthermore, these changes will only be sustainable if changes are made to the mechanisms for regulating human resources, bringing them in line with the new models of care and including clear targets for expanding equitable access to health services.

Health system transformations have made significant strides in terms of equitable access to services by changing the way the services are organized, but challenges still remain. These are related to the need to reduce segmentation, and the need to sustain improvements in access to services. These kinds of reforms tend to be limited to the public sector, and have little influence on social security. Progress must be made in coordinating or integrating the public sector and social security, which is key to achieving equity and efficiency in the funding model. Such changes are feasible if more public funds are spent (allocated to the public sector), and by introducing pooling mechanisms which make it possible to assume the health needs and financial risks of both sectors together ().

These reforms will also require that progress made in access be sustained, if there is to be consistency in the development of new mechanisms for the regulation of human resources and incentive systems aligned with the new models under which health services are organized.

Strategic interventions for health system transformations toward universal health

In order to advance toward universal health and health equity and guarantee the right to health, it is necessary to make organizational, institutional, and policy changes, with additional efforts to invest in human resources and public financing. The shift toward a people- and community-centered care model (recognized by a majority of countries in the Region), should be the focus of health system transformations in the 21st century.

This section presents the strategic lines of action for transforming health systems in order to advance toward universal health, in light of the policy changes needed to strengthen the stewardship of the health authorities. It includes a social dialogue with a broad array of stakeholders, institutional changes related to reducing segmentation and fragmentation, and the need to increase public investment in human and financial resources.

Strengthening the stewardship of the health authorities and social dialogue

The stewardship of the health authorities is understood as their leadership in instituting and supporting collective action to bring about the institutional and organizational changes required for health system reform. This is an essential political ingredient, because it determines how these transformation processes will be developed and implemented ().

It is crucial to include and empower State actors (with health authority duties that cannot be delegated—including special emphasis on the regulation of health systems) as well as other social stakeholders committed to furthering the cause of universal health. This should include the participation of social movements, health professionals, and academics that help analyze, evaluate, produce, and manage knowledge about the transformation of health systems ().

“Social dialogue” is both a tool and a platform for raising issues about access and coverage, and for legitimizing the needed transformations. Evaluation, debates, and social forums on the limitations and transformation of health systems are typical examples of this type of initiative. It is essential to include key actors, members of the health sector, and people from other social sectors in order to formulate and implement health policies. Similarly, it is fundamental to allow the health sector to participate in the formulation and implementation of social and economic policies that have an impact on the social determinants of health.

Analysis and evaluation activities afford opportunities to interpret the issues and provide ways to target different audiences. These activities include not only stakeholders in collective health, but also those interested in formulating other social policies, such as housing, social development, nutrition, etc., and those working in public finance and economic policy. Work teams should be interdisciplinary and include multiple sectors, allowing information and knowledge from the social, economic, and health sectors to come together.

All of these analysis and evaluation activities require the formation of multidisciplinary and multisectoral teams capable of addressing these complex issues and finding strategies to move toward universal access to health and universal health coverage. The information and agreements resulting from the social dialogue should meet these three criteria: i) consistency in the inclusion and relationships among the main components, which lends technical legitimacy; ii) social and political legitimacy of the actors involved in producing institutional arrangements that contribute to universal health; and iii) the drafting of reports targeting different audiences, with direct or indirect influence on the remaining challenges for universal access to health and universal health coverage.

The political capacity needed to make health a greater priority in the development of inclusive social policies requires greater integration and coordination between the health system and the housing, nutrition, education, security, labor, and environmental sectors. Strengthening the health authorities and establishing collective leadership in the formulation and implementation of social policies are essential components for staying on track toward universal health ().

Strengthening the essential functions of public health and the resiliency of health systems

Health systems and the populations they serve continue to be very vulnerable to risks that directly affect the capacity of systems to serve the needs of the population. These risks include disease outbreaks, natural and other disasters, climate change, economic and social crises, among others. Such risks can significantly jeopardize health at the local, national, and global levels by weakening the response capacity of health systems and reversing progress made with health outcomes. Thus, the fragility of national health systems poses a problem for individual, collective, national, and global health. The H1N1 virus pandemic in 2009, the Ebola virus outbreak in West Africa in 2014 and 2015, and introduction of the chikungunya (2013) and Zika (2015) viruses in the Region of the Americas revealed the serious impact that a disease outbreak can have on the health system, particularly the demand for integrated and emergency health services. Inadequate surveillance, response, and health information systems; lackluster execution of infection prevention and control strategies; health professionals insufficiently prepared to handle communicable disease outbreaks; inaccessible health services and health institutions that lack adequate infrastructure; and the need to rapidly mobilize additional financial resources to support surveillance and response activities constitute important structural deficiencies in the current health systems. These deficiencies at the national level are also failures in the application, implementation, and compliance with the International Health Regulations (IHR) ().

The IHR is a global legal instrument whose scope and purpose are “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade” (). They accomplish this by strengthening and maintaining essential public health functions at the national level—defined in the IHR as core competencies—which constitute the foundations of a system to manage public health events worldwide, in a holistic and cross-sectoral fashion. The common provisions adopted in the IHR text at the World Health Assembly in 2005 entered into force in 2007. As globalization increases, health systems are increasingly interconnected. Consequently, investment in the resiliency of national health systems should be considered a global public good supporting national health and well-being, reducing risks to health systems beyond national borders, and safeguarding social capital, confidence in health systems, and health governance mechanisms at all levels of the global health system.

Intersectoral interventions that address the social determinants of health

One of the central features of health system transformation—considered to be an integral part of the emergence of a new paradigm in social protection systems—is the development of intersectoral interventions to address the social determinants of health (). These intersectoral interventions, which are expressions of the health in all policies approach, are indispensable for making progress toward universal health ().

First, the development of mechanisms to regulate the production and consumption of mass-produced goods (e.g., the food industry, use of pesticides, regulation of alcohol, drug, and tobacco use) serve to curtail risk factors for the health of the population. These strategies use mechanisms to regulate activities and processes outside the health system, generally at the macro-national level, with a significant impact on the health of the population. In such cases, the advocacy and technical capacity of the health authorities are key factors in getting the most out of regulations, which were previously in the exclusive purview of other areas of government (Ministries of Finance, Trade, or Agriculture). In recent years, the health authorities have joined forces with social movements to increase their influence by establishing economic and trade mechanisms, marking a departure from the health sector’s traditional role.

Second, certain intersectoral interventions complement reform processes that seek to expand coverage under the social protection systems. These regulatory frameworks play a cross-sectoral role to the degree that they include public health conditions as a risk factor related to social protection or to certain social conditions (poverty) or demographics (children or the elderly) that have an impact on public health. Processes based on increasing formal coverage—with explicit benefits, beneficiaries, and resources administered by new actors or agencies—have gone hand-in-hand with the expansion of social protection system reforms. In this case, the relationship between the health sector and other sectors is complemented by mechanisms to regulate social protection systems by adding benefits and beneficiaries to coverage expansion initiatives.

Third, a set of intersectoral initiatives should be encouraged. These innovations are characterized by the emergence of State entities and structures that seek to coordinate public policies, traditionally working from within the various social sector ministries and managed by them. But here, the intersectoral approach is linked to efforts to integrate social policies, with the objective of expanding access to public services. The issue addressed by these initiatives is the fragmentation of social policies and their limited effectiveness. These new entities or intersectoral structures (created ad-hoc to manage across sectors), include the participation of social movements with a presence on the ground as a way to improve coordination with social organizations in different parts of the territory.

Finally, other intersectoral interventions with a major impact on the social determinants of health should be promoted at the locations where health services are delivered and managed. Such efforts aim to shift the model of care toward greater focus on the needs and culture of people, families, and communities. The human security approach has been used as a strategy to promote local intersectoral interventions, in which empowerment of the population and the community plays an active role.

Reducing the segmentation of health systems

There are many problems related to the multiplicity of insurers, in which risks and resources are not regulated or compensated. First, the large number of organizations performing this function makes it hard to reach a critical threshold for pooling resources and spreading health risks, as required by insurance. Second, when different insurers (or groups of them) have different levels of resources, coverage rules, access rules, and population needs for health services, it is difficult to ensure equity and efficiency with the available financing.

Most countries in the Region of the Americas (with some exceptions, e.g., Canada, Costa Rica, Cuba, and Uruguay) have high levels of segmentation and inequity (see in topic 5 of Chapter 1, “Health Financing in the Americas“).

Reducing segmentation in health insurance would entail confronting a wide array of rules, depending on the structure in each country. Addressing the social security system’s impact on the segmentation of health will require changes to the system’s rules on contributions, redistribution mechanisms, coverage, and definition of services covered. Similarly, integrating and coordinating public subsystems (financed with revenue from taxation or the exploitation of natural resources) and social security entities would also help reduce segmentation. In the latter case, the institutional innovations required would range from the creation of regulatory mechanisms and standardization of coverage rules to the pooling of financial resources.

While the kinds of reforms aimed at reducing segmentation will determine which stakeholders are affected or involved, the central players are the contributors who pay into each insurance system and the corresponding beneficiaries. What is in dispute is the redistributive capacity of insurers, when those who benefit most are those who have the least ability to pay into the system but the greatest need of health services.

An important component of the relationships among the actors with an impact on reforms is the positioning of professionals and for-profit private corporations involved in providing goods and services. Often, while the inclusion of insurers enhances the capacity to negotiate better prices for services (thus reducing costs for the health system), and improves the ability to regulate effectively, private actors may resist.

This shows that reducing segmentation not only creates more equity; it also improves efficiency in financing. However, it is necessary to consider matters of political economy, given the weight of the forces aligned with the status quo. In order to address these issues, other actors in the regions and health funds need to be empowered with political capacity, which will enable them to adopt redistributive mechanisms to mitigate inequity. The technical challenge is to analyze inequities and gaps between different coverage funds or geographical regions that receive fiscal monies, compared to the health service needs of the population and the resources allocated. This implies that work must be done to integrate fiscal and financial information, and examine epidemiological conditions and the clinical effectiveness of health interventions.

Depending on the magnitude of the segmentation issues and the types of institutional innovations, there may be opportunities to open a social dialogue with a broader group of stakeholders. An analysis of the gaps between social security organizations and the public sector points to the need for political actors and the most financially vulnerable beneficiaries to be included and empowered, in order to achieve universal health.

When the agenda for debate revolves around regional differences, there is a need to strike a better geographical balance to empower a broader spectrum of stakeholders from the most disadvantaged areas. Among the countries studied, there are high levels of regional inequality when resource allocation mechanisms for the health sector are geared toward subnational agencies. There is no proper analysis of the health service needs of those regions, which not only causes inefficient allocation of resources, but also replicates and exacerbates inequities in access to health services between regions.

Finally, greater equity in the insurance and financing models, within social inclusion for health policies, has positive effects for all of civil society—both the for-profit and non-profit sectors. A society that is experiencing less conflict, due to financial protection from a system moving toward universal health, engenders greater social cohesion and a better business climate, improved conditions for developing quality health services, and greater productivity for human talent.

Reduced fragmentation

Improving how health services are organized is a strategy that will yield results in terms of more equitable access and more efficient performance by the health services. In keeping with the resolution on universal health, we must not only strengthen the response capacity of primary care by putting together trained and motivated health teams, and making sure that drugs, technology, and the necessary infrastructure are available, but also by transforming the model of care and strengthening coordination between different organizations and levels of care ().

The problems of political economy are explained by the radical change entailed in this new organizational model for the health services system. Different groups of professionals and suppliers vie for organizational spaces, jurisdiction over the scope of professional practices, as well as regulatory mechanisms and criteria, and professional autonomy.

In each country, the players involved in these innovative processes will vary, depending on the type, scope, and progress of reforms implemented, and the organizational capacity and positioning of the players. The SAFCI program in Bolivia took the path of radically changing the model of medical care in a context of latent conflict with medical associations (). However, its development is still incipient and it is not yet fully integrated with the health services network. Brazil has been an emblematic case after two decades of a family health program that has managed to significantly expand coverage (). Under this model, Cuban physicians were sent to the most socially vulnerable regions where there is no access to services, making it possible to address persistent challenges. However, the open conflicts between health authorities and professional associations reveal some of the issues of political economy mentioned before, in which State regulation is pitted against professional practice.

In all of these cases, disputes over changes in how health services are organized have arisen between groups of health workers and professional, political, and technical actors in government, reverberating within the health sector. The technical complexity mentioned above, along with the professional nature of these disputes, has limited this discussion to a small circle of parties. Social dialogue would be one strategy for expanding the debate to make it more constructive and innovative, including activities such as a review of experiences in other countries, and taking a systematic approach to alternatives, while looking at potential costs and effects in moving toward universal health ().

Fiscal space to increase public health expenditures and efficiently decrease inequity

The benchmark for public financing of health has been set at 6% of GDP. This money is to be used efficiently, sustainably, and in a fiscally responsible way to expand access and reduce inequities through increased financial protection and efficient interventions. Increased financial protection will reduce inequities in access to health, through a planned and progressive process with the growing use of collective mechanisms that tap into various sources of funding to replace out-of-pocket payments.

Within each country’s unique circumstances, new spending should aim to strengthen primary care in order to boost its response capacity—the ultimate proof of its effectiveness and its capacity for coordination within service networks.

Political will and social dialogue play an essential role in creating fiscal space (). Connecting social need with political decision-making requires transparency and justified use of resources (). Political consensus is a characteristic shared by countries that have been successful in improving access to health care and public spending on health.

International evidence shows that it is technically possible to create fiscal space; all that is needed is the political will to do so. It is also advisable to diversify funding sources to ensure that it is sustainable, because diversification helps stabilize the economy and maintain fiscal balance. Furthermore, it also seems advisable to mobilize more internal than external sources of funding, and to use tax revenue and non-tax revenue rather than outside money in the form of aid and loans. External funding may be highly volatile and additional debt could destabilize the fiscal balance and not be sustainable over the long run. Tax increases, a review of tax-related expenditures, the establishment or increase of taxes on products that are harmful to health, more efficient public spending, and better tax administration are fundamental options when facing this challenge.

Strengthening of human resources

The shortage of health workers, their inadequate distribution, and the need to ensure consistency between skills and job requirements in order to enhance the efficiency of the sector require innovative solutions tailored to the countries of the Region of the Americas ().

The United Nations recently provided an initial response to this need by drafting the report, “Working for health and growth: investing in the health workforce” (). This is particularly relevant to the transformations underway in the health systems of the countries in the Region. The report reaffirms the idea that the health sector is essential for the economy as a whole. It adds that the sector is vital to production and the creation of decent jobs, for inclusive economic growth, for human security, and for sustainable development (). It also argues that in order to make the changes needed to redefine health priorities—such as changes in demographics, morbidity, technology, and economic conditions— a major transformation in the health workforce is needed. Health workers must be able to address social determinants and take on the priorities of health promotion, disease prevention, and development of primary health care, at different levels and through different entities, which will inevitably lead to expanded education for health workers. Finally, the United Nations High-Level Commission on Health Employment and Economic Growth calls for countries to make a political commitment and work collaboratively to help workers realize their social and economic potential in the health sector, and to do so in accordance with the SDGs ().

Furthermore, strengthening the governance of human resources for health (addressed in the sections on stewardship and governance) entails a need for new regulatory mechanisms in the job market, a new understanding of professionalization aligned with innovations in the models of care, and processes of continuing and ongoing education. This is an indispensable (and often pending) aspect of sustaining the health system transformations of the past decade.

Sustainability of health systems for universal health

In the Region of the Americas, health systems will need to make progress sustainably. In addition to the problems of fragmentation and segmentation, which exacerbate inequity, there are challenges associated with the growing costs of health care due to the introduction of new technologies, aging and epidemiological change, and growing public expectations of receiving timely, quality service.

Although these phenomena are observed in other regions of the world, they are likely occurring more quickly in the Region of the Americas. For example, according to the Pan American Health Organization (), population aging can be considered a result of improvements in the health of the population, and a consequence of successful public health policies aimed at development. Indeed, economic and social development has given rise to increased life expectancy, which together with a decline in fertility rates, determines population aging. Developed countries such as Japan, the U.S., and some European countries have already experienced this demographic transition. But the process is currently happening more quickly in developing countries and this is regarded as a worldwide phenomenon ().

In this context, policies to contain costs through efficiency and equity face problems with implementation. These are due to the complexity of existing health systems, posing problems in terms of coordination and regulation of the various institutions involved, regardless of the specific arrangements in each country.

The financial expression of health systems and public spending, which occurs in budget formulation and execution, has special connotations for budget management at this level. Planning, transfer, and resource utilization mechanisms, within a context of fiscal sustainability, require the creation of appropriate tools for governance, operations, and regulation. For this reason, it is particularly important to have updated and accurate financial and budget information, along with systems to flag problems so that they can immediately be corrected. It is also important to coordinate budget execution at the national and subnational level.

At the same time, several commonly promoted mechanisms have yet to be seriously examined in the Region. Some entail providing incentives for the transfer of resources; others include appropriate policies to regulate systems, particularly when insurance offers incentives for overuse and discrimination in terms of benefits and beneficiaries, tends to waste resources and not help strengthen primary care, and fails to encourage health promotion and prevention—the building blocks of sustainability. In the sphere of technology, it is essential to promote the use of generic drugs and procurement policies that reduce prices, and to list medications and assess the economic impact of new techniques and technologies. Furthermore, it is imperative to strengthen management systems as well as policies on revenue generation, and to create fiscal space to address the problem of insufficient public spending in the Region.

In conclusion, health systems will become sustainable through health promotion, which includes addressing the social determinants of health through intersectoral interventions. Similarly, it is essential to improve disease prevention and early detection (particularly for chronic diseases) to reduce the incidence of catastrophic illnesses, and to give timely access to health services, particularly primary care. In the area of financing, as direct payment at the time of service delivery is eliminated, progress will be made by pooling funds, developing integrated health service networks, and improving the quality of expenditures and interventions.

References

1. Pan American Health Organization. Strategy for universal access to health and universal health coverage. 53rd Directing Council, 66th Session of the Regional Committe of WHO for the Americas, Washington, D.C., 2014 Sept. 29–Oct. 3 (CD53.R14). Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/7652/CD53-R14-e.pdf?sequence=1&isAllowed=y.

2. Yamey G, Shretta R, Newton Binka F. The 2030 sustainable development goal for health. BMJ 2014; 349:g5295.

3. United Nations. Enhancing social protection and reducing vulnerability in a globalizing world. Report of the Secretary-General. 39th Session of the Commission for Social Development, New York, 2000 Dec. 8 (E/CN.5/2001/2). Available from: https://documents-dds-ny.un.org/doc/UNDOC/GEN/N00/792/23/PDF/N0079223.pdf?OpenElement.

4. Inter-American Social Protection Network. Social protection systems in Latin America and the Caribbean: the challenge of inclusion [Internet]. Available from: http://www.socialprotectionet.org/iaspn-blog/social-protection-systems-latin-america-and-caribbean-challenge-inclusion-0?_ga=2.167976801.1717604190.1499869466-1405718849.1499869466.

5. Franco R. Los paradigmas de la política social en América Latina. Revista de la CEPAL 1996; 58:9–22.

6. Duhau E. Las políticas sociales en América Latina: ¿del universalismo fragmentado a la dualización? Revista Mexicana de Sociología 1997:185–207.

7. Fleury S. Política social, exclusión y equidad en América Latina en los 90. Nueva Sociedad 1998;156:72–94.

8. Almeida C. Reforma de sistemas de servicios de salud y equidad en América Latina y el Caribe: algunas lecciones de los años 80 y 90.  Cadernos de. Saúde Pública 2002;18(4):905–925.

9. Ministerio de Salud, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). Diseño e implementación de una metodología de evaluación, seguimiento y acompañamiento de la reforma de la salud de Chile. Informe final. Santiago de Chile, 2012;

10. World Health Organization. Everybody’s business. Strengthening health systems to improve health outcomes WHO’s framework for action. Geneva: WHO; 2007.

11. Pan American Health Organization. Renewing primary health care in the Americas: a position paper of the Pan American Health Organization/World Health Organization (PAHO/WHO). Washington, D.C.: PAHO; 2007. Available from: https://www.paho.org/hq/dmdocuments/2010/Renewing_Primary_Health_Care_Americas-PAHO.pdf.

12. Báscolo EP, Yavich N, Denis JL. Analysis of the enablers of capacities to produce primary health care-based reforms in Latin America: a multiple case study. Family Practice 2016;33(3):207–218.

13. Hufty M, Báscolo E, Bazzani R. Governance in health: a conceptual and analytical approach to research. Cadernos de Saúde Pública 2006;22(Supplement):S35–S45.

14. Hodgson RC, Levinson DJ, Zaleznik A. The executive role constellation. Boston: Harvard Business School Press; 1965.

15. Báscolo E. Gobernanza y economía política de las políticas de APS en América Latina. Ciência & Saúde Coletiva 2011;16(6):2763–2772.

16. Seo M-G, Creed WD. Institutional contradictions, praxis, and institutional change: a dialectical perspective. Academy of Management Review 2002;27(2):222–247.

17. Tejerina H, Soors W, De Paepe P, Santacruz EA, Closon MC, Unger JP. Socialist government health policy reforms in Bolivia and Ecuador: the underrated potential of integrated care to tackle the social determinants of health. Social Medicine 2009;4(4):226–234.

18. Ramírez HS. Aspectos interculturales de la reforma del sistema de salud en Bolivia. Revista Peruana de Medicina Experimental y Salud Pública 2014;31(4):762–768.

19. Pan American Health Organization. El Salvador en el camino hacia la cobertura universal de salud: logros y desafíos. 1st ed. San Salvador: PAHO; 2014.

20. Urriola C, Infante A, Aguilera I, Ormeño H. La reforma de salud chilena a diez años de su implementación. Salud Pública de México 2016;58(5):514–521.

21. Restrepo J, et al. Transición en el sistema de salud colombiano. Observatorio de la Seguridad Social. Grupo de Economía de la Salud (GES) Año 15. N° 30. Facultad de Economía, Universidad de Antioquia. Medellín, junio del 2015.

22. Bernal O, Barbosa S. La nueva reforma a la salud en Colombia: el derecho, el aseguramiento y el sistema de salud. Salud Pública de México 2015;57(5):433–440.

23. Pan American Health Organization. Report of the Regional Forum on Universal Health: an indispensable investment for sustainable human development [unpublished report]. Washington, D.C.: PAHO; 2015. https://www.paho.org/salud-en-las-americas-2017/?p=73.

24. Arbulo V, Pagano JP, Rak G, Rivas L. El camino hacia la cobertura universal en Uruguay. Análisis de la cobertura poblacional del Sistema Nacional Integrado de Salud y de la incorporación de colectivos al Seguro Nacional Salud. 2012.

25. Mínguez Gonzalo M. El nuevo reglamento sanitario internacional: RSI (2005).Revista Española de Salud Pública 2007;81(3):239–246.

26. World Health Organization. Revision of the International Health Regulations. 58th World Health Assembly, Geneva, 23 May 2005 (WHA58.3). Available from: http://who.int/csr/ihr/IHRWHA58_3-en.pdf.

27. Organización Mundial de la Salud. Foro regional. Salud universal: una inversión indispensable para el desarrollo humano sostenible. Informe. 2015.

28. Yavich N. Quinto Informe Técnico. Proyecto: Intervenciones intersectoriales para la equidad en salud en Argentina y América Latina. IDRC. 2017.

29. Ramírez Hita S. Salud Intercultural. Crítica y problematización a partir del contexto boliviano. La Paz: ISEAT. 2011.

30. Gil CRR. Primary health care, basic health care, and family health program: synergies and singularities in the Brazilian context. Cadernos de Saúde Pública 2006;22(6):1171–1181.

31. Durán-Valverde F, Pacheco JF. Fiscal space and the extension of social protection: Lessons learnt from developing countries. Extension of Social Security Paper 33. Geneva: International Labour Office; 2012.

32. Marcel M. Budgeting for fiscal space and government performance beyond the great recession. OECD Journal on Budgeting 2014;13(2):1A.

33. United Nations High-Level Commission on Health Employment and Economic Growth. Working for health and growth: investing in the health workforce. New York; United Nations; 2014. Available from: http://www.world-psi.org/sites/default/files/documents/research/en_who_cheflyer.pdf.

34. Pan American Health Organization. Human resources for health: increasing access to qualified health workers in primary health care-based health systems. 52nd Directing Council, 65th Session of the Regional Committee, Washington, D.C., 2013 Sept. 30–Oct. 4 (CD52.R13). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=23410&Itemid=270&lang=en.

35. World Health Organization. World report on ageing and health. Geneva: WHO; 2015. Available from: http://www.who.int/iris/bitstream/10665/186463/1/9789240694811_eng.pdf?ua=1.

×

Reference/Note:

1. Twenty-nine percent of the population living below the poverty line and the poorest 40% of the population receiving less than 15% of all income.

2. This point was specifically addressed Chapter 1, topic 5, “Health Financing in the Americas”.

Regional Office for the Americas of the World Health Organization
525 Twenty-third Street, N.W., Washington, D.C. 20037, United States of America