Rethinking and decolonizing the theory and policies on health systems in Latin America and the Caribbean
By Gonzalo Basile*
Within the "Latin American Critical Thought Notebooks" Collection, CLACSO presents the research "Rethinking and Decolonizing the Theory and Policies on Health Systems in Latin America and the Caribbean" by Gonzalo Basile, Coordinator of the Working Group "International Health and Health Sovereignty"
INTRODUCTION:
The likelihood of individuals and populations being healthy is conditioned by existing social structures and systems. Risk factor theory and biomedicine have had some impact on the health-disease process at the clinical-individual level, but they remain insufficient for transforming the health of populations and social groups, as well as for comprehensively addressing inequalities and the socio-environmental determinants of health and life in the Latin America and Caribbean region (Breilh, 2010).
The moderate 2008 report by the World Commission on Social Determinants of Health (WHO, 2009) presented a significant body of evidence demonstrating that social and economic processes, as well as inequalities in power and access to common resources and public goods, impact health outcomes at both the individual and collective levels. In other words, how one lives, gets sick, and dies (Bronfman, 2001). In this context, health systems not only impact collective health (Granda, 2001), but are themselves social systems or determinants that reflect, reproduce, and solidify the prevailing inequalities and inequities in society. However, they can also be successful mechanisms for addressing, reducing, and transforming the social conditions of life (Benach, 2005).
In other words, health care systems, as collective institutions in their historical and temporal construction, signify the social and material response that a State and Society give to the needs, priorities and demands of collective health of a people.
The influence of socioeconomic conditions—class, ethnicity, and gender—that determine unequal patterns of illness and death among individuals, families, social groups, and populations can be reproduced, deepened, and amplified by health services and systems. The health system itself is a social determinant that is often overlooked and forgotten as a mediating process in shaping the health of societies. Therefore, health systems can play a key role in building social citizenship, distributing wealth, and empowering the people, acting as a catalyst for improving well-being, quality of life, and the overall well-being of societies (Laurell, 2013).
However, the radical transformations produced by the slogans of the end of history (Fukuyama, 1992) and prophecies of the Washington Consensus (Lechini, 2008) that many governments and countries sacramentally accompanied during the 80s and 90s and are being reintroduced in this century in Latin America and the Caribbean with the unofficial intervention of international organizations such as the International Monetary Fund (IMF), World Bank (WB) and the Inter-American Development Bank (IDB); They not only had direct consequences on the financialization of the economy, the commodification of life, the destruction of social and natural rights, the deepening of unhealthy and unequal living conditions (Breilh, 2009), and the impact on economic and political sovereignty, among other dimensions, but they also worked fervently on building a new reconfiguration of the State based on liberal rationality and neoclassical economics to produce private goods, where one of the central dimensions was and is the regressive reforms on health and social security systems.
This article aims to review, describe, and analyze the content of the dominant trend in health system reforms currently underway in the Latin American and Caribbean region, focusing particularly on the cases of Chile (1982) and Colombia (1991), as well as Peru, the Dominican Republic, Argentina, and other countries. In the second part of this work, we will analyze the context in which regional and global socio-political actors and dynamics led to the implementation of what is now known as Universal Health Coverage (UHC) and/or Universal Health (UHC). This section reviews seven premises and postulates identified in the UHC reform and developed by structured pluralism at the regional level. Finally, we will outline approaches to alternative emancipatory paths in the health policy and system agendas currently being pursued by Bolivia and Mexico, the still-relevant foundations of the Cuban revolution in public health, and the innovative and historical aspects of the Brazilian health reform.
STATE, SOCIETY AND HEALTH
A brief characterization of the cycles of state reforms is key to the first thesis of this work. Radical reforms and changes to the state were a determining factor in health policy and the resulting health and social security systems throughout the historical development of each Latin American society. That is to say, rather than observing and analyzing sectoral reforms—in this case, in the health field—as merely imperfections and/or technical-health debates, it is necessary to understand and study the transformations in the legal and administrative machinery that occurred in the public sphere and the state, transformations that had direct impacts on society.
The geopolitics of the social reform cycle reconfigured the State and left profound marks and subjective foundations in Latin American and Caribbean societies. According to Boaventura de Sousa Santos (2010), while we demanded that the State create universal public goods, decommodify certain collective and common goods that cannot be left at the mercy of capitalism, and guarantee political and territorial sovereignty, the opposite occurred. The State became increasingly concerned with producing private goods from the governance of the public sphere, for example, by handing over pensions to individual capitalization by banks (as in the cases of Chile, the Dominican Republic, and El Salvador), healthcare to the medical-industrial-pharmaceutical-financial complex, and social protections to risk insurers. As Laurell (2013) states, “the public institutional fabric was destroyed, making the reconstruction of a universal social policy very difficult when it comes to governing, and the use of the State for its own weakening was legitimized.”
If the first wave in the 80s and 90s was related to the adjustment and structural change of minimizing the welfare state, privatization of public goods in the climate of the Washington Consensus with transfer of responsibilities even to society (expansion of NGOs with functions previously in charge of the State), in the health sector the correlate will start from the bases of the document "Investing in Health" (WB, 1993) promoting focused assistance, hospital self-management, management care , defunding of public health due to structural adjustment, loss of capacities of public services and greater fragility of health systems.
This cycle of structural reforms entered a period of inactivity at the end of the 20th century due to the resulting social and economic crises, which led to political changes with transformative aspirations. From the 21st century onward, the lost legitimacy of the multilateral international organizations that spearheaded the first reforms gave rise to a second wave with a recycled agenda focused on modernizing the state, emphasizing vulnerability, and managing risk within the framework of social risk management theory, which would permeate public policies (Holzmann and Jørgensen, 2001). This period also saw a shift in terminology: these same organizations and their technocrats would speak of the role of the "state," "rights," "equity," "gender," "accountability," "cultural relevance," "citizen participation," and other related concepts. It is in this second wave that the program of extending health coverage with health insurance systems will gain strength (Hsiao and Shaw, 2007) and from 2012 onwards the birth of the global Universal Health Coverage (UHC) device that we will analyze.
DE-CITIZENSHIP, HEALTH AND SOCIETY
It is evident that the residual liberal social protection model and the meritocracy model did not resolve the social issue of inequality in Latin America and the Caribbean. However, the processes of reform to the state and health systems generated what we call the “de-citizenization” of large social groups in Latin American and Caribbean society, who became disconnected in the material reality of their lives from the public sphere, from the fabric of common and collective affairs in society. In this work, we identify two types of de-citizenization (Fleury, 1997):
- De-citizenization through commodificationSignificant sectors of society, who perceived themselves as middle and upper class, found themselves resolving their material needs through the market as the state failed to meet them. This involved sending their children to private schools, paying for private health insurance, using their own vehicles, and living in gated communities and/or private towers, spatially segregated from the rest of the city. They consider this a result of their own effort and individual achievements.
- De-citizenization through dispossessionLarge groups and subordinate social segments in exclusionary Latin American societies have never had effective access to public and social goods essential for life, such as citizenship rights and intergenerational advancement. Their connection to social goods necessary for life is through partisan political patronage and/or by feigning poverty to receive benefits. This language and the prerogatives of technocrats... poorology They produced a subjective dispossession in the linking, appropriation and collectivization of the State in excluded sectors of society.
In both social groups, we could say that their relationship with the public sphere as a space for shared, collective commons and universal social goods for life (Education, Health, Housing, Work, Food, etc.) is close to zero.
THE STRUCTURING OF (DE)REGULATED MARKETS IN THE FIELD OF HEALTH SYSTEMS
In the context described above, health system reforms in Latin America and the Caribbean have been and continue to be linked to the expansion of a dominant theory defined by its authors as structured pluralism (Lodoño and Frenk, 1997). This theory originated in Chile with the dismantling of the National Health Service in 1981 and the expansion of insurance coverage through the creation of private health insurers called Isapres (Health Insurance Institutes), most of which belong to the financial system. It was later further developed in Colombia in 1991, serving as a prime example of its application (Almeida, 2002). The central tenet of this approach is that health system reform itself should enable the structuring of pluralistic markets with regulated competition in healthcare coverage and access. Translation: To build differentiated health coverage through various insurance plans for different social strata, with differentiated service packages, and by separating functions between the State and the market, opening the door to financial intermediation and modulation by insurers, a competitive provider market, and public-private partnerships. The case of Colombia is the emblematic example of this (Hernández, 2010).
Based on this theorizing, which uses a “cube” as its icon to demonstrate the strategy of extending differential coverage, a geopolitics of health dependency emerged, aligned with a Global North agenda. This agenda imposed a roadmap and fast-food recipes of evidence-based policies “à la carte,” produced by the very liberal health technocrats of the World Bank and the Inter-American Development Bank in the region. Those who designed the reforms also generated the evidence of the supposed achievements. These diplomatic efforts exerted significant influence on both neoliberal governments and progressive and left-leaning administrations, which ultimately reproduced the liberal global health agenda (Basile, 2018).
Conducting a brief review of cases, in addition to the precursor, Pinochet's Chile in '81, the neoliberal reform of Colombia with Law 100 in the '90s, was followed by other regressive reforms of structural change (Mesa Lago, 2008):
- The Social Protection System for Health was launched in 2004 with the creation of the Popular Health Insurance (SPS) in Mexico, intended to cover 48 million Mexicans. In practice, it weakened and jeopardized public health through demand-side subsidies and fragmentation into minimal service packages. Furthermore, it sought to dismantle the Mexican Social Security Institute (IMSS) and the Institute of Social Security of Mexico (ISSM) by attempting to unify them with the SPS, an effort that ultimately resulted in the loss of capacity, quality, and funding for these institutions.
- The enactment of the Universal Health Insurance (AUS) Law in Peru in 2009 (Law 29344, 2009) defined a benefits plan—the Essential Health Insurance Plan (PEAS)—and PEAS financing would be provided through three systems: contributory, semi-contributory (partial voluntary payment with state contribution), and subsidized. Health Insurance Fund Management Institutions (IAFAS) were created; these insurers provide health risk coverage to population groups, including the public insurer, the Comprehensive Health Insurance (SIS), for the poor. The provision of services became known as Health Service Provider Institutions (IPRESS), with both private and self-managed public services.
- The Dominican Republic's social security system was created in 2001 (Law 87-01, 2001), mirroring the Colombian model with a regulated market of contributory and subsidized schemes. It established Health Risk Insurers (ARS) linked to the financial system, providing coverage for contributory insured individuals, and a publicly funded insurer called the National Health Insurance (SENASA), accessible through a means test (SIUBEN, a system for registering the poor) and offering a minimum package of procedures and services (Basic Health Plan). Private ARS insured individuals have access to the PDSS (Health Services Plan), with exclusions and coverage options depending on the procedure and co-payments. Demand-side subsidies are funded by SENASA coverage.
- In Honduras, Paraguay, and Haiti, there are plans to export the Peruvian model, using the example of comprehensive health insurance for the poor.
The case of Argentina is interesting because it represents a low-intensity reform where, for decades, World Bank agreements have generated a network of institutional arrangements that have become the de facto state policy: from the decentralization of the health system with the loss of national public leadership in health in the 90s, hospital self-management, outsourcing, and the expansion of insurance, first the Plan Nacer (maternal and child health insurance), then SUMAR, along with the provincial health insurance agreement in the period 2002-2015. As a schematic summary, this is where the World Bank will implement Universal Health Coverage (UHC) in the 2016 agreement, which proposes: 1. The expansion of coverage through the development and strengthening of Primary Health Care for the poor, 2. The unification of the subsectors of the health system into what they call the "National Integrated Health System - SNIS" (WB, 2016).
According to Laurell (2013), most countries undergoing this wave of reforms systematically defunded their public health and healthcare systems and services, leading to a spiral of deterioration, ineffectiveness, inefficiency, and loss of capacity that becomes a self-fulfilling prophecy: the state, as provider, fails to serve or respond to the collective needs of the population. A second element of this process is that, faced with the absence or lack of capacity and/or availability of certain (specialized) services in the public sector, public funds are transferred to pay a complex network of for-profit and financial private actors. This is systematically justified by the need to avoid creating the conditions for health sovereignty (Basile, 2018), that is, to avoid maximizing the capacity, even of new services, of the public health system, which remains fragile. In this scenario resulting from the tsunami of reforms to the State and health systems, families and social groups (even low-income ones), exposed to a vertical public health system of low quality and resolution, migrate to buying insurance or private out-of-pocket services, often of low quality, pay for their procedures and treatments through family collections or sales of their assets, buy medication and supplies, and address other social issues in health.
THE FALLACIES OF UNIVERSAL COVERAGE AND THE HEALTH INSURANCE MARKET
However, the current Second Generation reforms (Laurell and Ronquillo, 2010) incorporated the word “universal” into their narrative: universal coverage or universal health. “The universal” was redefined.
As the liberal Kutzin pointed out, universal health coverage is “a set of objectives that pursues
the health system,” and is “a direction rather than a destination” (Kutzin, 2013).
This directionality will involve transforming the CUS into the platform to relaunch reforms of (de)regulated markets in health systems and building a new fluid discursive grammar with an umbrella narrative where everything fits: under this name even the expansion of financial insurers and the private sector.
A kind of stakeholder map and timeline helps contextualize this initiative. At the “Health Systems Global” meeting, which brought together the private health sector in Beijing in October 2012 under the theme “Inclusion and Innovation for Universal Health Coverage,” the World Bank presented China’s experience of expanding private insurance as a path to UHC. That same December, in Bellagio, Italy, sponsored by the Rockefeller Foundation, the global symposium of the private health sector was themed “The Future of the Health Market,” where experts emphasized the importance of insurance and expanding health coverage for the market. In the Bellagio Declaration [1], they made it clear that it is necessary “ to consider how markets can better meet the needs of the poor in low- and middle-income countries…”. At the same Bellagio summit, Allan Pamba, Director of Access Initiatives and Public Engagement at GlaxoSmithKline, stated that “the African region is of increasing interest to companies, beyond philanthropy, as it is a future growth market. Companies that moved early into China and India have an established and dominant market share, and it is difficult to change that, regardless of the amount of money spent trying to do so .” Pamba argued that “ a cultural shift is needed among stakeholders to appreciate the role of the private sector in healthcare markets .”
In January 2013, the World Economic Forum in Davos, which brings together multinational corporations, presented the report “Sustainable Health Systems” prepared by MacKinsey & Company [2] which in its conclusions proposes promoting UHC and that while “ corporations offer new products and services as markets are liberalized, governments reduce public services and a new sense of conditional solidarity emerges…we must be vigilant in influencing the leaders of developing countries… ”.
Under this dynamic of the political complex of liberal global health (Basile, 2018), finally on September 24, 2013 at the United Nations General Assembly, the World Health Organization (WHO) itself joined the Rockefeller Foundation and the World Bank to launch the report on “Universal Health Coverage”.
In Latin America and the Caribbean, following a series of regional consultations with the World Bank and Rockefeller, at the 53rd Regional Assembly of the Pan American Health Organization (PAHO) in September 2014, all country representatives, including those from Argentina, Brazil, Cuba, Ecuador, Uruguay, El Salvador, Bolivia, and Venezuela, approved the Universal Health Coverage (UHC) initiative without reservations (PAHO CD53/R14, 2014). The term "universal access" was added, but the UHC framework was promoted and endorsed throughout the region.
Recently in September 2019 at the High-Level Meeting on UHC organized by the Universal Health Coverage Partnership (UHC2030), a global pact was relaunched, which was endorsed by the United Nations General Assembly with the political declaration: " Universal health coverage: moving forward together to build a healthier world " [3].
In this declaration and process, the Core Action Group had and has a leading role, constituting an institutional space of the private health sector within the UHC2030 where pharmaceutical corporations, groups of suppliers of medical inputs and technologies, insurers, and other private corporations are located.
This explains why the Universal Health Coverage (UHC) framework has been implemented with hybrid terminology from its inception. According to the WHO, UHC “ implies that all people and communities receive the health services they need without having to suffer financial hardship to pay for them ”… “ UHC does not imply free coverage of all possible health interventions, regardless of their cost, since no country can afford to offer all services free of charge in a sustainable way.” In each of the UHC documents, declarations, and resolutions, there is a glaring omission: the word “public.” Public health systems and public goods appear outside the overall framework.
In summary, this geopolitical power dynamic of actors, corporations, and international organizations from the Global North managed to transform the historical universalization of social rights and universal public goods as a substantial component of equality, equity, and comprehensiveness in responses, into a universalization of a “type” of health coverage that, in principle, has differentiation (inequality) and the expansion of coverage markets in the direction of financialization and the creation of privatization niches in health systems.
This analysis of the content and statements of the actors of neoliberal hegemony in the field of health reveals that they managed to generate logical fallacies using premises that contained their own conclusions, hybrid generalizations, and convincing justifications for their objectives. Other authors would call this alibi of deception.
In logic, a fallacy (from the Latin: fallacia , 'deception') according to Hamblim (1970) is an argument that appears valid, but is not. That is, they are cognitive biases that develop a pattern of reasoning leading to fallacious arguments and conclusions.
In the content analysis and documentary review of the insurance policy and its interrelationships with the CUS, fallacies are identified that reproduce the policy of health insurance expansion in Latin America and the Caribbean. If one studies these experiences, one quickly identifies that: 1- Health insurance (CUS today) was not an effective path to universal health coverage (Chile case after 38 years), 2- Insurance failed to be comprehensive or cover all needs (its coverage is linked to a list of diseases and minimum benefits), 3- They are ineffective and inefficient in developing primary health care strategies and addressing the preventive-epidemiological dimensions in the face of our prevalent regional endemic and epidemic diseases, 4- Demand-side subsidies with a social risk approach and the opening of public-private competition did not improve access to or quality of health care and increased public transfers to the private sector, 5- Decentralization was used to de-responsibility and reduce the fiscal burden on the national state, 6- Attempts were made to link Latin American CUS with the gradual implementation of European universal health insurance or the Costa Rican model, when both cases were post-war phenomena in contexts of expanding welfare states. It is important to understand that these precedents were reformulated with the new conceptual framework of social risk management (SRM), where the foundations of reform are no longer the same as in the 90s or the first part of this century. In other words, the CUS does not use Colombia, the US, or Chile as current examples, but rather Uruguay, Costa Rica, or Europe to legitimize the conceptual and political umbrella of second-wave reformism.
In summary, the CUS with expansion of insurance or guarantee systems:
- They sought fragmentation, not due to a design error, but to divide service providers, insurers and intermediaries, and users/populations, in order to create competition and market niches.
- Segmentation of societies. Between "poor" insured persons and "middle-class" insured persons.
- The private and financial sectors in the region (banks and insurers) understood that the expansion of financial coverage had a limit to its growth: a maximum of 15 to 20% of the total population in the region. For obvious reasons of income and income inequality, a private out-of-pocket insurance market could not grow any further. To expand coverage markets, they needed to deregulate and manage state funds (public financing and public-private partnerships), even to retain mixed coverage for the informal labor market.
- They produced the weakening of public health sovereignty, imploding any strengthening of the state's capacity as guarantor of rights and provider of public goods. After decades of "development" cooperation, Africa only experienced greater dependence on a "development" aid industry (De la Flor, 2008).
DECOLONIZING THEORIES AND POLICIES ON HEALTH SYSTEMS
Even today, the typology used to study and classify social protection models and health systems remains Eurocentric in universities, schools of public health, and regional studies centers. The typology of the following continues to be repeated: the Anglo-Saxon residual liberal model, the Bismarckian model of employment-linked social insurance, and the universal Beveridge model—three theoretical models developed by the Global North to categorize its reforms and processes. Opening a decolonial shift (Maldonado Torres, 2008) in theories and policies on health systems is still an ongoing academic and grassroots endeavor for the Global South.
In general, the theorizing about universal health systems entailed a critical review of Latin American social medicine/collective health itself, in the construction of a new body of knowledge that addresses the social determinants of health and life as the foundation of universalism in the Global South. The organization of universal systems as a strategy for confronting these determinants and their impact (Breilh, 2010). This stemmed from the understanding that it was not simply a medical perspective of universalizing biomedicine and vertical public health for population control, of “eradicating,” “eliminating,” “monitoring,” or “combating” diseases in populations and individuals.
The explanatory theoretical framework of Latin American critical health theory assumed that a model of health organization, networks, and management built upon universality, comprehensiveness, and interdependence is the most effective way to decommodify health and life and respond most efficiently to the needs of the complex and inequitable societies that still exist in Latin America and the Caribbean. The premise was that a comprehensive and universal public system is the safest option for the collective health of society.
The approaches have been and are multiple, with advances and setbacks according to scenarios and fields of forces in society and the State: eliminating access barriers, shock of funds in public services that generate citizenship and income distribution, enhancing capacity for attention and response to unequal epidemiological profiles, prioritizing intercultural dialogue, popular participation and gender equity, reforming the State, and others.
But undoubtedly, historical experiences allow us to consider other directions for health systems in Latin America and the Caribbean. The unique characteristics of Cuba and its revolution, with the creation of a fully state-run national public health system encompassing all levels of complexity, universal access to basic medical care, and a high capacity for resolving complex cases, demonstrate the most effective outcome indicators in the region. Brazil, with its health reforms of the 80s, incorporated citizen participation in the decision-making and management of a Unified Health System (SUS), which, despite facing significant challenges today, serves 75% of the Brazilian population. The precedents set by Argentina and Chile, with the creation of their national public health systems and services during the administrations of Ramón Carrillo and Juan Perón in the 50s, and Salvador Allende in the 60s, also offer valuable lessons.
Currently, Bolivia, after long national debates, created its Single Public Health System with interculturality as a central dimension, with a first step of implementation that is the guarantee of free access at the point of care, a health revolution for a country that still had to pay for access to public services.
Mexico recently, in April 2019, eliminated the Seguro Popular de Salud (Popular Health Insurance): the targeted health insurance program for the poor created by Julio Frenk, one of the architects of neoliberal reforms. His solution was to create the Instituto de Salud para el Bienestar (INSABI) (Institute of Health for Well-being) as a way to stop subsidizing demand and instead prioritize funding public health services for the recovery and restructuring of the healthcare system, with greater coordination with the IMSS (Mexican Social Security Institute) and the ISSM (Social Security Institute of Mexico).
However, a matrix of a new universalism to address the social question in the South requires assuming and elaborating starting points on three structuring adversities of inaction (and sometimes of our failures):
Material adversity: In general, within state government, it is assumed that the public institutions resulting from reform cycles lack the capacity to universalize public goods and fundamentally restructure them. " It can't be done with this state ." Consequently, a cycle of expanding coverage through sector-specific approaches (children, health, education, disability, women, etc.), targeted assistance programs and conditional cash transfers, and palliative social policy measures for poverty alleviation is constructed. Often, the theoretical framework for the state and governance is underdeveloped, particularly in the fields of public health and social medicine.
Economic hardship: The first thing that will appear in any attempt to establish a foundational framework for universalism and citizenship is economic constraint. How is it financed?: “ This universalism they talk about is impossible to finance in Latin America .” This statement will then determine the “possible” social and health public policy, generally starting from a bias of overlooking and failing to consider and problematize tax systems, tax burdens, and fiscal justice as a distributive horizon that is generally proclaimed but has had little material impact in recent decades.
Political adversity: the opposition of actors from the Global North (OECD, US, others), corporations, international organizations (IMF, World Bank, WHO, etc.), and internal colonialism itself, all of whom seek to dictate the direction of “development” in countries of the Global South. But misunderstandings also sometimes appear on the national stage, as do economic interests within the Latin American and Caribbean political system that aim to change the government electorally without altering the fundamental processes that structure society and the state.
This work understands that an emancipatory and alternative project cannot be described solely as its final outcome. It requires a complex framework of redesigning, revitalizing, and reconstructing a multi-stage process for the effective decolonization and emancipation of both the state and society.
With the risk that without citizenization and subjectivation (Fleury, 2010), in a strategy with horizons of transformation, of turning this into a political and social agenda of majorities (or intense minorities), it may also end up being only laudable statements.
- [email protected] Director and Associate Researcher, South-South International Health Program, FLACSO Dominican Republic / Coordination of the Working Group on International Health and Health Sovereignty, CLACSO (Latin American Council of Social Sciences). Latin American Network of Health Systems and Policies ALAMES (Latin American Association of Social Medicine)
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[1] Bellagio Meeting Declaration (2012): http://www.futurehealthsystems.org/publications/future-health-markets-a-meeting-statement-from-bellagio.html
[2] Davos Economic Forum (2013) – https://es.weforum.org/reports/sustainable-health-systems-visions-strategies-critical-uncertainties-and-scenarios
[3] UN (2019). World leaders approve health declaration to achieve universal health coverage, [Online] https://news.un.org/es/story/2019/09/1462542
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