Structured pluralism: towards an innovative model for health system reform in Latin America1
Introduction
Health systems are at a crossroads. Throughout the world there is a search for better ways of regulating, financing, and delivering health services. There is a sense of impending innovation as countries at all levels of economic development and with all types of political systems engage in reform processes. Although the final outcome is still uncertain, it is possible that this search will lead to new conceptual and practical models for health systems.
This paper seeks to develop options for restructuring health systems. In particular, we attempt to examine the shortcomings of present models and to advance an alternative. Our approach is both systematic—in that it analyzes every element within a coherent framework—and systemic—in that it looks at the entire health system, with emphasis on the relationships among its major components. In today`s complex environment, most problems tend to be interrelated. As a consequence, solutions cannot be focused only on one aspect of the health system, while ignoring the rest. For example, if reforms are limited to decentralizing services without changing the financing mechanisms, the incentives or the criteria for setting priorities, one is likely to simply multiply the problems of the previously centralized system. Such problems demand comprehensive approaches that deal with the health system as a whole. Because present failures are systemic, the reform response must also be systemic.
While the issues raised here are of interest to both wealthy and poor countries, we will mostly refer to Latin America. We are aware that generalizations are hampered by the enormous heterogeneity among and within the countries of the region. In fact, our analysis will emphasize the need to develop policies that take into account the diverse conditions coexisting in the region. To a large extent, social and economic inequality explains the mixed picture of health challenges in Latin America, where the problems of both the very rich and the very poor countries of the world are juxtaposed. This inequality is reflected in and reproduced by the heterogeneity of health-care institutions, which have responded to the needs of the different social groups in a fragmented way.
The paper will begin with a brief analysis of the main challenges facing the population and the health-care institutions in Latin America. We will then propose a conceptualization of the health system based on a series of key relationships and functions. This framework will serve to identify and compare the main existing models for organizing the health system and the options for reforming them. Having analyzed the limitations of extreme alternatives, we will develop a model of structured pluralism as a balanced approach to health system reform. We will also examine what appears to be a convergence towards this model. In order to move towards questions of implementation, the paper will then discuss the main policy instruments that are available to carry forth the reform process. Finally, we will look at the strategies to increase the political feasibility of reforms.
Section snippets
The dual character of challenges
Many Latin American countries today face multiple opportunities stemming from advances in economic reform and democratization. At the same time, however, these societies have to contend with complex challenges, which to a large extent derive from the rapid transformations of the postwar era. During the last half century, many Latin American countries have experienced changes that currently developed countries underwent over longer periods of time. This rapid modernization has occurred at very
Components and functions of health systems
The first step in comparing present arrangements and in designing options for reform is to have a clear conceptualization about the health system. All too often, health systems are seen as a simple collection of organizations. Instead, we would like to propose a dynamic view of health systems as a set of structured relationships among two major components: populations and institutions. It is beyond the scope of this paper to specify in detail the various dimensions of each of these components
Current health system models
Through a web of economic, political, and cultural forces, every Latin American country has developed a unique health system. Without denying this specificity, it is valid to attempt to identify the common patterns that emerge across countries. Such an exercise can only be possible if one focuses on the essential components of health systems, abstracting from the myriad details that make each national situation unique.
As a result of the historical process of most Latin American countries, the
The search for new options
The many shortcomings of the four models analyzed so far has led to an intensive search for other solutions, which has inspired the health system reform movement in Latin America and other parts of the world.
In particular, the most common current arrangement, represented by the segmented model, has increasingly been brought under scrutiny. Because this model segregates population groups with different ability to pay and social organization, its sustainability depends on the duality of labor
An innovative model: structured pluralism
The concept of `structured pluralism' tries to convey the search for a middle ground between the extreme arrangements that have so much hampered the performance of health systems. `Pluralism' avoids the extremes of monopoly in the public sector and atomization in the private sector. `Structured' avoids the extremes of authoritarian command-and-control procedures in government and the anarchic absence of transparent rules of the game to correct market failures. In this respect, it is interesting
Towards implementation: instruments and strategies
Progress in the reform agenda is not based only on an accurate diagnosis of current deficiencies and a rigorous design of the preferred model to improve the situation. It is also necessary to move towards questions of implementation, which have two main dimensions: the technical and the political.
Conclusions
The present conditions of health in Latin America and the trends that are already defining its future all point in a clear direction: the need for a comprehensive reform. In this effort, it will be important to preserve the elements of progress achieved during the past half century. At the same time, it will be necessary to identify and supersede the obstacles to further improvement.
Reform must be guided by a systemic approach that looks at populations and institutions. In this way, it will be
Acknowledgements
This paper was initially prepared for the Technical Department for Latin America and the Caribbean of the World Bank. A preliminary version was presented at the Special Meeting of Ministers of Health from Latin America and the Caribbean on Health Sector Reform, organized by the Pan American Health Organization, the World Bank, the Inter-American Development Bank, the Economic Commission for Latin America and the Caribbean, the Organization of American States, the United Nations Childrens Fund,
References (31)
Dimensions of health system reform
Health Policy
(1994)Comprehensive policy analysis for health system reform
Health Policy
(1995)- Morley S. Poverty and Inequality in Latin America, Baltimore: Johns Hopkins University Press,...
- Londoño JL. Poverty, inequality and democracy in Latin America. Paper presented at the First Annual World Bank...
- Altimir O. Economic Development and Social Equity: A Latin American perspective, Economic Commission for Latin America...
- Deininger K, Squire L. Measuring Income Inequality: A New Data Base, Washington, D.C.: World Bank,...
- Frenk J, Bobadilla JL, Lozano R. The epidemiologic transition in Latin America. In: Timaeus IM, Chackiel J, Ruzicka L,...
- Murray C, Lozano R. The burden of disease in Latin America. Paper prepared for the Technical Department for Latin and...
- Inter-American Development Bank, Economic and Social Progress in Latin America, 1996 Report. Special Section on Making...
- Desjarlais R, Eisenberg L, Good B, Kleinman A. World Mental Health: Problems and Priorities in Low–Income Countries,...
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This is a jointly authored paper; the authors names are listed in reverse alphabetical order.
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Former Minister of Health of Colombia. Presently senior economist at the Office of the Chief Economist, Inter-American Development Bank, 1300 New York Ave., N.W., Washington, D.C. 20577. When this paper was written, he was principal human resource economist, Technical Department for Latin and the Caribbean, The World Bank, Washington, D.C.
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Executive Vice President of the Mexican Health Foundation and Director of the Center for Health and the Economy, Periférico Sur 4809, Col. El Arenal Tepepan, 14 610 México, D.F., Mexico.