viernes, 5 de noviembre de 2010

The Argentine health care system

Argentina, the third largest country in Latin America, has a population of more than 40 million people, with 90% of them living in urban areas. More than a third of Argentina’s population lives in the area that surrounds the capital city of Buenos Aires. According to the United Nations Development Report, 2003, Argentina was ranked 34/175 countries, with a Human Development Index 0.8491 (UNDP 2003). The WHO overall health system performance score situates Argentina in the spot 75 between 191 countries (whereas Canada is 30, and USA is 35). This combined measure of overall health system achievement is based on a country’s goals relating to health, responsiveness, and fairness in financing. The measure varies widely across countries and is highly correlated with general levels of human development as captured in the human development index (WHO 2000). 

Since the last dictatorship, but especially since the beginning of 1990s, Argentina has seen how gradually, often abruptly, its socio-economic situation deteriorated. Argentina is becoming more and more impoverished and unequal, with wider economic gaps between the higher class and middle and lower class (Destremau & Salama 2002). The last economic crisis between 1998 and 2003 brought more inequalities and poverty, the economic growing phase between 2003 and 2007 only slowly improved the social conditions of the lower classes. From October 1998 to October 2003, the poverty incidence among the entire Argentine population increased from 26% to 47.8%. The increase of extreme poverty (destitution) was even higher; it passed from 6.9% in October 1998 to 27.7% in October 2003. If the problem is observed by region, the Northeast presents the highest poverty and extreme poverty rates, and the provinces of Corrientes and Chaco have the highest indices of all country (68.7% and 65.5%, respectively). Seventeen of the 24 Argentine provinces have higher poverty rates than the national rate. Due to the direct relation that exists between those circumstances and the health of the population, the threat to the sanitary status of the Argentines is definitive (PAHO Basic Health Indicator Data Base). 

The national statistics agency (INDEC) had a major credibility crisis due to Nestor Kirchner’s (last President between 2003 and 2007) intervention. Now INDEC’s indexes are not reliable. Therefore, private consults have provided more reliable statistics. For instance, SEL consultant affirmed that poverty in 2007 affected 32,3% of the urban population. This means that 11.5 million were poor (some may argue that is probably higher, even 20 million, that is, 50% of the total population), and within that population 3.9 million were extremely poor. In the Great Buenos Aires Area numbers were similar (31.2% of poverty and 9.7% of extreme poverty). The main differences were between the city of Buenos Aires (13.9% of poverty and 3.1% of extreme poverty) and the areas surrounding the Federal District (36.8% of poverty and 11.8% of extreme poverty). In some provinces in the Northeast or Northwest poverty went up to 70% (SEL 2009). Just as a mere comparison, we could contrast Argentina and Canada in regards to distribution of incomes (see table 1). In Argentina, the lowest 40% of the population has access only to 11% of the national wealth, whereas the highest 20% of the population owns 55%. This level of inequality and the dimension of the gap situate Argentina in a completely different social scenario in comparison to countries such as Canada.

Table 1: Family Distribution of Incomes according to Lowest and Highest Social Groups

Family distribution of Incomes (%) 1995-2005*, 40% lowest

Family Distribution of Incomes (%) 1995-2005*, 20% highest







Source: UNICEF 2009.

However, there are signs of improvement in the last 3 years. The Human Development Index of the UNDP shows that Argentina improved 4 places from 2005 to 2010, and now Argentina is in the 46 place among the nations. And when we adjust the HDI for inequality Argentina is on the 55 place. Since November 2009 the government has implented the Universal Provision for Child which currently is aproximately 55 u$d per month. Only with this political decision total poverty was reduced from 26% to 22% and the gap between the richest and poorest that in 2001 was in 39 times went to 24 times. So there are social and economical changes in a good direction but still the richest are even richer.In Argentina, 60% of the population under the age 14 are poor, and 25 children under the age of 1 die per day from hunger and its consequences.[i] Argentina has an infant mortality rate (under 1) of 15 every 1,000 babies born alive, whereas Canada has 5 every 1,000 babies born alive, and a country like Cuba has 5 every 1,000 babies born alive as well. In the case of under-5 mortality rate the numbers stay almost the same (see table 2).

Table 2: Under-5 and Under-1 Mortality Rate Comparison Among Argentina, Canada and Cuba (2007)

Under-5 mortality rate, 2007

Infant mortality rate (under 1), 2007










Source: UNICEF 2009.

The medical system is overexploited and always close to collapsing. In 2001, the total health expenditure per capita in Argentina was Intl$1,130 corresponding to the highest amount in the region. This health expenditure compares with other South American countries as follows: Uruguay $971, Colombia $356, Peru $231, and Ecuador and Bolivia $177 (both countries shows the lowest figure in the region).

Total health expenditure in Argentina represents 9.5 % of GDP. This figure compares with 10.9% in Uruguay (the highest percentage in the region), 7.0 % in Chile, 5.5% in Colombia, 4.7% in Peru, and 4.5% in Ecuador (the lowest percentage in the region).

Even though official data is currently unavailable, it is supposed that the devaluation of Argentina’s currency in 2001, and especially the political manipulation after 2007 of the special agency that keeps track of the economic indexes (INDEC), have significantly distorted these figures.

The health care system in Argentina is organized around three main providers:

* The public sector: which supplies free clinical care for hospital inpatients and outpatients. A charge is made to outpatients for medicines but if the patient does not have money he or she can have it for free. There is also a national drug bank for specific conditions which is free (oncological, HIV, transplanted people). This sector used to cover about 50% of the population but it seems that now this percentage has increased drastically. The public system serves those not covered by social plans or the private sector. Argentina’s public system shows serious structural decline and administrative ineptitude. The major portion of the public system is under the provincial level. There's a constant struggle for resoures and labor disputes. Staff and publics need more investment in the health system for better infraestructure, equipments, wages, and supplies and so very often there are public manifestations and/or staff strikes. Often Municipalities are in charge of the primary level of care. Since the major 2001 socio-economic and political crisis more and more people rely in public services.

* Social plans (“obras sociales” in Spanish) (around 300 in number): administered by trade unions but now “flexible” to service any client that wants to join it. Employers and employees each pay a fixed fee. The social plan covers the cost of medical care and medicines in varying proportions; the patient pays differences between the fixed fee and the actual cost of treatment. The top 30 Obras Socials hold 73% of the beneficiaries. In the past, these plans have usually covered around 40-45% of the population, although the percentage has recently dropped sharply due to growing unemployment and under the table working conditions, with more and more people having the public sector as the only source of health provision.

* The private sector: where patients meet the total cost of their medical care; this sector covers around 5-10% of the population. The main characteristic of this sector is its diversification and fragmentation; there are many kinds of facilities but just a few powerful networks. There are over 200 organizations, which covers approximately 2 million Argentines. These three sectors very often overlap. Hence it is hard to calculate the degree to which beneficiaries are dependent on the public and/or private sectors. What is clear is that de-regularization of the health care system helped to develop powerful private companies that are taking bigger portions of the market.

However, these percentages vary according to the regions; in the poorest provinces more than 75% of the population can only access the public sector, and those public hospitals are usually badly maintained. Many provinces send their patients to the national hospitals of high complexity, which are mainly located in the City of Buenos Aires. Although these provinces cover the costs of these patients, this situation creates a bottleneck at the high complex hospital in Buenos Aires. Even patients from the bordering countries such as Paraguay and Bolivia often use these services. Each of the three sectors has their own organization of health care provision. Public sector has institutions at the national, provincial and municipality levels, and according to primary, secondary, and terciary care. Social plans by trade unions have their own hospitals and clinics. Private sector also has its own private clinics and hospitals. The county and national hospitals in the city of Buenos Aires attract many patients from the surrounding greater Buenos Aires area (1/3 of the whole Argentine population lives in this area). But the current political situation in the city of Buenos Aires, with a right-wing government pro-market, and pro-“efficient spending” is creating a major crisis at the 15 county hospitals. And, on top of that, the lack of good services at the Province of Buenos Aires creates a bottleneck in both the few good public hospitals in the Province of Buenos Aires and the many good hospitals in the City of Buenos Aires. Professionals tend to work in the three sectors; usually if they are staff workers at the public institutions they work in the morning until 2 pm and then they work in the private sector or in their own private offices.

In terms of significant figures, the health care system in Argentina has more physicians (150,000) than nurses (85,000) and there are also more medical specialists than general practitioners or family doctors. It has also reduced the infant mortality rate (per 1000 live births) from 24 in 1990 to 14 in 2006[iii].

According to Regazzoni (2008), the Argentine health care system is strongly inefficient; he says “The system in the current situation ruin the lives of many. And the Argentine health has no cure if deep changes are not made in its system” (2008: 102, my translation). Regazzoni finds that the types of prevailing illnesses in Argentina are heart diseases, stroke, maternal mortality, tumors, respiratory diseases, car accidents, and infections like diarrhea and hepatitis; these conditions are caused by poverty, working conditions (or unemployment), education, infrastructure, and eating habits. He also says that half of the population does not have any medical coverage,
therefore, either they use public hospitals or they pay from their own money for medical services, and more importantly, 45% of all mortality rates are related to poverty, maternal health and pregnancy. But the health problem in Argentina has one of its epicenters in the Province of Buenos Aires where one of three Argentines lives, particularly in the Great Buenos Aires Area that surrounds the city of Buenos Aires (the Northeast and Northwest of Argentina have also extremely high rates of poverty and bad health quality). In this area the trend is that the majority are poor, with lower levels of education, higher levels of unemployment or working under the table, and with lack of social benefits. The Province of Buenos Aires is short of beds for hospitalization, and the quality of its hospitals are generally bad, so inhabitants of the province go to the City of Buenos Aires where the quality is better and this creates a tremendous pressure on the health care system. When facing a health problem, people have three basic options: do nothing, go to the collapsed public system, or pay from their own pocket. Half of the health expenditure in Argentina comes from the private sector, that is, it comes directly from the citizens in context of extreme poverty and unemployment. Therefore, the wealthier the patient the better the quality of health service received; and this is a crucial part of the social inequalities. Regazzoni says, “Each time that the poor has to collect money among family members, friends, and neighbors for buying a medicine or conducting a test, in this same measure society would fail to redistribute its resources. In our country this failure is no less than 50%” (2008: 122, my translation). Half of the children under the age 4 in the Province of Buenos Aires do not have any medical coverage. This is connected with the current situation in the Children’s Hospital in which this project will be conducted, because 1 out of 2 child that comes to the hospital is from the Great Buenos Aires area where children are living in extreme poverty conditions.

Current Palliative Care provision in Argentina

In the beginning, professionals working on Oncology or pain control started to study palliative care and to develop teams of Palliative Care within their medical institutions. From three or four Palliative Care teams at the beginning of the 1990s, there are 14 palliative care services[iv] and more than 80 teams throughout the country today; 11 of them working in pediatric palliative care. Most of these services are hospital based although a small number of the more developed services also provide home care. In Argentina there is a gradual development of health policies promoting and establishing Palliative Care services within the three main providers, especially official recognition at the public hospitals of not only staff palliative professionals (doctors, nurses, psychologists, social workers) but also the need of developing residencies on Palliative Care in order to secure the creation of more human resources specialized in Palliative Care. One of the main obstacles that Palliative professionals confront is the low availability and the high cost of analgesics, and they are struggling for the provision and universal access of opioids for patients experiencing acute and chronic pain and suffering, especially patients experiencing life-threatening conditions and on terminal phase.

In spite of all these teams in the country, the famous English Palliative specialist (with close ties to Argentine Palliatives) Dr Robert Twycross from the University of Oxford, after visiting many of the Palliative Care teams throughout the country, says “The Palliative Medicine in Argentina is fragmented, and possess limited resources, besides the fact that society ignores its right to receive it through health programs”[v]. In the same token, Dr De Simone from the Palliative Care team at the Hospital Udaondo adds, “Palliative Care are currently included in the Mandatory Medical Program of the National Ministry of Health, but the program was drastically cut and Palliative Care is yet unavailable for the majority of the population”[vi]. Therefore, Palliative Care in Argentina still needs to confront many challenges in a general context of perceived crisis.

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