Section II.
Analysis of Health Care Policies

Chapter 2.
The Context and Process of Health Care Reform in Argentina

Introduction

The reform of the health services system (HSS) in Argentina came about as a consequence of the grave economic crisis of the 1980s. At that time, the role of the state in the economy and social welfare was shaped by the need to cope with the explosive growth in demand that arose from the recovery of democratic institutions. As well, over the past 15 years, Argentine society had undergone profound changes to its economic structure and political system, which generated particular problems with respect to social integration.

The impact of the crisis on Argentine society was similar to that which occurred elsewhere in Latin America, being characterized by a marked drop in production levels, accelerated inflation, a drastic reduction in economic activity, and high unemployment. External indebtedness imposed the need to generate ever larger trade surpluses, while maintaining a balanced budget to ensure monetary stability. Other effects of the crisis included increasing instances of social exclusion, the pauperization of the middle classes, and an alarming spread of extreme poverty.

The most apt word to describe Argentine policies in the 1980s is “adjustment”: adjustment of the productive apparatus to world market conditions; adjustment of the financial system to production levels; and adjustment of state spending to available resources. The unavoidable modernization of the state reinforced the socially exclusive features of the economic policies adopted by emphasizing cutbacks in personnel and spending without directing available resources toward social programs.

Beginning in 1991, the success of the Convertibility Plan[1] stimulated the recovery of internal and external investment, making greater flexibility in spending possible. Important changes had taken place in the structure of the productive apparatus, as well as in social and institutional forms of organization.

The most salient features of the new economy were as follows: the consolidation of new economic and financial groups representing local capital; the development of specialized natural resource-intensive industries; and the redefinition of the terms of entry into international trade, particularly in matters concerning the profile of exports. In addition there have been important changes in the world market, in trade union activity, and in the production of certain public services, as a result of new strategies of deregulation, privatization, and the opening up of the economy.

No less important were the changes in the political system, which have not been confined to the recovery of democracy. President Menem’s administration has continued the “presidential” tradition whereby the executive takes the leading role and parliament shows little initiative. The Menem administration benefited from much better conditions for untroubled government than its predecessors and was able to take advantage of a favorable international climate and obtain support for its transformation policies from large national and international investors. Other factors that worked in the government’s favour and helped get the reforms underway were as follows: the support of the supreme court of justice, which enabled the President to legislate by means of Decretos de Necesidad y Urgencia (emergency decree); the inability of the opposition to appear as a feasible alternative; the weakening of the trade unions; and, in particular, the fragmentation of the labour movement.

These policies had a number of positive results in terms of macroeconomic indicators: inflation control; high investment rates; a large growth in the gross domestic product (GDP) between 1991 and 1994; an increase in productivity in specific sectors; a significant increase in the export of goods and services; and recovered equilibrium in terms of balance of trade and balance of payments. Negative aspects included a contraction of the labour market, with accompanying unemployment and underemployment; difficulties in achieving fiscal balances in 1995, 1996, and 1997; and excessive dependence on international financial flows due to an underdeveloped local capital market and insufficient domestic savings.

In the area of social policies in general, and those relating to the health sector in particular, there were important differences between the policies pursued by the Alfonsin administration (1983–89) and that of President Menem (1989 to the present). In the former case, rationalization and cost-cutting strategies were oriented according to guidelines advocating strong state intervention, maintaining the bases of solidarity, a tendency toward universality, and the participation of business, trade unions, and professional associations. By contrast, the present administration has emphasized deregulation, privatization, and contracting freedom in matters related to the organization and financing of health care, especially since implementation of the 1991 Convertibility Plan. At the same time, It has put into effect plans to focus on and support social demands in specific areas on the basis of agreements reached with the World Bank.

Background Influences

The HSS that existed between the 1960s and the 1990s was characterized first and foremost by the decline of the public subsystem — the one responsible for providing health care to the poor — both in terms of financial and material resources and in technical and managerial efficiency. This decline was compensated for by the growth of the social security sector and by an expansion of services on the part of the private sector.

The social security sector was composed until recently of a large number (about 370) of institutions called obras sociales that acted as health insurance funds for workers and their dependents. The obras sociales originated and grew under the trade unions’ control. The system was institutionalized in 1970 with the passing of Law 18.610. This law made it mandatory for employers and employees to contribute to the obra social administered by their trade union. The obras sociales provided health care to their beneficiaries in two ways: through their own health services and by contracting facilities from the private sector. This form of organization became the basis of the HSS, which gradually grew more varied and fragmented as each trade union developed its own health care service, or subcontracted it from the private sector, with little regulation or coordination by the state. In less than a decade, a considerable expansion of private facilities occurred, measured in terms of physicians, hospitals, and technology.

In the absence of state regulation, the HSS fell under the control of two large groups of associations: the obras sociales, on the demand side, politically represented by the Confederación General del Trabajo (CGT, general labour confederation); and the medical federations and private hospital owners’ organizations, on the supply side. Since the 1960s, private health care institutions have been grouped into large federations at the national level comprising physicians, biochemists, pharmacists, dentists, and providers of services for inpatient care. Until very recently, these large tertiary federations, representing provincial federations and local associations, have maintained control of the power to contract with the obras sociales.

The Instituto Nacional de Obras sociales (INOS, national institute of Obras sociales,) was the state agency responsible for managing the system. Its main function, according to Law 18.610, was to regulate the operation of the obras sociales, so as to reduce the large differences in financial capacity between them and to guarantee their beneficiaries access to a basic set of health services. The INOS was responsible for monitoring contracts between financing institutions and the large physicians’ federations. The regulatory capacity of the INOS proved insufficient to reduce the inequalities between obras sociales, however, and they continued to vary in terms of number of beneficiaries, institutional regime, consumption profile, cost structure, and service model. The result was a mosaic of arrangements, differing from region to region and union to union.

No sooner was the system introduced in 1970, than attempts were made to reorganize it. The proposed reforms attempted, on the one hand, to assure better use of resources and a more equitable distribution of benefits. On the other hand, they sought to take control of the obras sociales away from the trade unions, which had gradually become a source of political and economic power, in many cases, to the detriment of their specific function.

Attempts to reorganize the system in 1973, 1978, and 1985 failed due to concerted opposition on the part of the CGT. With the passing of Laws 23.660 and 23.661 in 1989, modifications were made in the norms regulating the system, but no changes were made to the fundamental parameters governing its organization. By this time, financial deficits were seriously hampering the operation of the obras sociales, prompting them to raise their members’ contributions on several occasions. Law 23.661, the purpose of which was to lay the legislative basis for the development of a national health insurance scheme, put the system under control of a new agency dependent on the Ministerio de Salud y Acción Social de la Nación (MSAS, ministry of health and social action). The Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration), as it was called, proved as incapable of imposing order as its predecessor, INOS. The new law also modified the system’s nomenclature, now referring to the heterogeneous group of obras sociales as “health insurance agents.” This initiative was based on the expectation that under the control of ANSSAL, the system would gradually expand through the voluntary incorporation of independent provincial obras sociales, as well as some mutual aid societies.

To complete this summary of the situation of the HSS at the time the reform began, it is necessary to take a look at private health insurance institutions, called Empresas de Medicina Pre-paga. These institutions originated in the late 1960s, but were of limited significance up until the beginning of the 1980s. From then on they grew in importance and became a supplement to, or a substitute for, the obras sociales as far as the higher-income segments of the population were concerned.

The private health insurance institutions were as heterogeneous as the obras sociales. Some were organized by physicians’ associations and large private hospitals with a view to increasing the number of options for financing their services. Others were companies that functioned exclusively as financing agencies, subcontracting private services for their clients’ coverage. To complicate matters, some of these companies acquired facilities of their own, with a view to becoming more competitive.

The Reform Process

Formulation of reform policy

The State Reform Law declared practically all state enterprises to be subject to privatization and modified the regime governing public services. The Economic Emergency Law firmly tackled the issue of reducing public spending. It suspended all subsidies and grants affecting the national treasury, promotion regimes for mining and industry, and all regulations restricting foreign investment. At the same time, it authorized the executive to divert to other uses funds having a specific purpose; to revise contracts with public employees, to modify the labour indemnity system; and to set up a penal regime for noncompliance with tax obligations. The reform strategies adopted a course decidedly favoring deregulation of the economy.

With respect to health, in 1991, the Ministerio de Economía de la Nación (ministry of the economy) launched a strategy aimed at centralizing social security contributions, with a view to facilitating control of these resources by state officials. To this end, the government established the Sistema Unico de Seguridad Social (SUSS, unified social security system), under Article 85 of the Economic Deregulation Decree (2.284/91). SUSS was dependent upon the Ministerio de Trabajo y Seguridad Social de la Nación (MTSS, ministry of labour and social security), and established the Contribución Unica de Seguridad Social (CUSS, unified social security contribution) to combine social security and health care contributions. The law gave SUSS the power to collect, administer, and supervise the distribution of all payroll deductions through the Fondo Solidario de Redistribución (FSR, solidarity redistribution fund), created under Decree 2.741/91. The percentage of funds destined for financing health care services was then apportioned to the respective obras sociales. This measure had the effect of making the system of resource collection and allocation more transparent, clearly establishing the number of beneficiaries, and facilitating the control of evasion.

In 1993, further advances were made on the reform policies in an attempt to solve two problems associated with the obras sociales. The first was related to the obligation imposed on workers to pay their health security contributions to the obra social associated with their particular trade union. In the view of the proponents of reform, this mechanism ensured a “captive” clientele incapable of raising the quantity and quality of services supplied or organizing a more efficient administration of resources. It was believed that generating a certain degree of competition between the obras sociales might stimulate a greater degree of efficiency in their management and lead to the concentration of many small institutions into a few large ones capable of generating an adequate risk pool. In this way, it was hoped to reduce the great differences between institutions as to numbers of beneficiaries and availability of resources, which are frequently alleged to be the source of inequality in terms of benefits.

The second critical factor was the growing proportion of beneficiaries of obras sociales who were compelled to seek health care from the public subsystem. This phenomenon related to financial difficulties that compelled the obras sociales to resort to extra payments (co-payments) for additional service coverage. At the same time, professionals dissatisfied with low remuneration from the obras sociales began to charge their patients an additional fee at the time of service delivery. This extra fee was too much for some low-income beneficiaries, who were forced to resort to the free public services. Surveys of several general public hospitals revealed that 30–50% of their patients actually had insurance, even though the hospitals recovered only a negligible fraction of their costs from insurers. Of obras sociales members who were hospitalized in 1994, 5% reported that they relied on public health services, frequently without cost recovery.

The adoption of new mechanisms that would allow hospitals and health centres to receive payment for their services has by and large been accepted, as it is believed that this will help alleviate their deficits and increase their cash flows.

Political perspectives on reform

Proposal backed by the World Bank

• introduce competition into the financial market, avoid risk selection;
• reassign resources from the Fondo Solidario de Redistribución (FSR, solidarity redistribution fund) strictly on the basis of income collected and risks per beneficiary;
• develop an effective regulatory framework;
• develop insurance institutions that are competitive, transparent, and accountable, to protect consumers’ rights; and
• provide financial and technical assistance to the obras sociales and the Programa de Atención Médica Integral (PAMI, comprehensive health care program)[2], to enable them to increase their efficiency, balance their accounts, and comply with new norms and regulations.

A proposal was also put forward to define a Programa Médico Obligatorio (PMO, basic services package), able to guarantee minimum coverage within budgetary restrictions.

The Fondo de Reconversión de Obras sociales (FROS, Obras sociales reconversion fund), was created to facilitate reform of the obras sociales’ management. This would include helping them balance their budgets, restructure their debts, rationalize personnel, improve their managerial and information capability, and sell off idle assets. Participation in the program is voluntary, but to date 73 obras sociales representing 5 million beneficiaries have joined the program.

Counter-proposal by the Confederación General del Trabajo

Should an obra social be unable to comply with the PMO due to misappropriation of funds, excessive management costs, inefficiency, noncompliance with quality standards, service irregularity, or any other cause detrimental to its function, ANSSAL has the power to merge it with another obra social.

The Fondo Solidario de Redistribución (FSR, solidarity redistribution fund), would not only compensate organizations receiving insufficient resources, but would also aid in such processes as staff restructuring, negotiating with suppliers, upgrading equipment and facilities, and canceling current liabilities through loans.

An important difference between the CGT project and the PARSOS project supported by the World Bank concerns distribution of subsidies by the FSR. In the CGT’s proposal, the subsidy bears no relation to individual contributions by entitled beneficiaries, but is related instead to the average income per beneficiary of the obra social.

Implementation

Dispositions regarding social security institutions and their relations with service suppliers

Decree 9/93 (7 January 1993)

The decree also undertakes to reform relations between obras sociales and providers of services through the following dispositions:

• The obras sociales are given freedom to contract with providers of services, without restriction as to scheduled fees, thus introducing price competition between health care suppliers.
• The obras sociales are forbidden to contract with institutions responsible for issuing professional licenses or limiting the right of their members to contract directly. This disposition excludes from the market those agents that have traditionally controlled the offer under oligopolistic conditions, that is, the professional associations.
• Contracts signed between obras sociales and providers shall contain criteria for categorizing and accrediting such providers, with the purpose of optimizing quality in health care.
• The obras sociales shall pay public hospitals for the services provided to their beneficiaries. This disposition is completed by Decree 578/93 regulating the hospitales de autogestión (self-managed hospitals). Self-managed hospitals are public hospitals that are empowered to manage their own resources independently of their respective jurisdictions (provincial or municipal) once they have complied with certain conditions stipulated in the decree. These hospitals will be discussed more fully in the section dealing with changes in the public sector.

Policies reducing employers’ contributions

Decree 292/95 (14 August 1995)

The resolution is important, not only because it guarantees minimum coverage and begins to recognize different risk levels, but also because it puts an end to the arbitrary distribution of subsidies on the part of the ANSSAL, a distribution that was historically motivated by political considerations.

Decree 492/95 (22 September 1995)

Unification of jurisdictions — Superintendencia de Seguros de Salud

Specific provisions make the SSS responsible for verifying compliance with the basic health services package; the Programa Nacional de Garantía de Calidad (national quality guarantee program); the norms concerning self-managed hospitals; and the right of workers to chose their own obra social.

Reform of the Public Subsystem: Decentralization of the Hospital System

Transfer of hospitals

With few exceptions, the decentralization process from the national to the provincial level was not completed by transfers from the latter to the municipalities. In several cases, however, the provincial systems themselves developed a high degree of centralization, although the outcomes varied by province due to different conditions.

The nation has created hospitals endowed from their origin with a legislative structure that permits their decentralization to the microeconomic unit (hospital) level. These are highly complex hospitals possessing, for example, the power to formulate budgets and set salaries, similarto the self-managed hospitals created and regulated under Decree 578/93.

Decree 578/93 (1 April 1993)

To be eligible for incorporation into this system, hospitals were required to fulfill the following conditions:

• comply with all basic requirements established under the national quality program, and be authorized and categorized by a competent authority;
• receive funding from the applicable jurisdiction on the basis of production, efficiency, and type of population served; and
• supplement their incomes with fees-for-services from persons able to pay, and with funds from contracts signed with private health-insurance companies, mutual aid societies, and obras sociales.

Experience acquired to date has been limited to a few institutions, and the outcome has not been uniform. In some cases, the enrolment of patients with coverage has excluded or limited the access of poor people to the system; in other cases, that risk has been explicitly removed through administrative mechanisms that effectively prevent discrimination. In any event, the additional resources obtained in this way are not great when considered as a percentage of the total budgets of these institutions.

Throughout the 1990s, three phenomena concerning the decentralization of the hospital system occurred simultaneously:

• The last of the national public hospitals was transferred to the provinces, achieving a decentralization that was merely administrative in its aims.
• The provincial health systems were reconfigured, with some centralization at the provincial level, but generally favoring decentralization toward the municipalities, thus giving rise to a heterogeneous set of provincial situations.
• A certain degree of microeconomic decentralization to the hospital level occurred in the form of the self-managed hospitals.

Evaluation

Effectiveness of reform — the underlying political conflict

The fact that reform decrees are issued at intervals of 2 years or so is linked with cycles of improvement and deterioration in the relations between the government and labour leaders. In more than a few instances, the existing system of obras sociales was allowed to continue in exchange for approval of other measures that the government deemed more important to the reform program.

On the other hand, the other pillar of reform — liberalization of contractual measures affecting supply and demand of services — has had a significant impact on the greater part of the country. One has to ask, however, whether this is a consequence of reform measures or a movement initiated by entrepreneurs who have better opportunities elsewhere in view of financial crisis in social security. This point will be developed in the next section. Thus, a paradoxical situation has arisen whereby deregulation favors the competitiveness of the supplier as a result of fragmented demand, in the form of the survival of a number obras sociales controlling different levels of resources.

In 1995, several events affected the decision to push ahead with deregulation of the obras sociales, and revived the conflict with the CGT. The first of these was the Mexican crisis in December 1994, whose repercussions caused an upheaval in the Argentine financial system that lasted several months and prompted a new vote of confidence in the Convertibility Program. A second event was the beginning of a recessionary phase in the economic cycle that highlighted the difficulty of controlling public spending and awakened well-grounded fears of a fiscal imbalance capable of threatening the monetary stability achieved earlier. Economic leaders stressed the need to deepen state reform and, to this end, to resolve outstanding questions concerning relations between the national and provincial governments, and between the state and the trade unions. As a step forward in the matter, negotiations were held with the World Bank spurred on by the need to achieve efficiency in the administration of expenditures.

In the second half of 1996, talks between the government and union leaders deteriorated as a result of the Executive’s decision to urge parliamentary sanction of the Leyes de Flexibilización Laboral, (labour flexibility laws). The CGT found all means of dialogue with the government blocked, and two general strikes were launched. The strikes received considerable public support given the government’s loss of popularity due to its inability to reactivate the economy, to reverse staggering unemployment figures, to curb public spending or to control numerous cases of corruption and waste.

The government continued its drive to make labour relations more flexible and at the same time set deadlines for the deregulation of the obras sociales. Since January 1,1997, beneficiaries have been able to choose their obra social.

Social bases of the conflict — new and old actors in the health sector

those individuals or groups occupying a strategic position in the decision-making system, and who are responsible, in the policy-forming process, for the functions of articulation of the cognitive field and the power field. In their role as mediators, it is they who define the issues of debate and the intellectual framework in which negotiations, alliances and conflicts sustaining decision-making take place.” (Pierre Muller, taken from Merhy 1992, p. 46)

To understand the changes in process, one must remember that competition between the political parties and these associations has been a relevant feature in Argentine politics since the 1940s. However, the last decade has seen the gradual weakening of the system by which associations represent their interests before the state. This is particularly noticeable in the changes that have come about in the relationship between the suppliers and users of services. Political analysts associate the weakening of corporate power with economic deregulation policies and with the decision to allow the rules of the marketplace greater play in the field of productive activity (Sidicaro 1995).

To understand the weakening of the corporations at a time of strong state influence on the economy, it must be borne in mind that policies aimed at opening up the economy have had different effects on different sectors, and this has precluded the possibility of each of the traditional corporations presenting a united front. This is not to say that power relationships have dissolved as a consequence of competition in the marketplace. Rather, economic interests will now be represented before the state through lobbying practices, which, once adapted to some of the traditional features of Argentine political culture, will find new ways to increase clients. This is another of the features characterizing the new system of alliances in the health sector.

The process was evident in corporations representing private hospitals even before contracting freedom between financing agencies and suppliers of health services was established. Faced with the financial crisis in the obras sociales, the institutions best able to compete began to offer more favourable contract conditions — in terms of costs and financial risks — to the obras sociales, either singly or collectively, thus giving rise to the first providers’ networks.

The weakening of the Confederación General del Trabajo (CGT, general labour confederation), manifested itself differently, though it surely had the same origin. The leadership of the trade unions was affected in the 1990s by three interrelated processes:

• structural transformations that modified the composition of the labour force and increased the heterogeneity of wages and employment;
• changes in the political culture of negotiating work conditions that have resulted in a general drive toward collective agreements by company as opposed to labour specialty, which was the foundation of much of the trade unions’ power; and
• antagonisms that have arisen between labour leaders adopting divergent positions with regard to the liberalization policies pushed by a government that purports to share their Peronist ideals but has relinquished, one by one, the traditional banners of the movement.

Thus, under Menemism, the labour movement has fragmented, giving rise to two groups opposed to the CGT: the Movimiento de los Trabajadores Argentinos (Argentine workers movement) and the Congreso de los Trabajadores Argentinos (Argentine workers’ congress). However, some components of the labour movement, those closest to the government’s liberal tendencies, have radically transformed their organizations into what has been called sindicalismo de negocios or business unionism.

Changes in the union movement go beyond the weakening the negotiating capability of the CGT, however. The labour leaders best able to profit from the privatization of public enterprises or the deregulation of services production have begun to incorporate entrepreneurial functions into their traditional activities The following are examples of positioning by trade unions in the face of changes affecting their place in the scheme of things: management of Programas de Propiedad Participada, shared ownership programs, in privatized public enterprises; organization of micro-enterprises for petroleum prospecting and electric power generation; and participation in companies that administer retirement funds or health care management organizations.

The CGT’s opposition to the deregulation of the obras sociales did not therefore come about in a context of institutional paralysis. Despite confrontation with the government at the political level, a large number of them have begun to develop a new managerial capability with a view to adapting to the new scenario. At present, their strategies are aimed in three main directions.

1. An important group of obras sociales — 73 institutions representing about 5 million beneficiaries — have opted for the advantages offered by the Programa de Reconversión del Sector Salud (health sector reform program), financed by the World Bank.
2. A second group — made up of smaller entities unable to form an adequate risk pool individually — have begun merging or forming federations. In the first case, that of a merger, the result is a new obra social. In the second case, a federation, the entities retain their legal individuality but pool the collection and administration of their financial resources.
3. Lastly, some obras sociales, individually or in groups of three or more, are associating with local or foreign companies to form a new association, under the legal form of a stock company or something similar, to act as health care management agencies for all their beneficiaries, and to provide an alternative in a deregulated situation.

Conclusion

The health services system could not remain untouched by the financial crisis and the transformations that followed. In the public sector, the reduction of fiscal spending aggravated long-standing conditions of decay and decadence. These public services, intended for the poor population, found their clientele increased by contingents of “new poor”: members of the lower and middle classes suffering the consequences of unemployment, informal labour, self-employment, and precarious labour relations. The obras sociales were affected by the same processes, through a decrease in the population covered and an attendant reduction of contributions; evasion on the part of contributors; and increased disagreement within the system as to the distribution of funds.

To these factors originating outside the health sector, must be added others equally or more important. They relate to longstanding deficiencies or distortions in the health services organization, including: extreme fragmentation and heterogeneity in the obras sociales; the reluctance of the state organizations concerned to put them in order; an overloading of public services due to the demands of those with insufficient coverage; the predominance of the private sector in the supply of services; the existence of methods of payment that encouraged oversupply and overcharging; and the expansion of installed capacity and a supply of technology that exceeded the ability to pay. All of these were manifestations of the exhaustion of the organizational mode prevalent up to that time.

The state’s response was expressed both in terms of freedom to sign contracts and deregulation in the area of social security, and in terms of localization and decentralization — at institutional and territorial levels — in the policies applied to the public sector. Contracting freedom between financing organizations and providers of health services was quickly adopted by the private sector in response to an oversupply of services. The corporations traditionally predominant in this sector quickly lost the oligopoly that they had enjoyed through control of contracts with the obras sociales. New forms of intermediaries such as service management agencies, transient company mergers, and suppliers’ networks undertook the management of risk contracts incorporating per-capita methods of payment. New forms of services supply were incorporated and cost-containment strategies that placed family physicians or general practitioners in a “gatekeeper” role, were tried out. Financing possibilities were enlarged through the expansion of private insurance organizations.

On the demand side, reform encountered obstacles that were harder to surmount because they were rooted in conditions outside the health sector, mainly the confrontational relationship between the state and the trade unions that had existed since the beginning of the 1950s. Interest on the part of reformers — part of the government and the World Bank — centered on eliminating the “captive population” of the obras sociales by allowing union members freedom of choice between institutions administering social security contributions. In this way, it was hoped to stimulate competition, to generate incentives to reduce administration costs, and to offer better quality health care. The refusal of the Confederación General del Trabajo (CGT, general labour confederation), which uses the obras sociales as a bargaining chip with the government whenever discussions arise concerning production policies, employment policies, or the survival of leaders’ privileges, has blocked the application of the reform decrees during the last 3 years.

The process has been more complex within the associations of suppliers, because these are not groupings of business organizations, but groupings of institutions having mixed political and trade-union bases. Their adaptation to the new contracting conditions has been accomplished by means of different strategies, such as the formation of private insurance companies, the purchase of private hospitals, the installation of ambulatory diagnostic and surgical centres, and the introduction of the associations into existing supplier networks. In this way, they have attempted to assure their members a place in the supply of services.

Private hospitals, obras sociales’ hospitals, and to a lesser degree, independent professionals continue to hold a predominant place in the structure of the health services system, particularly in matters relating to the regulation of supply conditions; the incorporation of technology; changes in the way services are organized, and in the control of supply conditions. Now, however, the regulation of supply conditions is no longer accomplished through a centralized entity guaranteeing equal access to demand by all members of the corporation, but rather through the dynamic interplay of business competition in quest of contracts with the obras sociales.

[2] PAMI is the most important obra social in terms of the number of beneficiaries, and is one of the leaders in availability of resources per capita. It has suffered from meddling by different governments and has fallen prey to inefficiency, political patronage, and corruption. It is currently in a situation of serious financial deficit. 
 
 

Copyright 2000 © Held by the Authors
pub@idrc.ca