Frankenstein and the Labyrinth: Common Features of Health Systems in Latin America

Caught between Frankenstein and an unfathomable labyrinth. That is how many Latin-Americans feel when navigating their country’s health system, explained prominent Argentinean health systems expert Dr. Rubén Torres, former Area Manager of Health Systems based on Primary Health Care of the Pan American Health Organization. (PAHO) during a recent journalist training session in Buenos Aires.

The PAHO believes that there are two characteristics of the Argentinean health system that make it inefficient and inequitable: segmentation and fragmentation. Segmentation exists because of the several forms of financing: through the public sector, the social security sector and the business sector (health insurance plans). Fragmentation results from each health system using its own assistance networks that coexist without allowing any kind of interchange. Torres illustrated the segmented nature of the system by using the image of Frankenstein (a “dummy assembled from different pieces”) and the fragmentation with the image of a person standing in front of a labyrinth. These characteristics are common in most Latin American countries’ health systems.

Private vs Public Expenditure

Typically in Latin America, the public sector spends less than the private sector. The problem posed by systems with a high private expenditure is that they are deeply inequitable and could, for example, drive a family into poverty. This is called catastrophic expenditure; Dr. Torres explains:

“There is often a technical misunderstanding, because when one speaks of catastrophic expenditure, one usually thinks about a transplant, or a complex cardiovascular surgery operation. And this is often true. But one should be aware of the fact that, for a person who is within the first quintile of the population, the poorest quintile, going to the chemist’s to buy medicine without a discount may be a catastrophic expenditure. By definition, catastrophic expenditure occurs when health expenses total 30% of a person’s income.”

Over the past ten years, all Latin American countries have enjoyed significant economic growth: the average growth rate has gone up from 3.9 in 2009 to 4.5 in 2013. This shows how economically powerful a decade it has been. But the question that should be asked is: has this wealth led to better health care and a bigger budget for health-related expenses? Said Torres, “Last year, we studied for the PAHO our countries’ health budgets for 2005 through 2010, the tail end of growth, and we found that although government expenditure on health has in fact grown by 0.8, when out-of-pocket expenses were measured, we found that it had virtually stayed the same.” 

Wanted: A New Kind of Doctor

Finally, Torres mentioned that another serious problem in the region was related to education: the issue of how many and what kind of medical doctors are needed. Although non-communicable (chronic) diseases are often the main health problem, they are not properly addressed. “The challenge is to make the patient visible, because today the system works like security at an airport: the patient appears on the radar screen, he or she is assisted and, theoretically, cured. Then, he or she disappears from the radar screen and is forgotten. This results in a huge number of preventable deaths, of persons who are rendered blind by diabetes or suffer from kidney deficiency. We need a different kind of doctor from the one we have today,” he reflected. Later, he mentioned that about 6,000 medical doctors graduate from medical schools in Argentina, while there is a shortage of nurses. In Europe, the doctor-nurse ratio is much more balanced.

The Airline Model for Health Systems

 “The best example for an equitable health system is that of an airline”, compared the specialist. He added: “Airlines guarantee that all the persons who buy a ticket take off and land and the same time, all of them eat, drink and enjoy the same safety standards during the flight, regardless of whether they fly First Class, Business or Economy. And this does not preclude some of them from traveling more comfortably than the others; what is important is that they are all offered the same safety measures. In Argentina, the health system is organized so that only the passengers flying First and Business class arrive safely at their destinations,” he concluded.