Argentina: Characteristics of the health care system; whether workers enjoy access to a parallel system; means by which workers access health services; means of accessing the public health care system

Argentina's health care system is composed of three principal elements:

i) a public sector, ... publicly financed and maintained; ii) a compulsory social security sector, organized on the basis of obras sociales insurance plans; and iii) a private sector, financed by voluntary prepaid insurance plans based on estimates of actuarial risk or direct fee-for-services (PAHO 2 Nov. 1998).

According to the Buenos Aires newspaper Clarín, roughly 11,500,000 people depend on the public sector, 19,500,000 are members of an obra social, and 2,650,000 make use of voluntary insurance plans (26 Dec. 2000).

In a 2 November 1998 report, the Pan-American Health Organization (PAHO) stated that

The public or official sector provides health services through the network of public health facilities. At the present time the provincial and municipal services, which possess the nation's most extensive infrastructure, provide services to: i) low-income groups without social security coverage and those who have limited access for geographic or other reasons; ii) the beneficiaries of obras sociales plans; iii) social groups with a greater ability to pay, who are attracted by institutional prestige; and iv) people affected by emergencies and accidents. The network also provides health education services. The public sector remains the principal service provider of emergency care and of care for psychiatric and chronic patients.

This information was corroborated by Susana Belmartino, a researcher with the Rosario-based Centre for Health and Social Studies (Centro de Estudios Sanitarios y Sociales, CESS), who indicated in a 2000 publication that public health services are

financed through resources from the national budget, and managed by the national, provincial, and municipal governments ...

The public hospital is the cornerstone of the public services subsystem. It provides care to the poor who have insufficient or no medical coverage; subsidizes the obras sociales by providing services to their beneficiaries without charge; and occasionally serves higher-income-earners who are attracted by the reputation of a particular institution or its medical personnel. The public hospital is also responsible for providing essential health emergency services; training professionals to the graduate and postgraduate level; and biomedical research (p. 6 of 21).

In the City of Buenos Aires, individuals using the public health system have access to 12 general hospitals, operated by municipalities, and 21 specialized hospitals, operated either by municipalities or the federal government (PAHO 1999). In the Province of Mendoza, the public system consists of 22 hospitals and 225 ambulatory clinics, operated either by provincial or municipal authorities (ibid. 1998).

While no payment is officially required from individuals making use of public health services (Clarín 11 Aug. 2001a; ibid. 11 Aug. 2001b; PAHO 2 Nov. 1998), a number of public hospitals in the Buenos Aires area have allegedly pressured patients to make contributions, generally of between one and ten pesos (between 1.55 and 15.50 Canadian dollars), before providing them with care (Clarín 11 Aug. 2001b). Furthermore, there is often a longer wait in public facilities than is the case elsewhere, with 74 per cent of low-income clients forced to wait more than 24 hours for a consultation with a health professional (World Bank Group n.d.). According to Susana Belmartino,

the public hospital today epitomizes all the contradictions in the health care system as a whole. It exhibits serious structural deterioration and managerial inefficiency; a high degree of administrative centralization at the provincial level; rigidity in its staffing structure and labour relationships; no adequate system of incentives; inadequate information systems on which to base decision-making and control; serious deficits in facilities and equipment maintenance; and a system of management ill-suited to its size (2000, p. 7 of 21).

This information was corroborated by Clarín, which claimed on 26 December 2000 that the quality of care available in public health facilities has deteriorated as a result of poor management, lack of adequate strategic planning and misallocation of resources.

Group insurance schemes known as obras sociales, funded through compulsory worker and employer contributions (PAHO 2 Nov. 1998), function as "sickness insurance funds, financing health care services for employees and their immediate families" (Belmartino 2000). According to the newspaper Clarín, 271 obras sociales were in existence in May 2000 (23 May 2000).

The majority of obras sociales, which are characterized by Belmartino as "semi-public" because of the state's role in authorizing their creation and overseeing their activities (2000, p. 5 of 21), are operated by trade unions (ILO 2000). Other institutions with responsibility for the operation of such schemes include the armed forces, along with municipal, provincial and federal state authorities (ibid.). The National Social Security Institute for Retirees and Pensioners (Instituto Nacional de Seguridad Social para Jubilados y Pensionados (INSSJYP) "covers some 22.4% of the population under the compulsory insurance system, and its resources come from contributions from active and retired workers, varying between 3% and 6% of their earnings" (Belmartino 2000, p. 5 of 21).

According to Fabio Bertranou, a professor of economics at the National University of Cuyo (Universidad Nacional de Cuyo, UNCuyo) in Mendoza, obra social beneficiaries pay "small fees or nothing" for ambulatory health services, and have

the freedom to choose any physician registered under the social health insurance organization ... There are no deductibles, and co-payments are limited to some services and prescription drugs (between 0 and 50 percent). Private physicians may charge a "plus" which varies across Obras Sociales and physicians; this "plus" means that the insured may have to pay additional out-of-pocket expenses. Obras Sociales contract the bulk of health services provided to their members with private providers. Private physicians and clinics are paid on a fee-for-service basis; the prices are negotiated between the Obras Sociales (normally at regional offices) and the corresponding local physician and clinic organizations (24 Aug. 1999, sec. 3).

According to Susana Belmartino,

the average revenue per beneficiary varies widely among obras sociales. Some of them have incomes of less than US $5 per beneficiary per month. Others take in over US $80 per beneficiary per month ...

Given the sharp differences in average income levels across obras sociales, there are wide disparities in the comprehensiveness of the services that they provide. Expenditure on health services in the higher-income obras sociales is six times that in the lower-income group; the annual number of consultations per beneficiary varies between 1.9 and 8.4, and expenditure on pharmaceuticals by "rich" obras sociales is 13 times that of "poor" ones.

In spite of their large total expenditure, the services provided by the obras sociales have become targets for criticism on several counts. The health care orientation is fundamentally curative, featuring highly specialized services, technology that is not always suited to the demand profile, and heavy reliance on inpatient care facilities. In general, the financing organizations have not participated in the development of service systems, confining themselves to covering the range of services supplied by the marketplace, with no other limit than their own financial capability (2000, p. 5-6 of 21).

The federal government has undertaken a number of measures to reform the obra social system. These include attempts to reduce imbalances among the various social security plans (ibid.); to allow individuals to choose the obra social to which they would like to belong (El Tribuno 4 Jan. 2001; Clarín 13 June 2001); and to require all social security plans to offer a basic package of benefits (Belmartino 2000).

The private sector forms the third major component of Argentina's health care system, and comprises of "professionals and private health care facilities that provide independent services for private patients with the ability to pay, those affiliated with obras sociales plans, or users" of voluntary insurance plans, known as pre-paid health care entities (empresas de medicina pre-paga, EMP) (ibid., p. 3; Belmartino 2000).

According to Belmartino, citing a 1995 World Bank Group study,

existing private insurance schemes constitute a very heterogeneous system with an enormous number of organizations, extremely high operating costs, and little transparency in the areas of competition and consumer protection. There are currently no effective mechanisms to protect users from bearing the brunt of increasingly fierce competition. Its flexible structure undoubtedly allowed the private insurance system to function dynamically as a marginal entity within the health care system in its initial stages. However, this flexibility may now represent an obstacle to maintaining and developing an integrated, transparent, competitive, and universal market (ibid., p. 7 of 21).

This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim to refugee status or asylum.

References

Belmartino, Susana. 2000. "Reorganizing the Health Care System in Argentina." Reshaping Health Care in Latin America. Edited by Sonia Fleury, Susana Belmartino and Enis Baris. [Accessed 21 Aug. 2001]

Bertranou, Fabio M. 24 August 1999. "Moral Hazard and Prices in Argentina's Health Markets." Paper presented at the annual meeting of the Asociación Argentina de Economía Política in Rosario. [Accessed 21 Aug. 2001]

Clarín [Buenos Aires]. 11 August 2001a. "Servicio totalmente gratuito." [Accessed 21 Aug. 2001]

_____. 11 August 2001b. Patricia Carini. "Está prohibido, pero cobran bonos en algunos hospitales." [Accessed 21 Aug. 2001]

_____. 13 June 2001. "El Gobierno quiere cambiar el sistema de obras sociales." [Accessed 21 Aug. 2001]

_____. 26 December 2000. Jesús Rodriguez. "Una mejor política de salud." [Accessed 21 Aug. 2001]

_____. 23 May 2000. "La equidad en el sistema de salud." [Accessed 21 Aug. 2001]

International Labour Organisation (ILO). 2000. "El sector privado de salud y los procesos de reforma en Latinoamérica." [Accessed 21 Aug. 2001]

Pan-American Health Organization (PAHO). 1999. "Ciudad de Buenos Aires (Capital Federal." [Accessed 21 Aug. 2001]

_____. 2 November 1998. Argentina: Profile of the Health Services System. [Accessed 21 Aug. 2001]

_____. 1998. "Mendoza." [Accessed 21 Aug. 2001]

El Tribuno [Salta]. 4 January 2001. "Suspendieron el decreto sobre las obras sociales." [Accessed 21 Aug. 2001]

World Bank Group Group. n.d. "La salud en Argentina." [Accessed 21 Aug. 2001]