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VII International Conference on Primary Health Care
“The Reform of the Health Sector in the Americas”
Palacio de Convenciones, Havana, Cuba
October 19 to 22, 1999

Paper of the Regional Committee on Community Health Promotion


HEALTH REFORMS IN CENTRAL AMERICA, VIEWS FROM THE PERSPECTIVE OF COMMUNITY HEALTH 

Background

Since 1991, the Regional Committee on Community Health Promotion (CRPSC) has been monitoring the changes in health policies inspired by the neoliberal direction that is being applied in our countries (PRODUSSEP y CRPSC, 1993).

Beginning in 1995, this monitoring became a permanent line of work, even becoming incorporated into the Strategic Plan for 1998-2000, under the responsibility of the Commission for Analysis of Reforms in the Health Sector (ASECSA - Guatemala, APROCSAL - El Salvador, CISAS - Nicaragua, COPROSA – Costa Rica).

In the systematization of the reform processes that are occurring in the countries of Meso-America, an important advance was made by the CRPSC in the Workshop Seminar “State Health Policies, Community Programs and the Challenges to Peace”, that took place in Chimaltenango, Guatemala in August 1996. More recently, the 1999 Annual Conference of ASECSA: “PRIMARY HEALTH CARE FACING THE NEW MILLENIUM” which took place in Chimaltenango from July 14 to 16, offered the opportunity for significant advancement in this work program. 

The CRPSC highly values the opportunity that was offered to participate and share its 24 years of experience and its vision before the VII INTERNATIONAL CONFERENCE FOR PRIMARY HEALTH CARE: THE REFORM OF THE HEALTH SECTOR IN THE AMERICAS, which was held under the auspices of the Ministry of Public Health of Cuba, the PAHO-WHO, UNFPA and UNICEF.

It is very worthwhile to hold this event within the context of the period for evaluation of achievements of the goals proposed by WHO at Alma Ata for “Health for All in the Year 2000”.

The CRPSC has been invited by the International People’s Health Council (IPHC) to participate in the development of the PEOPLE’S HEALTH CHARTER. Along with the respective reports and proposals on the current state of Health for All 2000, this Charter will be approved in the People’s Health Assembly to be held in December 2000, in the People’s Health Center, Dacca, Bangladesh.

The conclusions and recommendations that emerge from this VII International Conference will be of great value to the CRPSC as it takes its positions to the PEOPLE’S HEALTH ASSEMBLY.
 

1. Background on Community Health Care in the Region (1960-1980)

1.1 The Internationality of the Primary Health Care Strategy 

In the 60s and 70s, pioneer experiences such as those of Ajoya in Mexico (Where There is No Doctor) and those of San Ramón, Costa Rica (Hospital Without Walls), were forerunners of and inspiration for diverse community grassroots organizations in all of the countries of the Region working to improve health and living conditions, with broad participation by the people.

These worthwhile community experiences received significant recognition and support with the consolidation of Primary Health Care (PHC) as a worldwide strategy – approved by the WHO in Alma Ata, URSS in 1978 – for the fulfillment of the goal set on that occasion of Health for All in the Year 2000. At the same time, this gave encouragement to popular organizations to continue their work to promote health in very adverse political and social contexts, such as those of the majority of Central American countries during the decade of the 80s and part of the 90s.


1.2 Governmental Political Will Toward the Strategy

With some exceptions, Primary Health Care was not fully assumed or developed by the governments of Central America, because the simplest forms of community participation were always interpreted as threats to the military regimes that dominated the Central American political scene from the decade of the 1960s until the 1980s. This was the case for Guatemala, El Salvador, Honduras and Nicaragua (until 1979).

Only those States that were willing to invest in social programs as part of their economic and social development strategy allowed, and in some cases encouraged, different degrees of community participation in health programs. The cases of Costa Rica, Panama and Belize stand out. The Popular Sandinista Revolution in Nicaragua, the negotiated solution to conflicts in the Region in the second half of the 1980s, and the opening of lines of international assistance, opened up new possibilities for PHC in Central America.


1.3 Community Application

It is certain that – with or without government encouragement – in all of Central America popular experiences developed in which diverse communities assumed the generation of health in their own hands.

Very different types of social and non-governmental organizations – such as community associations, cooperatives, unions, peasant unions and ministries of the church, among others – encouraged the formation of health promoters and workers, support to midwives and healers, the organization of grassroots health groups, and the construction and operation of health posts and centers as well as people’s pharmacies with medicinal plants and essential medications. 

Maternal and infant health programs, with the promotion of community and school gardens, vaccination and care for malnutrition, emphasis on oral rehydration therapy – ORT – to confront diarrhea and parasitosis, recognition and use of natural therapies and medicine used for generations in the communities, improvement in the hygienic conditions through the development of rural aqueducts and the adequate disposal of human excrement and solid wastes, an increase in the accessibility of services through the development of rural roads and the construction of new health units, among others, constituted some of the fields of intervention assumed by community health workers. These we were undertaken with the active participation of the communities and, in some cases, in the absence of public health institutions.

In the countries with military regimes, added to the community’s own resources was the assistance of some national and international organizations that were in solidarity with the development of the poorest communities. Where the States assumed PHC as a national health strategy, the governments channeled resources through the Health Ministries and other institutions and sectors linked to community development.

Between 1975 and 1991, the CRPSC was able to form a network with some of the most valuable community PHC experiences emerging from this diversity of political models present in the Meso American region.


1.4 Social Security and the PHC Strategy 

After the Second World War – in the 1940s and 1950s – Social Security systems were only significantly developed in Costa Rica and Panama. In the rest of the Central American countries, Social Security was, at the most, a prerogative of small groups of salaried workers in the urban centers. In addition its focus was primarily curative.

The emphasis on the prevention of illnesses and the promotion of health, as well as the less sophisticated attention, all part of PHC, were left in the hands of the Health Ministries, through coverage extension programs with basic health services directed at the poorest communities, both urban and rural. Because of this, some people came to characterize it as “poor medicine for the poor” since the middle classes had Social Security and private services were at the disposal of the people with the greatest resources. This was the reality despite the official discourse in the majority of the Central American countries. (PRODUSSEP and CRPSC, 1993)


1.5 Impact of the Strategy (Indicators from the period of the 60s-70s)

With the exception of Costa Rica and Panama, the advances in health issues cannot be explained as a result of intentional public health programs in development.

For the majority of the countries of the region, the advances resulted more from the combined effect of deliberate efforts of many community organizations and of civil society developing PHC action. This progress was also due to some positive effects in the living conditions of certain sectors of the population, impacted by the production modernization process, with the incipient industrialization of the Central American Common Market and agricultural diversification aimed at the priority of satisfying the internal market. However, these positive effects were seen to be counteracted by the model that the Economic Commission for Latin America and the Caribbean (ECLAC) characterized as concentrated on the economic and excluding the social, caused by the series of military dictatorships that occurred over three decades. (Verdugo, 1999)

The preceding can be demonstrated by comparing the evolution of infant mortality in Guatemala and Costa Rica. In both cases, there were important reductions in the deaths of children under one year of age from the 1970s to the 1980s. But while in Guatemala the reduction was 29.5%, in the case of Costa Rica the reduction was 46.8%. The very same points of departure and results in the indicators show significant differences in the levels of social development, consistent with the evolution of poverty in both cases: 65% in Guatemala, 22-24% in Costa Rica. 

In Guatemala, PHC was a working concept for Health Promoters, Midwives and Healers in the communities at the time that CRPSC (1975) and ASECSA (1978) were formed. In Costa Rica, the Minister of Health organized the Rural Health Program with 90% coverage of the disperse rural communities in the same period.


Central America: Some social and health indicators for the 1970s and 1980s
 

Country	GUATEMALA		BELICE		EL SALVADOR		HONDURAS		NICARAGUA		COSTA RICA		PANAMÁ
Years	70-75	80-85	70-75	80-85	70-75	80-85	70-75	80-85	70-75	80-85	70-75	80-85	70-75	80-85
Under Poverty Line	-	65%	-	-	-	-	65%	-	-	-	24%	22%	-	36%
National Life Expectancy	54.0	58.9	-	-	58.7	56.9	54.0	61.9	55.3	59	68.1	73.8	-	-
Infant Mortality	83.3	58.7	-	-	82.2	57.4	89.8	68.4	92.9	61.6	36.5	19.4	31.6	22.7
Gross Mortality Rate	13.4	10.5	-	-	10.9	11.2	13.7	9.0	12.7	10.4	5.8	4.0	-	-
Potable Water	-	-	-	-	-	-	-	-	36%	53%	-	-	-	-
Sanitation Coverage	-	-	-	-	-	-	-	-	42.5	80%	-	-	-	-

(Developed from OPS, 1994 and Rocha-CISAS, 1999)

2. Structural Adjustment Programs and Reforms of the Health Sector (1980 to the Present)

2.1 Community Care and Armed Conflict

The polarization and radicalization of social and political conflicts that lead to the development of different processes of armed conflict – especially in Nicaragua, El Salvador and Guatemala – and the intense military repression of social conflicts in Honduras, significantly limited the coverage that the weak health service systems in the region were able to give.

This circumstance converted extensive rural areas into war scenes, in which the only state intervention was of a military type, under the supposition that these areas were collaborating with the guerillas. (Ramírez, 1998) 

The populations affected by the war had no health care except that which was provided by the social and non-governmental organizations, with the aggravating factor that, in addition to the health problems related to poverty, the armed conflict provoked additional physical and mental traumas. Very quickly, the people linked to the community programs for PHC were converted into victims of the armed violence just for having promoted the search for better health conditions for their communities. The organized participation of the population was incompatible with the military regimes and only the negotiated end to the conflicts has reestablished new conditions for the development of PHC in Central America.

In the Nicaraguan case, the development of the Popular Sandinista Revolution and the subsequent war of aggression to which it was subject by the Reagan Administration, established a similar situation for the brigadistas, midwives and volunteer health promoters of the Nicaraguan Communal Movement. The only advantage was that they and their communities could depend on the support of the network of state health and development institutions.

Even in such adverse conditions, the decade of the 80s was characterized in this country by the broadening, consolidation and deepening of the popular participation in health processes.
The investment in health increased significantly up to a high of 5.2% of the GNP, the One National Health System (SNUS) was created with decision-making agencies with broad representation such as the National Popular Health Council (CNS) and the Local Popular Health Councils (CLS).

The Ministry of Health directed the community organization and management through a program of Popular Education in Health, and gave priority to PHC with risk criteria, at the same time that it strengthened the programs for formation and training of health personnel. (Rocha-CISAS, 1999) 

The results of this strategy can be evaluated through the drastic reduction of imuno-preventable diseases in the population under five years old, the reduction of the infant mortality rates (from 110 per thousand live births in 1978 to 53 per thousand live births in 1985), and the increase in access to health services to 85% to 90% in 1986 according to figures from PAHO/WHO and the Ministry of Health. 


2.2 Macro-Economic Measures and Their Impact on Health 

2.2.1 Production, Consumption and the Environment 

Beginning with the dizzying scientific and technological advancement, especially in the field of communications, the informatization of productive processes and genetic engineering applied to agricultural production and to human health, the new international order/disorder has accelerated the globalization processes of the western culture. This is particularly true in the area of the economy with the hegemony of financial capital and the predominance of speculative practices.

It has generated a process of restructuring of capitalism through the recomposition of the economic blocks. In our continent, it is worth highlighting the processes of MERCOSUR and Free Trade Agreements, both within the perspective of AFTA-2005 (American Free Trade Area).

“Globalization” appears to be an irreversible process, part of the development and expansion of capitalism of the 20th century (Gallardo, 1999), which has relative independence from the ideological approach that directs it.

But this process is accompanied by another parallel process, which should not be confused with the former, which has been given the name “neo-liberalism” (IMF: “everything has a price”). This corresponds to an ideology characterized by its pessimism in the face of the human capacity to achieve planned development, and its tendency to leave history in the hands of the auto-regulatory mechanisms of the whole market (Gallardo, 1999).

To the displacement of the workers from the productive sectors to the service sector, produced by the globalization boom, neoliberalism adds to and fosters “the increasing precariousness of the labor markets, their segmentation, their false feminization and their informalizaton, contributing to the invigoration and expansion of the already-existing circuits of poverty” (Gallardo, 1999).

All of this has had negative consequences on the state of health of important social sectors, a product of the deterioration in their living conditions.

Studies done on the neoliberal reform of the Public Sector conclude that “the orthodox adjustment programs have had an especially devastating impact on public services, which has brought great deterioration of salaries, employment and the quality of services, contributing to the exacerbation of problems faced in the region by a growing number of poor and unemployed people…” (Evans, 1995)

At the same time, disordered urban development and agroexport production has grown at the cost of deforestation and the general deterioration and contamination of the environment. (Ramírez, 1998)


2.2.2 Reforms to the Health Sector: A Part of the Reform of the Social State 

The philosophy of the whole market requires complete freedom for production and trade, in other words “for good business”. Deregulation is therefore the magic formula that is proposed to the countries that want economic development in the context of neoliberal globalization.

The “social investment” development philosophy, which was fostered in Latin America starting in the 1950s, has been supplanted since the beginning of the 1980s by that of “control of state spending”. The greater part of the state powers should be transferred to private enterprise so that the market price can be established there without the supposed “distortions” that the state had been effecting.

This change in direction has had a varied effect on the different countries of the Americas: a suspension and backsliding in those countries that had progressed in the development of broad-reaching social policies, and an impossible utopia for those peoples that were still dreaming of moving beyond oligarchic and dictatorial states toward scenarios of representative democracy and social development.

The PAHO/WHO recognizes that “the economic crisis of the 1980s, the stabilization programs and the structural adjustment programs have had a profound impact on the configuration of national spending and financing of the health sector in the countries of Latin America and the Caribbean”. These institutions call attention to “the relatively high national spending for health as a percentage of the GDP, and the great importance of private spending as a percentage of national spending on health” (PAHO/WHO, 1994).

In analyzing the spending and funding, both public and private, of the health sector in Latin America and the Caribbean, the PAHO/WHO arrived at the conclusion that these countries spent, at the beginning of the 1990s, about 5.7% of the GDP in the purchase of goods and services for health (some $112 per capita per year in 1988 dollars). This is less than the average for the industrialized countries (7.8% of the GDP). Only Argentina, Costa Rica and Panama had levels of national spending that were higher than that average, and this coincides with the fact that they are countries that have social security systems with broad coverage.

This percentage of spending on health in the Latin American countries rose to 7.3% of the GDP in 1995, compared with 9.8% in Canada and 14.3% in the United States (PAHO/WHO, Vol. I., 1998)

When the composition of national spending in health is examined, it is found that private spending ($69 per capita per year) represents around 57% of the national spending on health and 3.2% of the GDP. For 1995, private spending represented 59% of spending on health and 4.3% of the GDP.

In the case of the Central American countries, public spending represents 55.9% of the national expenditure on health, although there are wide variations between El Salvador (25%), Costa Rica (73%) and Panama (78%).

National Expenditure on Health as a Percentage of the GDP in Central America, 1995
 

	GUATEMALA	BELICE	EL SALVADOR	HONDURAS	NICARAGUA	COSTA RICA	PANAMÁ
Total	4.2	3.9	6.8	7.4	9.2	8.6	9.2
Public	1.9	1.8	1.7	3.7	5.8	6.3	7.2
Private	2.3	2.2	5.0	3.8	3.5	2.3	2.0

(Source: State of the Region Project, 1999, from the PAHO 1998)

Despite the reduction of income per capita in the 1990s in relation to that of the 1980s, the increase in demand for services was accompanied by a reduction in the relative cost of private health services and medication, of auxiliary diagnostic services and the cost of labor in the health sector, together with the absence and lack of application of regulatory policies. All of this translated into a 25% increase in the per capita expenditure for health from 1980 to 1994.

The decrease in availability and quality of public services – motivated by the low salaries in the public sector – as well as the generalized introduction of systems for charging for services, has affected the relative price of access to public services in comparison with that of private services. From 1992 to 1996, the percentage of the population in Latin America that was affiliated with private systems of insurance rose from 12.3% to 15%. (PAHO/WHO, Vol. I., 1998). The average expenditure per beneficiary by publicly administered insurance institutions was $165 and in those institutions that were privately administered it was $356.

For 1990, it was estimated that 62% of the population was covered by social security systems, with the levels of coverage varying greatly between countries:

• Less than 10%: El Salvador, Dominican Republic.

• Less than 20%: Bolivia, Colombia, Ecuador, Guatemala, Honduras.

• Equal to or more than 60%: Argentina, Costa Rica, Chile, Mexico, Panama and Uruguay. Brazil reported 100% coverage. (PAHO/WHO, Vol. I.,1994)

In the case of Central America, only 27% of the population is covered by social security. Again, the cases of Costa Rica (85%) and Panama (61%) contrast with the coverage in the rest of the region: 14% in Honduras and El Salvador, 16% in Guatemala and 18% in Nicaragua. It is significant that around 25.5 million people are not covered by social security systems. (State of the Region Project, 1999).

In 11 of the 29 countries of Latin America, a reduction in the relationship between spending for health and total spending can be observed. Among these, there are countries that have carried out drastic structural adjustment programs and significant redirection in their development strategies, such as the cases of Bolivia, Chile, El Salvador, Jamaica, Mexico and Monserrat. (PAHO/WHO, 1994)

Even in the case of a country like Costa Rica – that maintains relatively high levels of investment in health – a recent study indicates that while the real GDP grew 56% from 1985 to 1995, the real spending in the health sector rose 27.5% during the same period. Two of the five institutions in this sector were seen to have reduced their real expenditures: the Ministry of Health by -3.5% and the Costa Rican Institute of Aqueducts and Sewage Systems by -48%. (Ickis et al, 1997).

2.3 Measurement of the Impact (Indicators from the 1980s to the 1990s)

In Central America, with a population estimated at 34.6 million people, 60% are below the poverty line and 20% live in conditions of extreme poverty. Fifty-one percent of the population lives in rural areas where there are the worst living conditions. Four of the seven countries are considered to be in intermediate development by the UNDP.


Central America: Human Development Achievements According to the HDI, 1998
 

	COSTA RICA	PANAMÁ	BELICE	GUATEMALA	EL SALVADOR	HONDURAS	NICARAGUA
Valor del IDH	88.9	86.8	80.7	61.5	60.4	57.3	54.7
HDI Position in the World	34	45	63	111	114	119	126

(Source: State of the Region Project, 1999)

The average life expectancy at birth is 67.8 years, with a lower life expectancy in four of the seven countries (Nicaragua, El Salvador, Honduras and Guatemala) and a life expectancy of more than 70 years in three of them (Costa Rica, Panama and Belize). Illiteracy among women is 76.6%, with three of the countries close to the average, one country under it due to its ethnic characteristics (Guatemala, 48%) and three countries over 90%.

Infant mortality is at 43 per 1000 live births and maternal mortality is at 164 per 100.000 live births. The mortality rate for children under five years of age due to diarrhea is 17.7%.

Among the great morbidity problems are pulmonary tuberculosis (28.2 /100.000) and low birth weight (14% in Guatemala and 6% in Costa Rica and Belize). AIDS represents a great challenge in public health and economic sustainability. Other major problems are measles, cholera, malaria and hemorrhagic dengue. The climatic changes in recent years have exacerbated the broad deterioration of the environment, as well as the social vulnerability of large sectors of the population. 

Sixty-six percent of the population has potable water available to them and 68% has adequate systems for the elimination of excrement, with the rural areas having less coverage. For every 10,000 Central Americans, there are 8.8 doctors, 5.0 nurses and 1.7 dentists. The population’s access to health services in general is 68%, with Costa Rica (96%) and Panama (79%) having the highest rates while the rest of the countries have medium accessibility. (Pereira, 1996)


Central America: Some Social and Health Indicators From the 1980s and 1990s
 

PAÍS	GUATEMALA		BELICE		EL SALVADOR		HONDURAS		NICARAGUA		COSTA RICA		PANAMÁ
AÑOS	80-85	90-95	80-85	90-95	80-85	90-95	80-85	90-95	80-85	90-95	80-85	90-95	80-85	90-95
%Below the Poverty Line	65	75	...	33	...	52	...	73	...	68	22	21	36	30
Illiterate		56.5		91		85		75.5		71.5		93		90
Life Expectancy at Birth	58.9	65.8	-	70.0	56.9	66.4	61.9	65.8	59.3	66.7	73.8	76.3	70.9	72.7
Inf. Mortality	58.7	54	-	41	57.4	56	68.4	45	61.6	62	19.4	14	22.7	18
Mat. Mortality		220		147		140		220		150		40		60
Gross Mortality Rate	10.5		-	-	11.2		9.0		10.4		4.0		5.4
Malaria	54958	...	2 800	...	44473	3 887	33828	44513	15130	44037	734	5 033	126	481
Cholera		30604		135		6573		1 925		6 473		4		42
AIDS acumul		499		82		630		3 473		66		587		644
Measles Cases	2 703	17	607	-	2 315	38	4 188	13	3 784	339	1 000	579	2 096	90
%Access to Potable Water		67		84		53		77		62		100		84
%Access to Sanitary Services		50		86		59		46	80	69		96		79
% Soc. Sec. Coverage		16		38		14		14		18		85		61
Doctors per 10000 people		7.80		6.24		8.39		6.96		4.36		12.62		16.43
Dentists per 10000people		1.10		0.65		2.19		1.14		1.24		3.76		3.81
Nurses per10000 people		3.20		5.48		4.92		2.48		5.56		9.46		10.46
Other nursing personnel per 10000 people		11.58		7.26		4.52		9.04		6.50		12.53		13.28

(Sources: PAHO, 1994; Rocha-CISAS, 1999; and State of the Region, 1999)

In summary, Central America appears to be a region with serious demographic, social and economic problems, with an insufficient ability to attend to common health problems and with an inadequate assignment of resources for the provision of necessary services (Pereira, 1996).
In its 1999 report, the State of the Region concluded that, at the end of the twentieth century, “…social equity is a pending challenge in Central America. The end of the armed conflicts, the democratization of the political regimes and the modernization of the economies has not achieved the reduction of historical social inequities in the region … between rural and urban areas, between rich and poor, between indigenous and non-indigenous, between women and men”. In such conditions, it becomes very difficult to construct healthy living conditions.


Elements for a Critical Vision of Health Reform

The Official Vision

Beginning in the 1990s, the processes for health reform intensified in the Central American countries, in consonance with the world economic changes. The official analyses done by the states have highlighted the following problems:

• little social participation

• low levels of resources assigned

• epidemiological transition

• low management capability

• insufficient planning and organization

• lack of adequate information systems

The preceding has given cause to establish reform plans with short, medium and long term objectives and goals, including:

• the search for efficiency, efficacy and equity

• financial sustainability

• the decentralization of decision-making

These plans have various components, among which are the following priorities:

• institutional development

• strengthening of leadership in the sector

• participation of civil society

• financial strengthening of the sector (Pereira, 1996)

These aspects, shown to be relevant issues for the reform agenda, even though they appear to be neutral proposals, in reality reflect the areas of interest of the privatizing processes promoted by the international finance organizations which has been giving funding for this (World Bank, Inter-American Development Bank). From the interests of the popular sectors, the issues are equally important but from the perspective of strengthening and deepening a reform that responds to their prioritized needs and problems.


Position of the Multilateral Organizations

The PAHO/WHO and other international agencies (IADB et al, 1995) identify the following problems with the reform processes:

• “the lack of consensus among the parties within each country and the aid organizations relative to the contents and nature of the reform;

• the political viability, that demands a great ability not only of leadership and negotiation, but also of adjusting to rapidly changing conditions;

• the lack of continuity of the parties responsible for promoting the reform, of directing the corresponding studies and negotiating proposals;

• the technical complexity, that sometimes makes it difficult to obtain sufficient political and social support to overcome the resistance of those that oppose the changes out of lack of adequate knowledge about the benefits of the reform;

• insufficient attention to community participation in the process;

• the holistic reform initiatives may face more difficulties and be much less viable than those that are directed at achieving partial changes;

• the partial reforms run the risk of producing incompatible changes, resulting in a less consistent model;

• trying to bring about reform in a brief period of time may complicate the reform, but if it is done over a longer period the sense of the changes may be dispelled. A method of gradual change is recommended within a strategic framework;

• in some countries the reform has been initiated for economic reasons (in others, as in the case of Nicaragua, it has been combined with political motives) and health issues have held a secondary place in the discussion. More effective intersectoral participation is needed, that has a pluralistic vision of the possible reform scenarios”.

Even the proponents of privatized reform have been forced to recognize that “It is important to highlight the need to be cautious with the introduction of market elements into the health sector. Left to its own devices, the free market will produce, among others, problems of access by the population without the ability to pay, problems in the quality of care in terms of the providers having an incentive to promote the services at the lowest cost, low production of public goods like vaccines, AIDS control, etc. and the screening for risk leaving the poorest and the sickest in the public system.” 
(World Bank, EDI-WB, CCSS, Ministry of Health 1997, p.72)


Position of a Sector of Academics

Two independent authors that carried out an extensive review of critical articles maintain that the recommendations made by the World Bank (World Development Report 1993: Investment in Health) correspond to “their ideological model of development which favors the nations of the North at the expense of the poor of the South” and that their proposal of “the index of years of life adjusted by function of disability contains serious theoretical faults, in a few years it will be of little value as a guide to formulate policies and could be used to deny essential health services to the poor of the third world”. (Ugalde and Jackson, 1995)

For their part, Sandiford and Martínez, propose that “the basic package of services” is one of the common elements of the different proposals for reform of the countries considering the possible funding or subsidy with public funds, establishing the inclusion of services under the criteria of cost effectiveness in terms of “profits” in health. The authors set forth two concerns: one is theoretical, in the sense that cost effectiveness negates from the beginning other utilities of the health system such as attention to the risk of spreading diseases, the care of the ill and equity of the services. Another problem is practical and political and has to do with the risk that it might become unpopular to reduce the supply of services financed with public funds, in generating double and differentiated health services. (Sandiford and Martínez, 1995)

Position of the CRPSC 

Since August of 1996, a detailed analysis has been carried out of the state of progress of the neoliberal reform processes in the health sector of the countries of Mesoamerica (CRPSC, 1996), which has brought the Regional Committee to the following conclusions:

1. Without exception, all of the reform processes are ideologically directed by neoliberal concepts.

2. There is promotion of processes for reorganization and regionalization of the Ministries of Health, directing them to assume the function of regulation of services with an emphasis on the strengthening of the “packages of basic services” of primary health care. In these processes, problems are being decentralized in order to be attended by the local systems, but without decentralizing the needed resources so that the municipalities and communities find it harder and harder to attend to this function adequately.

3. Responsibility for the second and third levels of care is being given over to the private sector, particularly those that offer these levels of care in social security institutions since, as these services require greater complexity of care, they are more profitable for private investors.

4. The initial lead role of the World Bank as the condition-making institution for the sectoral reform process is gradually being transferred to the IADB in its role as regional organization.

5. The development of repressive systems of control toward social and non-governmental organizations that participate in the implementation of primary health care programs is well known. These controls are under the responsibility of the Ministry of Planning (Dominican Republic), the Ministry of the Interior (El Salvador) or even the Armed Forces (Mexico).

 

In conducting an update of the analysis produced Sandiford and Martínez, in June of 1994, two years later, it is possible to state the following:

6. Except in the case of Panama (where it is not known whether even the preliminary studies have been done), in all of the countries of the region that form part of the CRPSC (Mexico, Central America and the Dominican Republic) reform has progressed to the phase of formulating the plans for reform

7. It is interesting how, in their majority, of the nine countries that were analyzed, only in two was a political consensus reached to develop the reform programs. And even where consensus was achieved (Nicaragua and Guatemala), there are peculiarities that raise doubts about the true legitimacy of those processes: It is said in the case of Nicaragua that the agreement between political parties has not translated to concrete commitments to put such reforms into practice. In the case of Guatemala, the agreements signed on May 6, 1996, within the framework of the peace accords, seemed to be more in the direction of strengthening the social state than of applying neoliberal policies. In the case of the Dominican Republic, the pressures applied by the College of Doctors and the Women’s Movement forced the legislative power to table the reform projects.

8. Four countries in the region appear to be the most advanced in compliance with the agenda defined by the World Bank: Nicaragua, Costa Rica, El Salvador and Guatemala. In the whole region, the governments have progressed with their privatization plans despite the objections of diverse sectors of civil society.

9. The analysis arrives concludes that the passive resistance that is seen in almost all of the countries of the region, should be transformed into a more proactive attitude of social and political movement, both at the national level and regionally. This should have the purpose of formulating alternative reform proposals, directed at defending and deepening the concepts that define health as a right of the people that should be guaranteed by the state institutions with broad participation of the population. (Cabrera - COPROSA, 1996)

Three years later, in 1999, it is possible to see how the above-stated tendencies have been maintained and deepened, with the corresponding elements peculiar to the political and social situation of each country.

For example, in Nicaragua, the changes directed at freeing the state from its responsibility of financing the social sector has brought it to promote, through the Ministry of Health, the organization of the Medical Supply Companies (EMP) and the Accredited Health Units (USAs), which sell medical services to the Nicaraguan Institute for Social Security (INSS). In this way all health care has been transferred to the social security institute, in practice subsidizing private companies out of the government coffers in an attempt to do away with the Single Health System created in the 1980s. Primary health care is no longer a priority.

In the “National Health Policy 1997-2000”, an obstacle to social participation policies was provided in the elimination of the National Health Council. This consultative body had already been reduced as had the National Commission Against Maternal Mortality. The Local Health Committees and the Hospital Support Committees were composed of businesspeople, dignitaries and organizations from civil society linked to the Catholic Church and to the most conservative sectors, marginating the community sectors that had been involved in the 1980s. (Rocha-CISAS, 1999).

The country is divided into territories according to the strategic political interests of the different international agencies and donor countries. This, in practice, creates health microsystems that can be in contradiction with each other and at the same time with the national policies fostered on a national level through the increasingly less significant role of the Ministry of Health.

The principal directions of health reform have emphasized the need for decentralization in decision-making, but since the beginning this strategy has had various problems. One of these, during the administration of Violeta Chamorro, was the non-decentralization of material and financial resources that invalidated all of the advances in decentralization. In the case of the current administration of Dr. Aleman, the tendency is toward a total reversal of this process; in other words, it supports a reconcentration of political and financial decision-making despite the rhetoric to the contrary.

In the case of Costa Rica, there is a program to create 900 Basic Teams for Holistic Health Care (EBAIS) in the hands of Social Security, in order to supplant the old but very effective Rural Health and Community Health Programs. The implementation of this program stalled at around 50% when the older PHC programs were dissolved with serious consequences for the poorest rural and urban populations. In place of this, direct purchase of services from individual doctors who have private practices in the communities has been begun. 

At the level of clinics and hospitals, there has been a fostering of “management agreements” among national authorities of the CCSS and the respective directors of the health establishments, as part of a policy of “administrative decentralization”. This provides more freedom in the purchase of private services where the institution is not able to respond, with the clear intention of provoking the gradual privatization of strategic specialized services (ophthalmology, radiotherapy, pathology and laboratory tests). Meanwhile, the private banks strengthen their levels of investment in entities such as the Cima Hospital in San Jose, with $10 million channeled by the Central American Bank for Economic Integration. At the same time, the opening up of the state monopoly on insurance is being promoted as the way of allowing the sale of private insurance in competition with the CCSS. In this way, the regimen of equity and solidarity is undermined. (COPROSA, 1999)

In El Salvador, there is a growing consensus emerging among diverse sectors regarding the need for reforms to the health sector. Up until now, proposals have been presented by five organizations: FUSADES (November 1998), the National Development Commission (January 1999), the National Health Commission (February 1999), the Doctors’ College (May 1999) and USAID’s Management Sciences For Health (July 1999). Just in the year 1998, ten desks were involved in the discussion and formation of proposals on this issue. However, these efforts have only been at the level of a few non-representative sectors and, occasionally, when convenient, at the executive branch level.

The current government is promoting reforms in the health sector through the National Health Commission, affecting the 78% of the population that is covered by MSPAS and the 17% covered by ISSS, due to the transfer of public and ISSS hospitals to private enterprise. It is proposed that a requirement for access to health services be the purchase of mandatory individual insurance policies that do not include the individual’s family. These will be paid according to the income of each person and will not cover all illnesses, but only those listed in a “basic or broadened basket of illnesses”. The Superior Council for Public Health – CSSP, will be substituted by a Health Superintendency. (Posada-APROCSAL, 1999)

Finally, in the case of Guatemala, since 1991, there has been a reform policy of the neoliberal cut. This has been ratified through a loan from the Inter-American Development Bank in 1993 and has now been translated into a new approved Health Code. The reform takes place at the first level of attention through the Integral System of Health Care (SIAS). It is a proposal in which the State-Civil Society and State-Market relationships are rearticulated, removing health as a social and human right and as an element of solidarity and economic redistribution in order to generalize the marketing of health services. (Verdugo, 1999). 

In the SIAS there is an excessive delegation to private entities. These entities become responsible for supervision. This model of care relies upon 94% volunteerism – consisting of health promoters and midwives, which becomes unsustainable and inequitable. There is an exclusion of indigenous medicine and a singular model offered in the face of situations and needs that are very diverse, refusing to recognize the valuable experience of the health “promoters” turning them into mere “guardians” of health. (ASECSA, 1999)


Conclusions

The reform is not taking into consideration problems that have always existed, such as the assignment of budget, improvement in the application of policies, improvement in record-keeping and control of medications, assuming the role of comptroller, providing an adequate solution to the health problems of the communities with equity and universality, attending to human resources problems including those of the health promoters. Reform in the health sector has not been discussed in all of its dimensions and possible implications with the all of the sectors involved in the health of the population.


As CRPSC, we propose that:

• Health should not be treated as a commodity, governed by the game of the free market; rather it should be a fundamental Human Right guaranteed by the State.

• The processes of health reform, in order to be sustainable, must begin with the broadest mechanisms of citizen participation, considering the particular needs and problems of the diverse human groups and their social, ethno-cultural, gender, geographic and other differences.

• Financial sustainability should be guaranteed through adequate state funding, falling under the principles of solidarity and distributed with the criteria of equity and universality. Privatization of health services should not be applied, as it further limits the access of the economically most vulnerable population (60% of the people in Central America).

• With the decentralization of services, resources and decision-making should be decentralized in addition to the responsibilities.

Our Commitments

The National Coordinators linked to CRPSC, jointly with other expressions of civil society, have been working for the constitution and strengthening of broad spaces for reflection to impact on the decision-making agencies in the area of health reform.

In Guatemala, ASECSA has accompanied the creation of the National Health Agency that is currently negotiating with authorities from the Ministry of Public Health and Social Assistance. Under these conditions, it is possible to achieve adequate participation of civil society in the SIAS and the process of reform in the health sector.

In El Salvador, APROCSAL is involved in the APSAL Network (Action for Health) which has been declaring No to privatization in the health system and is demanding that the government install a National Health Council with broad participation from civil society.

In Nicaragua, CISAS forms part of the Network of NGOs and Social Organizations that demand that the Executive Branch reinstate the National Health Council as the agency for broad participation in decision-making, as it had been since the 1980s. In addition, as part of the Civil Coordinator for the Emergency and Reconstruction that brings together more than 300 civil, community and labor organization, it has presented a holistic proposal for reconstruction of the health sector.

In Costa Rica, COPROSA is an ongoing part of the efforts of the Front of Union and Social Organizations in the Health Sector (FOSSS), as well as in the Working Group on Health (GTS-PNUD-UNICEF), which advocate for the establishment of officially recognized spaces of broad participation for the development of public policy on the state of health. 

Before this Latin American Forum, we ratify our commitment to continue to work and struggle with the communities to achieve better conditions for health and for life. 
 

3. Vision – Action by the CRPSC

3.1 Historical Summary (1975-99)

The Regional Committee for Community Health Promotion is a network of programs and/or coordinators of programs in Primary Health Care in the Meso American area, which was created in 1975. The principal activities of the Committee are training, technical assistance and follow-up to member groups through international gatherings, national and bilateral workshops, educational exchanges and provision of educational material.

The number of members of the Regional Committee, as well as the quantity and variety of activities that it carries out and promotes, has increased considerably since its beginnings. Today there are more than 200 programs and groups associated through the National Coordinators, which are presented below according to the year of the formation and their respective country:

1978 - Guatemala
ASSOCIATION OF COMMUNITY HEALTH SERVICES (ASECSA)

1983 - Nicaragua
INFORMATION CENTER AND ADVISORY SERVICES IN HEALTH (CISAS)

1983 – Dominican Republic
POPULAR HEALTH COLLECTIVE (COSALUP) 

1983 - Mexico
PROMOTION OF HEALTH SERVICES AND POPULAR EDUCATION (PRODUSSEP) 
NATIONAL MOVEMENT FOR POPULAR HEALTH (1980)

1986 - El Salvador
ASSOCIATION OF SALVADORAN COMMUNAL PROMOTORS (APROCSAL)

1986 - Costa Rica
COORDINATION OF POPULAR HEALTH PROJECTS (COPROSA)

1989 - Honduras
HONDURAN WOMEN’S PROGRAM FOR COMMUNITY HEALTH (PROFEHSAC)

1991 - Panama
NATIONAL ASSOCIATION FOR THE DEVELOPMENT OF COMMUNITY HEALTH (ANADESAC)


These National Coordinators and associated groups name their representatives to the Coordinating Commission that is the organ that plans, coordinates, implements and evaluates the annual activities of the Regional Committee. 

Since its creation up until the present time, during 24 years, it has held 22 International Meetings on diverse health issues, such as:

1975 Regional Meeting on Paramedic Programs, Guatemala.
1977 Regional Meeting on Rural Health Programs, Guatemala.

1980 Regional Meeting on Rural Health, Ajoya, Sinaloa, Mexico.
1981 Community Health Meeting, Women’s Health, La Talanquera, Honduras.
1984 International Meeting on Medicinal Plants, Mexico.

1986 Insecticide and Occupational Health, Coronado, Costa Rica.
1986 Mental Health Workshop I, Santo Domingo Tultenango, Edo. Mexico.
1987 Mental Health Workshop II, Mexico.
1988 Regional Meeting (of professionals) on Essential Medicines, Managua, Nicaragua.
1989 Regional Meeting (of promoters) on Essential Medicines, Tepoztlán, Mexico.
1989 Diagnosis for Social Promoters, Tapachula, Mexico.
1990 Workshop on Child Health in Central America and the Caribbean, San Cristóbal de las Casas, Chiapas, Mexico.
1991 Neoliberal Health Policies in the Region, Special Meeting of the Coordinating Commission of the CRPSC, San Ramón, Costa Rica.
1993 Health and Human Rights Workshop, Santiago de San Ramón, Costa Rica.
1993 Workshop on Puppets as a Strategy for Community Work, Nicaragua.
1994 Regional Meeting on Health and Culture, Chimaltenango, Guatemala.
1994 Regional Seminar on AIDS, Managua, Nicaragua.

1995 Regional Meeting on Gender and Health, Dominican Republic.
1996 State Health Policy Seminar/Workshop, Community Programs and the Challenges of Peace, Chimaltenango, Guatemala
1997 Regional Workshop on AIDS Education in the Rural Area, El Salvador. 
1998 Workshop on Making Health with Medicinal Plants, El Salvador.
1998 Follow-up on the Regional Workshop on AIDS Education, Honduras. 
1999 Regional Workshop on Alternative Therapies and Medicinal Plants, Costa Rica

Each meeting is multiplied at the level of the organizations that belong to the Regional Committee in national workshops and, later, at the level of the communities where community health workers live. 


3.2 Vision - Mission of the CRPSC

The target population for activities of the Regional Committee is composed of community health workers in each of their individual expressions depending on their country or region. There are health workers located in the community that are responsible for the health of women – in other words, midwives -, for the health of children and for general health. The Regional Committee prioritizes support to those grassroots groups, collectives, and organizations in the marginal rural or urban areas that work in holistic community health at the community level.

The Regional Committee seeks to prepare multipliers of knowledge that can impact on the formation and practice of the health workers within the community. In this way, through the kinds of actions that the health workers do in their communities, the Regional Committee is facilitating access to knowledge that allows the extension of coverage of health services to marginal and poor populations in the region. The same dynamic in the Committee’s activities seeks to guarantee the democratization of knowledge and participation in decision-making about health in the communities.

There is an emphasis on the need to deepen the relationship between community health and the health rights of citizens and health services. It is very clear that the community promoters are being affected intensely by the structural adjustment measures, and by the patterns of power, both political and generic patterns. In particular, there is a growing understanding of the interrelationship of these different issues. In its most recent meetings, the Coordinating Commission has identified the need for the integration of knowledge with the purpose of promoting guidelines for a regional strategy of defense and development of health as a right of everyone. 

The current period of neoliberal reform in the health sector in the Meso American countries has required more and more attention, such as support for those national coordinators with the greatest possibilities of having a technical and political impact on the national decision-making spaces.


Bibliography 

ASECSA. Annual Seminar 1999 of ASECSA: Primary Health Care in the New Millennium. Chimaltenango, Guatemala, June 14 to 16, 1999.

World Bank, EDI-WB, CCSS, Ministry of Health. Minutes: Seminar on Reform of the Health Sector in Costa Rica, Its Political Viability and Its Financial Sustainability. San Jose, October 1 to 3, 1997.

IADB, BIRF, CEPAL, OEA, OPS/OMS, UNFPA, UNICEF, USAID. Special Meeting on REFORM IN THE HEALTH SECTOR. Washington, D.C., September 29-30, 1995.

Cabrera, Mario; COPROSA. Toward a National Health System with Popular Participation: Health with Participation, Without Privatization! Presentation at the First National Meeting of Unions, Church and Community, Survey Analysis; Past, Present and Future of the Health Sector, Presented to the Union Organizations of the Health Sector (FOSSS). San Jose, Costa Rica, August 12 to 13, 1996.

Cabrera, Mario; COPROSA. Social Participation in the Reform: only a principle. Presentation to the Forum – Workshop “Toward a State Policy on Health”, Working Group on Health, Ciudad Universitaria Rodrigo Facio, San Jose, Costa Rica, July 29, 1997

Cabrera, Mario; COPROSA. Health Reforms in Latin America. Presentation to the Annual Meeting of ASECSA in 1999: Primary Health Care in the New Millennium. Chimaltenango, Guatemala, June 14 to 16, 1999.

COPROSA. Report on the Meeting of the Coordinating Commission of the Regional Committee for the Promotion of Community Health. Acosta, Costa Rica, May 8 and 9, 1999.

CRPSC. Summary of the Workshop of the Regional Committee for the Promotion of Community Health held in Nicaragua from June 9 to 11, 1995. (Situation of Health in the Region and progress in the process of implementation of Reform of the Health Sector).

CRPSC, IDEPAZ. Minutes from the Workshop Seminar: STATE HEALTH POLICIES, COMMUNITY PROGRAMS AND THE CHALLENGES TO PEACE. Chimaltenango, Guatemala, August 2 to 4, 1996.

Evans, Trevor, Coordinator. Neoliberal Transformation of the Public Sector. Structural Adjustment and the Public Sector in Central America and the Caribbean. Latino Editors. CRIES, Managua, 1995.

FOSSS. Basic Platform for Reform of the Health Sector. Front of Union Organizations from the Health Sector, San Jose, Costa Rica, August of 1998.

Gallardo, Helio. Globalization, Social Struggle, Human Rights, first edition, San Jose, Costa Rica: Ediciones Perro Azul, 1999.

Ickis, J.C.; Sevilla, C. and Iñiguez, M.R. Study of the Health Sector in Costa Rica. Study sponsored by Merck, Sharp & Dohme (I.A.) Corp. and done by professors of the INCAE, Harvard University and Stanford University. Alajuela, Costa Rica, June 1997.

National Health Agency – For the Defense of Democracy and the Right to Health, The Development of Reform in the Health Sector and the Responses of Civil Society in Guatemala. Guatemala, May 1999.

OMS. Health for All in the Twenty-first Century. Electronic publication on the Internet. 1999.

OPS/OMS. Health in the Americas. Vol. I, 1994 Edition. Washington, D.C.

OPS/OMS. Health in the Americas. Vol. I, 1998 Edition. Washington, D.C.

OPS/OMS. The Cooperation of the Pan American Health Organization in the Face of the Processes for Reform in the Health Sector. Washington, D.C., March 1997.

OPS/OMS. 7 The New Role of Governmental Regulations in Health Under the Ministries of Health. Series on the Organization and Management of Systems and Services. Washington, D.C. July 1998.

OPS/OMS. 9 Sub-regional Meeting on Sectoral Management and Leadership in the Ministries of Health. Series on the Organization and Management of Systems and Services. Final Report, Guatemala, April 23, 1998.

Pereira, J.A. Participation of Social Security Institutions in the Goal of Achieving Health for All Central Americans. (Preliminary Version). Preparatory Meeting of the Central American Council of Social Security Institutions. Panama, August 1996.

Posadas, Margarita; APROCSAL. Summary of Health in El Salvador. San Salvador, 1999.

PRODUSSEP y CRPSC. Panorama of Health in Mexico, Central America and the Caribbean. Mexico. 1993.

State of the Region Project. Report on the State of the Region in Sustainable Human Development. San Jose, Costa Rica: State of the Nation Project, 1999.

Ramírez, José Danilo. El Salvador. Report on the Situation of Health for the CRPSC Workshop. Pro-Life Institution. 1998.

Rocha, Nubia; CISAS. Advances in the Reforms in the Health Sector in Nicaragua. Managua. September 1999.

Sandiford, P. y Martínez, J. Health Sector Reforms in Central America. Series of Technical Reports on Health in Central America, ICAS-01. Central American Health, San Jose, March 1995.

Ugalde, A. y Jackson, J.T. The Health Policies of the World Bank: A Critical Review. Current version of “The World Bank and International Health Policy: A Critical Review” Journal of International Development 7 (3): 525-541. 1995.

Verdugo, Juan Carlos. Risks in the Reform of the Health Sector and the Role of the Civil Society in Guatemala. (Between a War Economy and a Market Economy) – A Text For the Debate. National Health Agency, Guatemala, October 1998.

Zúniga, María, CRPSC. Historical Summary of CRPSC. Managua, February 1998.