Transforming health systems in Latin America: a vital conversation

We asked this question to Román Vega, Global Coordinator of the People’s Health Movement (PHM), during his recent visit to Argentina to participate in the Tenth Congress of General Medicine and Health Equipment organized by the Asociación Bonaerense de Medicina General AMGBA, in which the PHM, Alames and other national and regional organizations defending the right to health participated. Dr. Vega spoke about primary health care, the pandemic and the need for movements, organizations, communities and governments to start a discussion on the transformation of health systems in Latin America. This is what he told us.

By Miguel García

In many scenarios we have heard about the transformation of health systems in Latin America, what is the scope of this discussion?

Román Vega: “The short answer is that it depends a lot on what interests are at stake, but we are also talking about the re-foundation of the health systems, in the idea that in our global south, in Latin America in particular, we have not created systems based on our own ideas, they have been imposed on us by global powers and have been immersed in colonial legacies with a long historical trajectory”.

Why did we come to this discussion in Latin America?

RV: “The question is: Why do we have to change or transform the health systems, that is the problem we all have “Why? We have been able to see that, in the first place, the whole neoliberal health policy, founded on the idea of this policy of privatization and commercialization of health systems as one more space for capital accumulation. This idea grew, and the reform of the previous Chilean health system created under the Pinochet dictatorship was the foundation of it. Then followed the Colombian model of structured pluralism; after Colombia there followed a process of progressive penetration of privatization and commercialization of health systems in almost all the countries of Latin America; in Peru, in the Dominican Republic, a copy of the Colombian model was made; in Argentina the social security systems have been penetrated by the private sector; Brazil’s single health system, which was created from the 1988 national health policy, which somehow followed the tradition of the 1968 Cuban socialized health system created by the Cuban revolution, was also strongly penetrated by one modality or another of private interests; of course this logic has also penetrated Europe, Africa, Asia in one way or another with nuances following the general trend. ”

In this context of privatization, what is the void generated by private health systems?

RV: “The first thing that happened with these privatized health systems was that they did not resolve one of the apparent postulates of justification of the model, which was to try to include the different social groups in the right to the provision of health services, especially by focusing almost exclusively on disease care and, secondly, that it maintained serious inequalities, there are social groups that do not have access.

Hence the segmentation of models such as Chile’s and the fragmentation of systems with different benefits, depending on the citizens’ ability to pay. This was a model that could not overcome this enormous challenge, since its logic was not aimed at solving the underlying problem of inequality within the health systems, of inequity, to put it better, because it was about creating spaces for investment, not in the sense of social investment, but of private investment for profit. To achieve this, many of these systems had to be universalized beforehand, because the best way to guarantee the return on the capital invested, without any space for leakage, was the total universalization of the neo-liberal health system model in middle-income countries in particular. That policy, one can clearly say, failed in terms of achieving the important health objectives.

But this model not only failed there, it also failed in scenarios that we have recently experienced, or are currently experiencing, such as the case of the health crisis generated by the Covid-19 pandemic. In this crisis, the privatized and commercialized models of health systems failed to implement preventive and promotional health measures, related on the one hand to public health, but on the other hand to other types of social actions to guarantee survival, timely management and avoid the enormous mortality rate.

In which systems were these failures evident to attend the population in an emergency situation such as that of Covid-19?

RV: “One of the biggest failures was that of the United States and I believe it is the most privatized model in the world and perhaps the most expensive, but the Colombian system also failed. The Colombian model failed in implementing preventive policies, in avoiding the enormous contagion and the enormous mortality produced in the country.

The Brazilian model also failed because of its defunding and because of all the policies implemented by Bolsonaro, already widely known. The health system in Chile also failed at the beginning of the pandemic. The Chilean health system, endowed with a primary care experience of more than 20 years, however, was not able, at the beginning, to move primary care to try to avoid the contagion and the mortality that was occurring in Chile, and the fundamental reason was in the very failures of the conception of primary care, but also in the defunding of primary care. For these privatized systems, primary health care is not a business, as public health is not, and since it is not a business, it is not necessary to invest in strengthening primary health care. This failure of the health systems was not only in the management of the pandemic but above all in preventing the increasingly frequent emergence of epidemics and pandemics, because what we are observing in the world is that Covid has not been the only recent pandemic, and what is foreseen is that pandemics are going to spread on a total, globalizing scale like Covid 19, or limit to certain regions of the world like in Africa or in the Middle East, where we have also experienced these situations”.

But these health systems had to focus, with support from primary care, on contributing to prevent the pandemic What was the failure then?

RV: “It is that the commoditized, privatized systems are not designed to understand what is behind the emergence of pandemics and epidemics as recurrent as the ones we have experienced, why are they not focused on avoiding this type of problems, on understanding the underlying causality, but on managing and assisting the sick? and why on assisting the sick? Because the business of this type of systems is based on individual attention, either through insurance affiliation or through the provision of services, but not on understanding what phenomena are occurring in the society-nature relationship, in what some would call the society-nature metabolism. Why has the balance in nature changed, why do viruses escape from their natural niches and reach urban scenarios with such potency as the virus in Wuhan in China? That phenomenon is not clearly stated and the role of privatized health systems has been none around to understand this. Up to now there has been a discussion on international health regulation policies, on pandemic treaties, whose axis is not to prevent pandemics from coming but how to mitigate them once they are established; this is a problem of health policy that has to do with health system models.

Now, what we also observe is that powerful public or socialized health systems were able in many parts of the world to avoid the mortality that occurred with Covid-19. Cuba operated in that direction, in spite of very particular historical circumstances such as the economic, commercial and financial blockade, the impossibility of obtaining medical technologies to prepare responses to phenomena of this nature. But the Cuban health system, which we followed very carefully during the course of the pandemic, was a system capable of helping the Cuban people, with the active participation of social organizations, the State, etc., to face a threat that would have been devastating for a tourist country, such as Cuba, under Cuba’s economic and social conditions. However, Cuba responded, but so did Vietnam, and why did Vietnam respond to such a pandemic? Well, because of the very strength of the Vietnamese health system which, without being totally socialized, has had a powerful strategy in place for primary care of a community character for a long time, and there is a clear integration, integration between individual care and collective health as a phenomenon, as a community process, that is a fact that has been recognized.”

A moment ago you were talking about the society-nature metabolism, can you expand a little on that concept?

RV: “There is a phenomenon in the world that we could define as a threat not only to health but to life itself, and not only to human life but to the total life on planet earth, which is the ecological crisis we are experiencing, and the roots of the ecological crisis are similar to the occurrence of frequent epidemics and pandemics because it has to do with the destruction of nature. The climate change we are experiencing has its source in that dynamic, and behind that dynamic there is an economic model, there is not simply a human action that can take nature as an object, but there is such a dynamic, destructive, of converting nature into an object, of using its resources in function of Profit Making, of obtaining profit through transnational corporations, daughters of an economic system that is the real source behind the model of the health system we have, behind the phenomena of pandemics, but also behind the process of the economic crisis.

So, when one thinks of transforming health systems, the other question that must necessarily be asked is this: Will it be possible to transform health systems in the right direction without transforming the very society in which we live? This is the dilemma we face.

In the Latin American context, how is this discussion taking place?

RV: “I believe that today there is a main current health policy in the world, which is the one that contains the proposal of universal health coverage (UHC). What is being proposed in Chile, for example, is the idea of creating universal insurance models. Per se, one would say, a universal insurance model can be a good thing, after all it is a question of socializing the financing of health systems. Because what lies at the heart of universal public insurance, and of quasi- or near-universal social insurance, is the socialization of financing through taxes and through contributions, and cross-solidarity by income or by age, or by whatever you like, between population groups. That is not a negative idea, it has also been a conquest of the workers in their historical struggle. But behind the idea of the universalization of insurance, which is the proposal, I repeat, of universal health coverage, what is hidden is also something that should attract our attention. Socializing financing does not necessarily mean socializing the model of care, the model of health service provision, because what they have been doing with this proposal, what they have realized, is that the business in insurance occurs when it is private insurance, but a society does not resist the idea of the existence of private insurance alone, because they are exclusive in nature and the social conflict arises demanding a change in the model. But they have realized that the business can be maintained and deepened within the framework of the provision of health services, that is the thing that is very clear, which also links the provision of health services with the whole medical industrial complex that we call the business of the pharmaceutical industry, of the production of technologies, many of them digitalized today, and of medical equipment of all kinds. This is the big health business in the world, in the field of the production of medicines and vaccines, for example.

So, we have a proposal that is summarized and synthesized in the idea of universalization, accepted by the WHO, I have to say it clearly, the WHO has approved the policy of universal health coverage, obviously playing into the hands of the privatizing and commercializing logic, but so has the World Bank, and that is the scenario we have.

Now, there is another problem, if one wants to rethink and modify health systems, in the case of Latin America, one would have to understand that there is not only western medical knowledge in health matters, that there are other important and relevant knowledge and knowledge practices in the conditions of today’s world. Our ancestral communities of all kinds have been building a knowledge of the care of nature and of the relationship between human beings and other living beings, with other expressions of nature, a knowledge accumulated in centuries of resistance, because it has not been a magical knowledge, no, it is a matter of centuries of learning, of survival of communities that have had to suffer the dynamics of the conquest, of the colony, of the internal wars in each of our countries.

In the discussion on Primary Health Care, how do you address the issue of transformation of health systems?

RV: The question about primary health care is not a new question, because since its inception, Primary Health Care was challenged by the global powers that rejected the idea of integrality of the Alma Alta Declaration of 1978 and built a selective conception, of cost-effective, cost-efficient interventions in vulnerable populations, with minimum benefits, which were then expanded until today, and it is in this historical tradition of PHC that the World Bank is going to propose us the transformation of health systems, using PHC as a synonym of packaged medical activities, benefit packages. That is what insurance is good for, because insurance cannot work without benefit packages, insurance has to have control over the cost of care and if it does not have, especially business-oriented insurance, cost control, it ceases to be insurance, because insurance is a technology embedded in health policies that has to do with risks, first of all. But we don’t talk about risks, we talk about social determinants, social determination of health, but insurance talks about risks, what kind of risks: Economic, not only applicable in terms of the financial protection of patients, but of the insurance organizations themselves, because what private insurance protects first of all is the possibility of making profits, that talk to you about the skimming of the entities of the system, of affiliating young population in which they do not spend and once they get old they have to abandon the insurance because it is very expensive and migrate to the public insurance to be assisted for the diseases, it is the logic of business, of risks and cost accounting very, very powerful in the logic of health systems.

Now, the question is, can we socialize the provision of services in the current state of affairs in our countries, it does not seem so easy. I cannot imagine Gabriel Boric in Chile making the decision to nationalize the private hospitals and clinics in Chile; neither can I imagine Gustavo Petro making the decision to nationalize, nationalize or control as much as possible the private hospitals and clinics in Colombia which are, in many cities, more than 90% of the providers and the average in the country is around 80% of the health service providers.

That is why I ask: when we talk about integration, what are we talking about, and it seems to me that this is the central discussion and the process in which we are involved. We have to put this debate in the communities, in the social organizations, in the unions, in the social movements, because the struggle for health is not only the struggle for the provision of services, it goes far beyond that, therefore, we have to put the debate there in order to achieve that the changes ride on the shoulders of the social struggle, it is not otherwise, the social struggle has moments, what happened in Chile, the social outburst, was an illuminating moment for the Chilean populations, like the social outburst in Colombia, that is why Boris and Petro won the elections, because there has been a huge struggle that brought us to the present, but the struggle is not over and to believe that by electing a government, having a progressive health minister, or something like that, we have guaranteed change is a mistake, we have to continue the dynamics of mobilization, organization and struggle with the people to influence the agenda, within the framework of the correlation of forces we have so that the changes are much deeper than those that can be made from the limitations of the State spaces, and there lies this need for us to open dialogue, discussion, monitoring, construction of proposals to transform the health systems.