Fiedler J L
Social Sectors Development Strategy, WI, USA.
Health Policy Plan. 1996 Dec;11(4):406-17. doi: 10.1093/heapol/11.4.406.
Most Latin American social security institutes are direct providers of medical care services to their beneficiaries. As many of the institutes have developed serious financial problems over the course of the last decade and a half, they have come under increasing attack for (a) exacerbating inequalities in access to and use of health care, (b) further heightening the geographic overconcentration of services, (c) focusing a disproportionate amount of resources on high technology, curative care to the near total exclusion of primary health care, and (d) being administratively top heavy and, more generally, inefficient. In the past few years, many Latin American countries have begun searching for methods to ameliorate these problems. This paper analyzes three recent efforts, all of which involve some degree of privatization: (1) El Salvador's partial privatization of specialty physician outpatient consultations, (2) Peru's minor surgery and its decentralized ambulatory care programme, and (3) Nicaragua's "administrative services only' approach wherein social security beneficiaries choose to join a certified public or private provider organization for one year, and, on behalf of the individual, social security pays the organization a fixed, annual, per capita fee to provide all health care for the enrollee. The paper also identifies political and technical considerations, as well as health care market characteristics that have shaped these efforts and that condition their likelihood of success, including: the size, composition, level of capacity utilization, degree of organization and geographic distribution of private sector resources; relative prices in the private vis-a-vis the public sector; and the size and nature of the private health insurance market. Other Latin American countries would do well to examine these factors and characteristics before embarking on efforts to reform their own social security health care delivery systems.
大多数拉丁美洲的社会保障机构直接为其受益人提供医疗服务。在过去十五年间，许多机构出现了严重的财务问题，因此受到越来越多的抨击，原因包括：(a) 加剧了获得和使用医疗保健方面的不平等；(b) 进一步加剧了服务在地理上的过度集中；(c) 将过多资源集中于高科技、治疗性医疗，几乎完全排斥初级医疗保健；(d) 行政机构臃肿，总体而言效率低下。在过去几年里，许多拉丁美洲国家已开始寻求改善这些问题的方法。本文分析了最近的三项举措，所有这些举措都涉及某种程度的私有化：(1) 萨尔瓦多对专科医生门诊咨询的部分私有化；(2) 秘鲁的小型手术及其分散式门诊护理计划；(3) 尼加拉瓜的“仅行政服务”模式，即社会保障受益人选择加入经认证的公共或私人服务提供组织一年，社会保障机构代表个人向该组织支付固定的年度人均费用，以便为参保人提供所有医疗保健服务。本文还确定了影响这些举措并决定其成功可能性的政治和技术因素，以及医疗保健市场特征，包括：私营部门资源的规模、构成、产能利用率水平、组织程度和地理分布；私营部门与公共部门的相对价格；以及私人健康保险市场的规模和性质。其他拉丁美洲国家在着手改革本国社会保障医疗服务体系之前，最好审视一下这些因素和特征。
