Londoño J L, Frenk J
Inter-American Development Bank, Washington, DC 20577, USA.
Health Policy. 1997 Jul;41(1):1-36. doi: 10.1016/s0168-8510(97)00010-9.
Health systems throughout the world are searching for better ways of responding to present and future challenges. Latin America is no exception in this innovative process. Health systems in this region have to face a dual challenge: on the one hand, they must deal with a backlog of accumulated problems characteristic of underdeveloped societies; on the other hand, they are already facing a set of emerging problems characteristic of industrialized countries. This paper aims at analyzing the performance of current health systems in Latin America, while proposing an innovative model to promote equity, quality, and efficiency. We first develop a conceptualization of health systems in terms of the relationships between populations and institutions. In order to meet population needs, health systems must perform four basic functions. Two of these-financing and delivery-are conventional functions performed by every health system. The other two have often been carried out only in an implicit way or not at all. These neglected functions are 'modulation' (a broader concept than regulation, which involves setting transparent and fair rules of the game) and 'articulation' (which makes it possible to organize and manage a series of transactions among members of the population, financing agencies, and providers so that resources can flow into the production and consumption of services). Based on this conceptual framework, the paper offers a classification of current health system models in Latin America. The most frequent one, the segmented model, is criticized because it segregates the different social groups into three segments: the ministry of health, the social security institute(s), and the private sector. Each of these is vertically integrated, so that it performs all functions but only for a particular group. As an alternative, we propose a model of 'structured pluralism', which would turn the current system around by organizing it according to functions rather than social groups. In this model, modulation would become the central mission of the ministry of health, which would move out of the direct provision of personal health services. Financing would be the main function of social security institutes, which would be gradually extended to protect the entire population. The articulation function would be made explicit by fostering the establishment of 'organizations for health services articulation', which would perform a series of crucial activities, including the competitive enrollment of populations into health plans in exchange for a risk-adjusted capitation, the specification of explicit packages of benefits or interventions, the organization of networks of providers so as to structure consumer choices, the design and implementation of incentives to providers through payment mechanisms, and the management of quality of care. Finally, the delivery function would be open to pluralism that would be adapted to differential needs of urban and rural populations. After examining the convergence of various reform initiatives towards elements of the structured pluralism model, the paper reviews both the technical instruments and the political strategies for implementing changes. The worldwide health reform movement needs to sustain a systematic sharing of the unique learning opportunity that each reform experience represents.
世界各地的卫生系统都在探寻应对当前及未来挑战的更好方式。拉丁美洲在这一创新进程中也不例外。该地区的卫生系统面临双重挑战：一方面，它们必须应对欠发达社会积累的诸多遗留问题；另一方面，它们已然面临一系列工业化国家特有的新出现问题。本文旨在分析拉丁美洲当前卫生系统的表现，同时提出一种创新模式以促进公平、质量和效率。我们首先从人群与机构之间的关系角度对卫生系统进行概念化阐述。为满足人群需求，卫生系统必须履行四项基本职能。其中两项——筹资和服务提供——是每个卫生系统都履行的常规职能。另外两项职能过去常常只是以隐性方式履行，甚至根本未履行。这些被忽视的职能是“调节”（一个比监管更宽泛的概念，涉及制定透明且公平的游戏规则）和“衔接”（这使得能够组织和管理人群、筹资机构及提供者之间的一系列交易，以便资源能够流入服务的生产和消费环节）。基于这一概念框架，本文对拉丁美洲当前的卫生系统模式进行了分类。最常见的模式，即分割模式，受到批评是因为它将不同社会群体分割为三个部分：卫生部、社会保障机构以及私营部门。每个部分都是垂直整合的，所以它履行所有职能，但只为特定群体服务。作为替代方案，我们提出一种“结构化多元主义”模式，该模式将通过按职能而非社会群体来组织当前系统，从而扭转局面。在这种模式下，调节将成为卫生部的核心使命，卫生部将不再直接提供个人卫生服务。筹资将是社会保障机构的主要职能，社会保障机构将逐步扩大覆盖范围以保护全体人口。衔接职能将通过促进建立“卫生服务衔接组织”来明确，这些组织将开展一系列关键活动，包括以风险调整后的人头费为交换，竞争性地让人群加入卫生计划、明确福利或干预措施包、组织提供者网络以构建消费者选择、通过支付机制设计并实施对提供者的激励措施以及管理医疗质量。最后，服务提供职能将向多元主义开放，以适应城乡人群的不同需求。在审视了各种改革举措向结构化多元主义模式要素的趋同情况后，本文回顾了实施变革的技术手段和政治策略。全球卫生改革运动需要持续系统地分享每个改革经验所代表的独特学习机会。
