El contexto de las reformas del sector de la salud / The context surrounding health sector reforms

RESUMEN

En América Latina, las reformas del sector de la salud han ido de la mano con los fenomenos sociales y economicos de la segunda mitad del siglo XX y han reflejado el concepto particular del "desarrollo" que ha predominado en distintos momentos. El estancamiento economico y el aumento del gasto social, fenomenos propios de los anos sesenta, llevaron a la crisis del modelo de desarrollo basado en la "sustitucion de importaciones", vigente desde principios de siglo, y dieron paso paulatinamente al modelo de "globalizacion" que tuvo inicio en los anos ochenta. Del anterior modelo se paso a una reestructuracion de los procesos productivos y a politicas de ajuste economico que redundaron, ironicamente, en una agudizacion de la pobreza en America Latina. Dos han sido las fases de implementacion de este nuevo modelo. La primera, denominada de "reforma social" o de "primera generacion", partia del concepto de que la pobreza se reduce a una suma de carencias materiales cuya resolucion radica en la reparticion equitativa de un volumen fijo de bienes que posee la sociedad. Este marco conceptual, completamente desvinculado de toda connotacion historica y de la politica economica, condujo a politicas sociales orientadas por entero a mitigar la pobreza mediante subsidios destinados a los sectores mas necesitados. En la segunda fase del modelo de globalizacion, iniciada en los anos noventa y denominada "de segunda generacion" o de "postajuste", entraron en juego nuevas reglas economicas, basadas principalmente en la competencia internacional, la eficiencia productiva y la transparencia del mercado de capitales. Y si en la primera fase el concepto estrategico de la politica social se centraba en combatir la pobreza, en la segunda paso a convertirse en la busqueda de la equidad, ya no entendida como la distribucion pareja de un volumen fijo de bienes de capital, sino como el ofrecimiento sostenido de mayores y mejores oportunidades para todo el mundo. Acostumbradas al proteccionismo del antiguo modelo de desarrollo, hoy en dia las sociedades latinoamericanas perciben la amenaza de un modelo nuevo que no les ofrece ninguna red de proteccion social. La viabilidad de las politicas de reforma economica y social de la segunda fase, que se ajustan a las exigencias de un mundo "globalizado", depende, entonces, de poder vencer la desconfianza de la poblacion y de lograr el respaldo de una mayoria politica, social e institucional

ABSTRACT

In Latin America, health sector reforms have gone hand in hand with social and economic trends during the latter half of the twentieth century and have reflected the particular concept of "development" that has been in vogue at different times. Economic stagnation and increased social spending, both hallmarks of the 1960s, led to the decline of the "import substitution" development model, which had prevailed since the beginning of the century, and slowly gave way in the 1980s to the "globalization"model. From the earlier model, a transition took place toward a restructuring of production and a series of economic adjustment policies that led, ironically, to an increase in poverty in Latin America. Implementation of the new model has occurred in two phases. The first, known as the "social reform" or "first generation "phase, sprang from the notion that poverty is the sum of a number of material shortages that can be corrected through an equitable redistribution of a fixed volume of goods belonging to society. This conceptual framework, which was completely devoid of all historical linkages and separated from economic policy, led to social policies whose entire purpose was to mitigate poverty through subsidies targeting the poorest persons in the society.In the second phase of the globalization model, which arose in the 1990s and became known as the "second generation" or "postadjustment" phase, new economic rules came into play that were based primarily on international competition, efficiency in production, and openness and fairness in the capital markets. And if during the initial stage the conceptual strategy behind all social policy was to fight poverty, in the second stage the strategy became one of achieving equity, which was no longer interpreted as the even distribution of a fixed volume of capital goods, but as the sustained provision of greater and better opportunities for all. Having grown accustomed to the protectionism inherent in the earlier development model, Latin American societies today feel threatened by a new model that offers them no social safety net. The feasibility of economic and social reform policies during the second phase,which reflect the demands of a "globalized" world, thus depends on the ability to overcome people's lack of trust and to garner the support of a political, social, and institutional majority