STRUCTURED PLURALISM - TOWARDS AN INNOVATIVE MODEL FOR HEALTH SYSTEM REFORM IN LATIN-AMERICA

Health systems throughout the world are searching for better ways of r esponding to present and future challenges. Latin America is no except ion 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 ch aracteristic of industrialized countries. This paper aims at analyzing the performance of current health systems in Latin America, while pro posing an innovative model to promote equity, quality, and efficiency. We first develop a conceptualization of health systems in terms of th e relationships between populations and institutions. In order to meet population needs, health systems must perform four basic functions. T wo of these-financing and delivery-are conventional functions performe d by every health system. The other two have often been carried out on ly in an implicit way or not at all. These neglected functions are 'mo dulation' (a broader concept than regulation, which involves setting t ransparent and fair rules of the game) and 'articulation' (which makes it possible to organize and manage a series of transactions among mem bers of the population, financing agencies, and providers so that reso urces can flow into the production and consumption of services). Based on this conceptual framework, the paper offers a classification of cu rrent health system models in Latin America. The most frequent one, th e segmented model, is criticized because it segregates the different s ocial groups into three segments: the ministry of health, the social s ecurity institute(s), and the private sector. Each of these is vertica lly integrated, so that it performs all functions but only for a parti cular group. As an alternative, we propose a model of 'structured plur alism', which would turn the current system around by organizing it ac cording to functions rather than social groups. In this model, modulat ion would become the central mission of the ministry of-health, which would move out of the direct provision of personal health services. Fi nancing would be the main function of social security institutes, whic h would be gradually extended to protect the entire population. The ar ticulation function would be made explicit by fostering the establishm ent of 'organizations for health services articulation', which would p erform a series of crucial activities, including the competitive enrol lment of populations into health plans in exchange for a risk-adjusted capitation, the specification of explicit packages of benefits or int erventions, the organization of networks of providers so as to structu re consumer choices, the design and implementation of incentives to pr oviders through payment mechanisms, and the management of quality of c are. Finally, the delivery function would be open to pluralism that wo uld be adapted to differential needs of urban and rural populations. A fter examining the convergence of various reform initiatives towards e lements of the structured pluralism model, the paper reviews both the technical instruments and the political strategies for implementing ch anges. The worldwide health reform movement needs to sustain a systema tic sharing of the unique learning opportunity that each reform experi ence represents. (C) 1997 Elsevier Science Ireland Ltd.