Argentina: Debate on Health Reform

Only a single state system can guarantee health care for everyone

By Guillermo Pacagnini, Doctor and CICOP Secretary General

In the last few weeks, from the Kirchnerist sector of the governing front, the idea of installing an “integrated” health system was launched. The mere mention of altering the health status quo generated a great commotion, with rejection from the private sector, the leaders of the union bureaucracy and the sectors close to Alberto and Ginés, against the proposal. However, the project outlined has a lot of progressive rhetoric and is not orientated towards serious changes. As we have been stating since the beginning of the pandemic, only a single health system allows not only to face the contingency but also to advance in a free, universal and egalitarian health.

Last December 20, in an event in La Plata, Cristina Kirchner warned about the wear and tear of the government one year after taking office and called for changing officials, ministers and adjusting some gears. In this context, she said “We have to move towards an integrated national health system between the public, private and social security systems that optimizes resources. The pandemic gave us the opportunity…”. Taking up the mandate, the provincial Vice-Minister of Health, Nicolás Kreplak, released a draft entitled: “Ejes centrales para un programa de salud 2020-2024”, proposing the unification of the health system by means of a national law. Reactions came soon and went beyond the counterpoint between the two health currents that dispute in the Frente de Todos: Soberanía Sanitaria de Gollán (Kicillof’s minister) and La Cámpora, defender of the project, and the Corriente Sanitaria Nacional del Movimiento Evita and the sectors close to Ginés, the PJ and the presidency.

The commotion was huge in the ranks of the cegetistas hierarchs, who held feverish meetings of leaders and referents of the unions on the one hand and of the heads of the private health sector with Belocopitt of Swiss Medical at the head. The national government was quick to dismiss the alleged project. A deja vu of what happened last year when Ginés stammered the idea of some kind of coordination between the subsectors and a few hours later he was disavowed by the President himself.

Belocopitt was categorical: “There is a fantasy of creating a single health system in order to have complete power (…) What you cannot do is to deteriorate the private system”.

On the side of the CGT, closing ranks around the millionaire social welfare funds, they warned against the “attempts to defund them” and defended the Solidarity Distribution Fund, with which governments blackmail and bureaucrats hand over conquests in exchange for its management.

The central government came out to cut to the chase saying that there was no decision in that sense with the Superintendent of Social Services, Eugenio Zanarini (Ginés’ man), as spokesman: “a single and integrated system is unfeasible”. Point for the government.

But the debate continues. Because, beyond the use of this issue for the official internal politics,  as we have been stating from the MST, the left and the militant union sectors, what is unfeasible is the fragmentation of the present system.

It is important, therefore, to uncover the truth of La Cámpora’s project, since there is a lot of double talk and progressive varnish, but there is a lack of real and deep measures.

The fine print of La Cámpora’s project

The letter of intent sounds attractive because it raises a series of general premises that include the logical aspirations of a large part of the active population that has been fighting for universal health care and that demands fundamental changes. They start by criticizing the fragmentation of the system and other evils of the crisis that the pandemic crudely uncovered, and reaffirm the general principles of left-wing healthcare. “We conceive health as a universal right, a social and historical conquest of the community and a non-delegable responsibility of the State”. And it proposes a restructuring moving towards an “Argentine National Integrated Health System, (SNISA)”.

But when it explains what it consists of, we see that the grandiloquent objectives and proposals for transformations are reduced to general statements and a lukewarm attempt to reinforce the “guiding” role of the National Ministry, to try to arbitrate a little the anarchy to which the current fragmentation leads, which worsened in the face of the pandemic when some degree of centralization and national planning was needed.

The project announces that “It is necessary to recover the governance of the health system through the global conduction of health policies…”. But it then goes on to say that this will be done “under a general criterion of normative centralization and operational decentralization”. In other words, the national ministry can set guidelines, but then – through the old World Bank formulation of “operative decentralization” …. – the private sector, the bureaucracy and the municipal or provincial pointmen continue to decide according to their own interests.

But the core of the document does not take long to appear: “To implement the system of recovery of the services rendered by state entities to subsectors of social welfare and prepaid medicine: the public subsector will obtain a remuneration for the services rendered (to social welfare and private entities) (…) with average discounts of up to 33% of the market values (…) in exchange for a system of automatic collection of the invoiced amount…”. In other words, another old “recommendation” of the World Bank to reduce budgets and look for alternative financing channels such as self-management and tariffs. Little to do with a single system.

The project does not intend to substantially modify the policy of the nineties on Social Welfare Funds: “To establish a new modality for the “free choice” among Social Welfare Funds…”.

Regarding medicines, it only attempts to propose some kind of price regulation and to relaunch the Remediar Plan. Without proposing an aggressive public production plan and even less to advance on the medical industrial complex that intertwines private medicine with multinational laboratory corporations.

Why the SNIS failed in the 1970s

The idea presented by Kreplak of an “integrated” system is not new. It has been a banner of Peronist sanitarism and sectors of progressivism that have long been in controversy with the single system and the socialist model of health that we advocate from the left. The latter has been labeled as utopian and the SNIS as the “possible” or as a step towards a superior model.

It is worth remembering the antecedent of the National Integrated Health System (SNIS) implemented in the Peronist government in 1974, Laws 20748 and 20749, achieved with the support of radicalism. And it was the preferred banner of the Peronist left and the progressiveness of the time. It declared health as a right, an issue absent in the National Constitution at that time, and defined the State as the guarantor, financer and director of the system. Although with very general statements, it gives the state a more active role and greater powers to intervene in the other subsectors than the current timid project. For example, in emergencies (such as a pandemic today) it could subordinate all sectors under its command. And it established a National Health Career. It also defined some mechanisms of articulation and integration, all things almost absent today in Kreplak’s draft.

However, in the capitalist and possibilist character of the norm lies the explanation of its resounding failure. Because neither the nationalization of the incipient private sector nor the liquidation of the privileges of the bureaucracy were considered in order to democratize and incorporate the social welfare funds. And if the power of these sectors is not taken away, it is impossible to advance in any unification of the system. Let’s see.

The first version of the social security system established the mandatory integration of all the health care providers into the health system. The closed opposition of the union bureaucracy determined that in the final draft the incorporation was left to the will of each entity by means of agreements. Of course, no social work ever adhered to it.

Regarding the provinces and municipalities, with the well-known argument of autonomy, it only proposed the execution of agreements. In spite of a much lower level of fragmentation than at present and a lower relative weight of the private sector, they quickly yielded to the pressures of the establishment. The same that, almost 50 years later and with more power because they were allowed to grow, are on the warpath against any movement that threatens to alter the current status quo that guarantees their privileges and profits.

The SNIS of the 1970s was repealed four years later by the dictatorship. But that was a formal step. It died as soon as it was born because it was never implemented, except for a lukewarm trial in only four of the smallest provinces.

The only truth is reality

The current project is inferior, it takes place in a framework of international crisis, and demand for adjustments different from that of the 70’s, the system is more fragmented and the private sector monopolizes 60% of capacity.  Therefore, what is utopian is to think that a project that does not propose anti-capitalist measures to seriously unify, could be feasible, hoping to convince the union bureaucracy and the private health merchants to yield a minimum portion of ground in a friendly way.

That is why Kreplak comes clean in a recent interview and declares that “what I am not sure about is exactly how to do it”.

That is why, unlike our proposal from the left which does propose how to do it, Kirchnerism remains in the double discourse and the provincial government approves a health budget reduced in real terms by 60% in agreement with the Macrist opposition. That is why Kicillof subsidizes private clinics with 400 million per month usurped from the IOMA funds, which is the workers’ money.

That is why the national government has just granted 2277 million pesos to the Social Security of 46 unions, which is added to the 7,000 million already granted throughout 2020.

Towards a socialist model. A single system is possible and necessary

The Kirchnerist position of “integration” agreed with those who have opposing interests is utopian. Because they are the pillars that maintain the current system fragmented, underfinanced and with the health team dehierarchized in terms of salaries and labor, in order to maintain their privileges and profits.

Without a declaration of social utility of all subsectors, nationalization of the private sector, management control by the health team and national centralization for planning, there is no single health system. The pandemic cannot be successfully confronted, nor, of course, can free and equal health care be guaranteed. On the contrary, the pandemic has exposed these shortcomings and the level of mobilization and debate that is taking place shows that it is possible and necessary to move towards a single system.

The emergency measures that we propose as an imperative need to successfully face the pandemic are also part of a strategy to solve the serious structural problems of the system and aim at a radical change towards a single system that advances towards complete socialization, towards a socialist model of health. Democratically planned and including preventive actions in all places of work and study and primary health care in all popular neighborhoods. And a single national and state system, which articulates all existing resources.

We propose to triple the budget, but as a step towards a system that works entirely financed from general revenues in charge of the state and based on heavy taxation of the rich and non-payment of the foreign debt.

We propose to increase staff and salaries in the emergency, but marching towards a global hierarchization of the entire health team with a Single National Health Career. With working conditions without exposure to risk and with updatable salaries that allow their continuous training during working hours and that do not need to practice poly-employment.

We propose the declaration of public utility subject to expropriation of all inputs and installed capacity of the private sector, advancing in its nationalization under social control and incorporation into the state system.

We propose the seizure of the necessary medicines and supplies, setting their price based on the real cost of production and advancing in the public production of medicines, serums, vaccines and supplies in general. Using all available installed capacity. And reconverting the productive branches that are needed on the road towards the nationalization of the laboratories of medicinal specialties. And their operation under workers’ control and in close relationship with the national universities and their research projects. As well as the cancellation of patents. This is the only way for medicine to be a social good, accessible and free and not a commodity. For example, now the production of vaccines against Covid would be a priority.

We propose the democratization of all the social security that today put their hand in the pocket of the workers, generate bad attention and enrich sold union leaders, and integrate them progressively to the public system.

We propose to move towards a single health system in charge of the state. To guarantee a shock in the offer of universal and absolutely free services for all. To put an end to a health system for the rich and another for workers. Nationalizing clinics, sanatoriums and the entire medical industrial complex. We need to join all the sub-sectors in a single state system, democratically administered by workers and users.

This socialist model of health is incompatible with capitalism, where the profits of a few are worth more than our health and our lives. Its development and consolidation will be possible in the framework of a more general fight, like the one we are giving from the MST in the Left Unity Front and the International Socialist League (ISL), towards a socialist society. We want to extend and deepen this debate and discuss with everyone these emergency and fundamental proposals.

Brief history of the scrapping

The Argentine system, which was a model of universality and state funding in the 50’s, is going downhill as a result of a progressive process of defunding, fragmentation and dehierarchization of its workers. This was the result of the austerity policies of successive governments following the two strategies of the IMF and the World Bank: freeing the State from investing in health by opting for alternative tariff financing and transforming health into a branch of services and capitalist production.

In line with these strategies, multiple tactics were tried:

Transfer of national effectors to provinces and municipalities initiated in 1957 and deepened during the dictatorship and the 1990s.

Law of Social healthcare 18610 of the dictator Onganía (1970). Deregulation in the 1990s.

Progressive reduction of budgets, inversely to the payment of usurious public debts.

Decentralization Laws and Menem’s Decree of Self-management in the 90’s.

Focal plans of the World Bank, such as Remediar (typical of the Peronist governments, Ginés being one of their followers).

Various attempts at mixed health insurance.

The so-called CUS (Universal Health Coverage) in recent years, where resistance and mobilization were key to stop totally or partially many of these measures. Thanks to this, the public sector has survived, but at a high cost. A reduced public sector, a private sector that has grown and a social security system deeply related to the private sector, especially after deregulation.

Radiography of the system

The so-called total expenditure on health represents 9.4% of GDP, but the state sector receives an investment that barely exceeds 2.7%. The rest reflects the spoils of the union hierarchs and the profits of the private sector. The public sector forms 80% of the human resources in health, attends 90% of the emergencies and almost half of the population… but represents only 28% of the so-called total “expenditure”. In 2004 the number of private hospital beds was 60,697, representing 47% of the available supply and then continued to increase steadily reaching in 2011 a total of 67,293 and reaching 50% of the total. Currently, its installed capacity is close to 60% and absorbs almost 57% of the human resources. It is imperative to add all these private resources, which today serve no more than 10% of the population with the capacity to pay, to a single state system, universal and free of charge.