Argentina: Promoting national policy in a federal system
“Argentina’s health system is in agony”
In March 2002, amidst an economic crisis and national healthcare emergency the then Minister of Health Gines Gonzales Garcia declared “Argentina’s health system is in agony… What is lacking is money, not drugs. Our country has the best pharmaceutical industry in Latin America. The problem is that the state and the medical insurance firms owe the system about one billion pesos (around USD 700 million).” Having extended this massive line of credit to the both public and private insurers who covered millions of Argentine patients, wholesalers and pharmacies eventually had to stop providing medication at the subsidized rates, cutting off access to essential medications. Simultaneously, the public healthcare system itself, composed of individual provincial institutions, struggled to provide basic healthcare services in many regions, and average uninsured patients actually lost access to the universal healthcare to which they were constitutionally entitled.
Five months later, in August 2002, Argentina’s federal government started to fight back by passing the Health Emergency Act. Simultaneously, the Ministry of Health created the national Plan Remediar to address those patients who had lost access to their medication, and in the process created what is now the largest free drug program in the world. Mauricio Monsalvo, the current National Coordinator for Plan Remediar explained that “When this program started, we purchased and supplied 21 different drugs to 2500 health centers, and in 2004 we extended our portfolio to 50 products and worked with 5000 health centers. Currently, we work with 7000 public health centers (primary care) covering the 79 different medications we currently provide.” Over the last ten years, Plan Remediar has also developed additional roles, as “today, Remediar finances, procures, stores and distributes these 79 drugs to primary healthcare facilities and public health centers across the country. We are also used as a public logistics operator by a variety of other ministry of health programs, so we distribute many more medications than just those that we procure.”
“Until recently there was no proper registration of the drugs inside the health centers.”
In the longer run, the creation of this national free drug program had consequences that were perhaps unforeseen. In Argentina, healthcare is one of the most important political issues across the section, and provincial governments hold strongly to their authority of the public health intuitions that they control. Yet, by providing drugs for free to the system, Plan Remediar developed an instrument of influence over the public health centers, and have since been able to encourage the professionalization of healthcare administration across provincial boundaries. For instance, Plan Remediar has orchestrated an “ambitious training program for inventory management that focuses on the storage of medicines, pharmacovigilance procedures, definition of demands, processing stock shortage conditions, inventory reconciliation procedures, forecasting future demand, and a few other areas. This new health center culture that we are fostering is very innovative for Argentina, as most government departments still don’t record what drugs they provide; until recently there was no proper registration of the drugs inside the health centers.”
“Evaluations have shown that the program has succeeded in increasing average birth weight, lowered the probability of very low birth weight babies, reduced early neonatal mortality, and increased Apgar scores.”
Plan Nacer is another program that was founded in the wake of the healthcare emergency that has evolved into an instrument of national healthcare policy. It was founded in 2004, with the initial providing “public health insurance to uninsured pregnant women and children under the age of six,” as the national coordinator Martin Sabignoso explained. By providing formal insurance with defined benefits to Argentinian’s who were technically already covered by Argentina’s “universal healthcare system”, Plan Nacer (which was absorbed by Plan Sumar in 2012) sought to improve the quality and accessibility of public health services that were delivered by the public health centers. By using “an innovative ‘pay for performance’ model that provides incentives to the provinces and health care centers to promote better access and quality of health services,” Plan Nacer/Sumar was able to establish influence over the public health centers, and the provincial ministries of health that they were usually funded by. The funds the program provides to the public health centers are allocated by their own staff (instead of by the provincial ministry of health), empowering them to decide how to best improve their ability to provide healthcare to their patients. Further funding was tied to the actual provision of services, or results, to incentivize the health centers to encourage mothers to enrol themselves and their children in the program.
The program has been astoundingly successful, helping to cut the infant mortality rate from 14.4 to 11.9 per 1000 between 2004 and 2011, and evaluations have shown that the program has succeeded in increasing average birth weight, lowered the probability of very low birth weight babies, reduced early neonatal mortality, and increased Apgar scores. Plan Sumar’s success has been audited and lauded by UCLA Berkley and the World Bank, who have publically recognized the success of the program. At the core of this success lies the program’s collaborative model and their efforts “to create space to build consensus and harmonize treatment standards, so it is critical that we include the provinces in our planning and prioritization process.”
“Now the provincial governments have added the term ‘good practices’ to their vocabulary and some of their legislation.”
Similarly to Plan Remediar, Plan Sumar also confronted the poor management practices that were holding the public back, although in a much more direct way. Mr. Sabignoso stated that the program’s “main challenge was to develop new management skills, and a more professional management culture at all levels of the public system: national, provincial and facilities level… Our goals are quite demanding and constitute a significant challenge to the status quo, as we require everyone to learn new procedures, operational standards, and a new philosophy, all of which force individuals to work much harder to achieve the same productivity, albeit at a significantly higher quality.”
Perhaps most indicative of the impact that the two programs have had is the impact they have had directly on provincial politicians. Mr. Sabignoso is proud to say that his organization is now respected as a source of intellectual leadership within the healthcare community, and has had enough success in “shifting the mentality towards public healthcare, [that] now the provincial governments have added the term ‘good practices’ to their vocabulary and some of their legislation.”
Article written by Alexander Ackerman