– Luciano Di Césare, Executive Director – Argentina
The Executive Director of Argentina’s social security health provider, PAMI, discusses the institutions mission and evolution, as well as his hopes for the future of the Argentinian health system.
What is the main mission of PAMI?
Our mission is to efficiently provide health, social and welfare assistance to a population requiring special attention, mostly elderly people; we cover all of the retirees and pensioners in Argentina. PAMI was the first a union based insurance program with primarily seniors as members, and was the pioneer and forerunner in care for the elderly in our country. Currently we have over 650 services offices distributed in the provincial capitals and major cities of the country. Our institution provides assistance to more than 4,600,000 members, and is the largest program of its kinds Latin America, and one of the largest in the world. We also take care of the children that are born to our affiliates, so technically we can that our youngest affiliate is just being born while our oldest is 108 years old!
One of the great things about PAMI is that it provides universal healthcare and social welfare services to anyone over 70 years even if they have not contributed to our system. We also offer services related to social, human and recreational issues in addition to our health services, and we seek to improve quality of life overall, not just in terms of health.
When PAMI was founded, the title the organization was known by was INSSJP, which meant “National Institute of Social Services for Retirees and Pensioners”, while PAMI was technically the “Comprehensive Medical Assistance Program”, a program managed by the INSSJP. In 2009 we underwent a transformation process and revealed the new mission statement, and unveiled a new formal title and definition of PAMI; “for an Argentina with Integrated Seniors”. We did this to show that it is not only important to improve the quality of life of the elderly but it is essential to fully integrate them into society, seeking and encouraging independence, autonomy and dignity of our members.
Can you give us an overview of the Argentinian Health care system?
The Argentinian system is divided into two branches, private and public. At the same time, the public branch can be subdivided into the non official-public sector and official-public sector. PAMI belongs to the non official-public branch or to the non-state public sector because our interests overlap those of the general population. Plans such as Nacer and Remediar are official-public organizations and they are regulated by general guidelines of the Ministry of Health; as such, these plans need to comply with the individual provincial ministries of health and are inhibited by the fragmented nature of the national healthcare system. Both types of public systems receive funding from the Directorate General of Social Security Resources, from taxes and tariffs which are collected by AFIP, but as a non state-public institution Pami receives 78 percent of its funding from dues and contributions paid by the working population. The main strength of our systems is that it is based in solidarity.
How has this financial role changed over the last 15 years? People are not as wealthy as they used to be in Argentina. Has this economic context changed the role of PAMI and how you have to finance things?
Recently, we have experienced a historic opportunity within our institution. PAMI was born in 1972 and at its infancy went through a very dark period for our country in 1976-1983; however, me managed to survive! Our greatest concern is to be prepared for the future requirements of our members; we want to ensure that we will adapt to any economic and political model and use our resources wisely, working both for this and coming generations. In our model we try to remember that the most efficient way of taking care of someone’s health is to ensure that they are healthy while young. A person who lives a healthy life when they are young is less likely to have health complications when they grow old.
Our contribution system has changed from a per-capita based scheme to a method we call “payment for services with allocated funding” where we only pay for instances of service and not available services; this is why we have so much technological infrastructure, as we have had to keep track of every service that is provided to our affiliates, in any PAMI facility they go to.
Can you talk about your relationship with the pharmaceutical industry?
They used to work within a fixed-price system that has recently evolved into an efficient procurement scheme. This financing method provides us with great benefits such as discounts because we are a very important buyer for them. Due to the nature of our institution, we usually support national laboratories because the gross consumption and demand of national products is much higher than international ones. I must add that Argentinian laboratories have a strong presence worldwide. Still, there are many products that we need to import.
In terms of prescriptions, we must respect the legislation in our country; this means all of our electronic prescriptions must contain the active substance of any drug. The process of choice of a specific product has to do with the benefit that the patient will get of the drug and not the cost. There is no real price competition in the Argentinian pharmaceutical industry. We must try to keep everything in balance, because if labs start trying to undercut each other by offering drastically lower prices of a particular drug, they will soon have to compensate by raising the prices of other drugs.
Our affiliates – who are mostly elderly people- do not like things changing every time they visit the doctor; with that mindset we try to keep things stable and the results tell us that our affiliates have peace of mind that they will receive the same product that they have used for 20 years and know that the quality of the products in their prescriptions is very high. Similarly, we must not underestimate the power of the placebo effect. If one day you get a red pill instead of a blue one (the one that you are used to), results might vary, and not for the best!
I understand that you’ve worked all along the Argentinian territory. Based on your experience, where do you see the Argentinian Healthcare system in 5 to ten years?
If the state keeps up with the good work by supporting social inclusion policies, the healthcare systems will naturally evolved and improve, allowing organizations such as PAMI to further specialize. The primary care system will treat 80 percent of the existing pathologies, basic specialties will treat 15 percent and high complexity institutions will treat the remaining 5 percent. I also see potential advancements in terms of giving better services while lowering the costs and improving profitability. What I would like to see is more fairness in our country; the most deprived and vulnerable people should have the priority access to public resources.
As we speak, everyone has the right to get medical assistance but still there is a large discrepancy between the quality of basic healthcare and the healthcare that people of means have access to. I feel proud of PAMI because we do not only treat pathologies but also work to prevent them, and we try to help elderly people participate more in our society and let them know that they have not been forgotten. We are aware that with a little bit of luck many of us will reach that age, so we are trying build strong foundations to make sure that everyone who reaches that age can be happy and healthy! Here in Argentina, everyone that is six decades old still has a life expectancy of 20 years more! But, let’s remember that living more does not equate with living better; our goal is to help people grow old happily, not to live in pain and misery. I like to see our role as that of a health promoter as opposed to a disease financier.