addressing systemic challenges to social inclusion in health care
TRANSCRIPT
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
1/32
Jason Marczak Nina Agrawal Gustavo Nigenda
Jos Arturo Ruiz Ligia de Charry
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
2/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
2
ForewordLatin America remains the most unequal region in the world, presenting
signicant challenges to overall regional development. A number o groups
among them the urban and rural poor (33.1 percent o the population),
indigenous populations, Aro-Latinos, and womencontinue to lack access to
critical pillars o development, including quality health care services.
With this in mind, Americas Society (AS), with support rom the Ford
Foundation and leveraging the relationship with its sister organization Council
o the Americas (COA), is working to strengthen the voice o these
marginalized groups by presenting new research and promoting resh debate
on how the public and private sectors can address systemic challenges to social
inclusion. In addition to health care, our eorts also ocus on education andmarket access. The AS Social Inclusion Program involves in-country research,
three white papers, dedicated issues oAmericas Quarterly, and private
roundtable meetings and public conerences with high-level public- and
private-sector leaders on topics o inclusion.
This white paper presents the ndings and conclusions o Americas
Societys research on health care. The goal o this paper is to draw
attention to a sample o new practices that increase access to quality
health care or marginalized populations and spur businesses,governments and nonprot organizations to commit more to address this
issue. We are not seeking to evaluate individual programs but rather to
present a variety o health care initiatives that all have the same goal:
providing care or those that otherwise would not have access to it. It is
essential that we consider these cases in their larger regional context
and use the lessons learned to promote greater social inclusion.
To begin the research process, Americas Society ormed a peer
review committee that helped identiy areas or research in thiseld. The next step included collecting inormation rom corporations,
nongovernmental organizations (ngos) and oundations about existing
initiatives. Preliminary ndings were presented at a conerence in
December 2010 where diverse stakeholders provided eedback and
direction or the drating o this white paper. Researchers in Colombia
and Mexico then set out to identiy examples o private programs or
public policy initiatives that have expanded health care access.
We thank the members o the peer review committee or their invaluableguidance and support: Cristian Baeza, director, Health, Nutrition and
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
3/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
3
Population, The World Bank; Thomas Bossert, director, International Health
Systems Program, Harvard School o Public Health; Gabriel Carrasquilla,
director, Center or Health Care Research Studies, Fundacin Santa F de
Bogot; Donika Dimovska, senior program ocer, Results or Development
Institute; Amanda Glassman, director, Global Health Policy, Center or Global
Development; Miguel ngel Gonzlez Block, executive director, Center or
Health Systems Research, Mexicos National Institute o Public Health; Gina
Lagomarsino, managing director, Results or Development Institute; and Bill
Savedo, senior ellow, Center or Global Development.
Jason Marczak, as/coa director o policy, leads the health care component
o our Social Inclusion Program in collaboration with Nina Agrawal, policy
associate. Our in-country counterparts include Gustavo Nigenda, director,
Innovations o Health Systems and Services Research, as well as his colleague,Jos Arturo Ruiz, at Mexicos National Institute o Public Health, and Ligia de
Charry, an independent researcher and epidemiologist in Colombia.
Christopher Sabatini, as/coa senior director o policy, directs the Social
Inclusion Program and Edward J. Remache provides project support.
no part of thi piatio a rpro i a for withot priio i writi fro th Aria
soit. h iw a oio rprt i thi whit papr ar th o rpoiiit of th
athor a rarhr a o ot rt tho of th pr riw oitt or r a oar
r of th Aria soit or coi of th Aria.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
4/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
4
IntroductionUniversal health care has become an increasingly pressingalbeit elusive
goal in countries across the Americas. With transitions to democracy and the
adoption o pro-market reorms sweeping the region in the 1980s and 1990s,
many governments also began making eorts to improve equality and e-
ciency in their health care systems. Oten, reorm was shaped by national laws
that modied the existing nancing systems to increase insurance coverage or
the poor. This was the case in Colombia and Mexicothe two countries o
primary ocus or this white paper. In other countries, or example Chile and
Brazil, reorms centered on making use o the private sector within publicly-
nanced health systems. In Chile, this has meant strengthening the nationalpublic health insurer and establishing a strong regulatory regime that covers
both private and public insurers; in Brazil, recent eorts have ocused on
establishing regulations or private insurers and experimenting with various
state-level public administration models.
Regardless o the orm change took, coverage has indeed expanded and
progress has been made on key health indicators. In Colombia and Mexico, or
example, ongoing national eorts have signicantly increased health care
access or those traditionally let out o the health care system. By the end o2010, Seguro Popularhad reached 42 million o Mexicos 50 million previously
uninsured,1 and by2011, the subsidized regime o ColombiasLey 100 was
providing health insurance to 11 million people who otherwise would have
had no such insurance.2
Meanwhile, countries in Latin America have made notable advances in the
areas o child mortality, maternal health and inectious diseases. By2008, the
regional average or the under-ve mortality rate was 23 per 1,000 live births,
down rom 52 in 1990,3
while maternal mortality had decreased by nearly halover the same time period, rom 140 deaths per 1,000 live births to 85.4 The
incidence o both tuberculosis and hiv/aids has also decreased in most
countries.5
In spite o these advances, there remain gross ineciencies and disparities
in care and health indicators across and within countries. For example, 20
percent o the population in rural areas lacks potable watera number that is
10 times higher than in urban areas. Inant mortality rates are consistently
highest among indigenous and Aro-descendent populations.6 This persistentlack o access to good health services directly and negatively aects labor
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
5/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
5
productivity, household income level and a amilys potential or upward social
mobility, impeding the development o a wide middle class and bearing
consequences or macroeconomic growth.
Given the social, economic and political ramications o inclusion, both
the public and private sectors have reason to invest in combating exclusion. To
some degree, this has been the case. Health reorm legislation and privateinitiatives in recent decades are tackling the challenge o greater social
inclusion. But more remains to be done. In particular, the private sectorin
this paper taken to include or-prot health insurers, or-prot health pro-
viders, or-prot rms that operate outside the health industry, and nongov-
ernmental nonprot organizationscan play a more signicant role in
expanding health care access or those let out o the system. Specically, the
private sector can ll some o these health care gaps by investing in inrastruc-
ture and human resource capacity, especially in inormation and communica-tions technology; educating the public; devising innovative nancing and
pricing models; and even providing aordable services directly. Most impor-
tant, though, is that the design, implementation and evaluation o health
policies and programs involve collaboration across sectors. By doing so, the
private and public sectors can nd new practices not only to provide care but
to do so in a way that is nancially sustainable.
The Americas Society set out to study select cases in which the private
sector is expanding access to primary health care among marginalized groups.We ocused specically on the private sector because o the unique resources
and perspectives it can contribute to expanding health coverage, and because
o the economic ramications o achieving universal health care. The cases
were selected or their geographic, strategic and institutional diversity in order
to provide a variety o examples to draw on or urther discussion. In these
instances we looked specically at the ways in which public policy can acili-
tate and help to expand the private sectors initiatives. Given that Colombia
and Mexico both recently enacted national legislative reorm to signicantlyexpand health care access, we decided to ocus on these two countries.
Rr o or comor,
r cor c ork rmork o
c oc o rdc cr cc.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
6/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
6
Preliminary in-country research and survey data rom coa members
provided initial insight into the areas o health care where the private sector is
involved. This includes nancing health care provision through grants or
donations as a part o corporate social responsibility as well as insuring or
treating patients at low cost as part o a rms business model. The ollowing
matrixby no means comprehensiverefects this inormation (see fgure
1). Organized by country, it groups the initiatives included in the survey by
more specic areas o operation: health care nancing, paying or the
provision o care through subsidies, vouchers or insurance; direct service
provision, providing acilities where actual medical care is oered; low-cost
medical treatment, acilitating access to discounted treatment, including
services, pharmaceutical drugs and medical devices; eHealth/mHealth,
leveraging inormation and communications technologies to expand access tocare; preventative measures/healthy liestyles, educating communities or
better long-term health; and health care policy advocacy, collaborating with
policymaking organizations and raising awareness about health care issues.
The rms surveyed are generally most active in providing direct services,
expanding aordable access to treatment and promoting healthy liestyles.
This last area, which includes disease prevention, will assume increasing
prominence in coming years as the burden o disease in Latin America shits
to chronic, non-communicable diseases.Notably, only a ew o these programs made use o inormation and com-
munications technology or diversied nancing streams. This was surprising.
Many o the newest innovations in low-cost health care delivery that are
gaining public attention utilize inormation and communications technology
(ict) or pro-poor health market models.7 With its enormous potential or
expanding access to care and inormation in remote areas, connecting health
proessionals, tracking disease patterns, and monitoring patient ollow-up,
eHealth/mHealth is an area ripe or urther investment. Greater attentionshould be paid to the sccessul eHealth/mHealth programs that exist.
One point worth bearing in mind is that health care is a eld with
numerous and diverse stakeholders. Rather than seeing one another as com-
petitors, the private sector can work within the ramework o public policy to
reduce gaps in accessor example, by lowering the costs o health care,
administering services more eciently, subsidizing the treatment o poor
patients with higher ees paid by wealthier patients, and reducing or over-
coming physical barriers to health care.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
7/32
Figure 1
eAl nevenns, by yPe And cuny
Coom
Mco
Or Cor
Health CareFinancing
DirectService
Provision
Low-CostMedical
TreatmenteHealth/mHealth
PreventativeMeasures/
HealthyLifestyles
HealthCare PolicyAdvocacy
Fundacin SOMA Fundacin Grupo Nacional
de Chocolates
Fundacin Mayaguez
Pfzer Inc. Cerrejn
Fundacin xito
Colgate-Palmolive Colombia
Fundacin Siemens
Cerromatoso
Mineros S.A.
Fundacin Alpina
Fundacin Corona
Fundacin Pavco
Fundacin Sanitas
Fundacin Propal
Sesame Workshop*
Fundacin Mexicana para laPlaneacin Famil iar, A.C. (Mexam)
Farmacias Similares SA /Fundacin Best, A.C.
Fundacin Adelaida Lan
Fundacin Comparte Vida Sistemas Mdicos Nacionales,
S.A. de C.V. (SIMNSA)
Fundacin Mexicana de Fomentopara la Prevencin Oportuna
del Cncer de Mama, A.C.
Fundacin Gen, A.C.
Centro de Investigacin MaternoInantil Gen (CIMIGen)
Sesame Workshop*
Johnson & Johnson*
Pfzer Inc.*
Manpower Inc.*
Telenica*
Pfzer Inc.*
Johnson & Johnson*
Microsot Corporation*
Cisco Systems, Inc.*
PepsiCo*
Digicel*
Manpower Inc.* SwissRe Financial
Services Corporation*
*Inormation acquired through a survey returned by the company.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
8/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
8
Colombias HealthCare SystemOpening the DOOR fOR the paRtiCipatiOn
Of fOR-pROfit COMpanies
Colombian society is characterized by proound social exclusion, in marked
contrast to the guiding principles established in its Constitution o1991. The
availability and access to public services and standard o living vary substan-
tially, both between urban and rural populations and between distinct regions.
For example, while potable water is accessible to 90 percent o the population
in municipal areas, it only reaches 60 percent in rural areas. On the Atlantic
coast health services coverage barely reaches 43 percent, compared with anational average o51 percent. In the department o Cauca, the percentage o
the rural population that lives below the poverty line exceeds the national
average by33 percent.8
During the 1990s, the government undertook a process o social policy
reorm, including passage oLey 100 in 1993, which sought to enroll the
population in one o two insurance regimes: a contributory regime or those
able to pay and a subsidized regime or those that could not. Under these
reorms, a guiding policy or the organization o the health system waspromoting the inclusion o the most economically vulnerable sectors o the
population by ensuring their access to health care through the government-
subsidized insurance plan. Care not covered by the insurancesecondary-
level care including some surgeries and diagnostic exams, or exampleis
oered at public hospitals. In spite oLey 100s ocus on specically insuring
economically vulnerable sectors, experiences ollowing the laws
implementation have shown that being insured and actually accessing health
services are not one and the same.Due to the complexity o achieving universal coverage and the institutional,
operational and nancial ragility o Colombias social protection systems,
certain groups o the population remain excluded. The steps taken in the
1990s have proven insucient in guaranteeing real access to health care, as
geography continues to pose an obstacle and unequal service allocation
persists. People in the lowest income quintiles living in semi-urban or rural
areasar rom state capitals and metropolitan centers where the physical
inrastructure and human and technological resources or health care areconcentratedare the most aected.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
9/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
9
Ethnicity and race are actors that not only create disparities in dierent
groups standard o living but also impact their health and access to services.
Evidence shows that, at equal levels o income, ethnic and racial minorities
have less access to services and exhibit poorer health indicatorsor example,
high inant and mortality rates and low lie expectancythan their counter-
parts. Further complicating the issue is that these minorities are overly
represented among the poorpresenting a double challenge or access.9 Both
are true in Colombia. Additionally, the elderly poor in Colombia, who lack
knowledge o available services and oten work in the inormal economy
earning very low salaries, remain under covered in social security and
excluded rom social services as well.10
While Colombias General System o Socia l Security in Health, imple-
mented viaLey 100, has been successul in removing the economic barriers tohealth care access or populations in the lowest income quintiles, the system
has yet to ully reachand thereby reduce social exclusion ormarginalized
groups such as ethnic and racial minorities and the elderly poor. Although
these groups have government-subsidized social security, they still cannot
access necessary health care services due to geographic isolation or simply a
lack o coverage or certain procedures. Today, approximately39 percent o
Colombians are insured under a subsidized regime that covers a range o
services greatly inerior to those provided by the contributory one. Given thisreality, the case studies below describe how the private, or-prot sector can
contribute to the governments eorts to improve social inclusion.
OveRview Of exaMples
Within this context, and with special attention paid to the existing and
potential role o the private sector, we identied 15 health care initiatives
undertaken by or-prot companies or the rst phase o our research.O the 15 initiatives, our ocus on nutrition and ood security, ve on
public health education campaigns, ve on service provision, and one on
technology utilization.
We chose three or urther analysis based on their potential ability
to improve care or underserved populations and to be sustainable over
time. Each case study refects the eorts o a or-prot company that is
making important contributions to the communities where it operates
and its workers reside. In doing so, they are improving the health andthus productivity o their current or uture labor orce while also contributing
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
10/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
10
to the overall well-being o those who may not otherwise be able to access
health services.
The rst, De Todo Corazn, is a program launched by Pzer Colombia in
strategic partnership with Mutual ser, a company managing ederal health
coverage or the elderly poor residing in municipalities o six states on the
countrys Caribbean coast. The second, Unidad Mvil de Salud, is run by the
mining company Cerrejn in conjunction with public hospitals in three
municipalities located in the department o La Guajira. It serves a majority
indigenous population. The third, Salud y Saneamiento Bsico, operated by
the oundation o the Colombian paper manuacturer Propal and our munic-
ipal governments in the department o Cauca, serves a majority Aro-Colom-
bian and indigenous population. Each is explained in more detail below.
All three initiatives either manage government health insurance or repre-sent a partnership with state-sponsored public entities such as mayoral oces
or public hospitals. They are models o how to integrate private-sector and
government eorts.
the thRee CasesexpanDing aCCess
Access to health care services can be dened and measured in distinct ways.
Some denitions ocus on use as a proxy or access. Others ocus on insurancecoverage or eligibility to receive health care services irrespective o whether
they actually use it. Here, we use service utilization and the number o people
receiving particular services to illustrate access.
PfizerMutual Ser: De toDo Corazn
A primary health challenge in a mountainous, geographically-challenging
country like Colombia is the physical inability o certain segments o the
population to travel in order to access certain types o care. De Todo Coraznseeks to reduce these geographical barriers or poor people over the age o45
who reside ar rom cities. Those enrolled in the program can access special-
ized medical services such as cardiology in their local communities, along with
critical ollow-up care.
The program began in 2004 when Pzer partnered with Mutual sera
company that manages the ederal insurance plan or people in the two lowest
income quintilesto develop a program to prevent and treat cardiovascular
and cerebrovascular diseases. For Pzer, this program is part o the companyseort to be a good corporate citizen. For Mutual ser, it is a means o pro-
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
11/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
11
viding coverage or additional services.
De Todo Corazn reduces the impact o catastrophic illnesses and provides
health care or a segment o the population that would otherwise not have
access to a specic set o services, due to suering rom diseases that are not
covered by the subsidized regime o ColombiasLey 100. The program was
launched ater ndings rom a study o nearly70,000 Mutual ser patients
showed that high blood pressure was the seventh leading cause o medical
intervention and that cardiovascular and cerebrovascular illnesses were the
leading causes o death.
The program includes our components: ongoing training or medical
personnel; patient medical care; health education or patients and their
amilies; and recreational activities. The training program is directed toward
primary care doctors, specialists, community health promoters (promotores desalud), nurses, and bacteriologists, and provides instruction on cardiology and
the treatment o high blood pressure, diabetes, dyslipidemias, and the use o
health sotware. To date, De Todo Corazn is responsible or the training o
200 general practitioners, 20 specialists, 150 community health promoters, 180
nurses, and 50 bacteriologists.
The medical care component includes yearly checkups by a general practi-
tioner, laboratory tests, prescriptions, and the necessary reerrals to cardiolo-
gists or internists. Specialized doctors reassess any preliminary diagnoses,determine cardiovascular riskin part with the help o medical sotware
and develop a monitoring and treatment plan.
Health education is a critical aspect o the programs prevention ocus.
Mutual ser community health promoters and sponsors (community leaders)
accompany doctors during home visits to patients at high risk or heart disease
or those who have suered cardiovascular episodes. During these visits, the
sponsors inorm, train and educate patients and their amilies about healthy
liestyles, disease risk actors and the importance o ollowing a diseasemanagement plan. The programs prevention strategy also includes organizing
40-person clubs that meet monthly or workshops, games and recreational
activities that ocus on the importance o diet and healthy habits.
The number o people served by the program increased rom 4,000 people
in 2004 to 21,982 in 2007. Additionally, 69 percent o patients adhere to the
programs ollow-up and educational regimens. De Todo Corazn clubs have
also taken o in popularity. By the end o 2007, 322 o the 481 existing clubs
(67 percent) were meeting regularly.Similar improvements are documented in regard to the health o poor
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
12/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
12
patients at high risk or heart diseasea number that has allen by
9 percentage points (rom 55 to 46 percent) within target communities. At the
end o2008, 74 percent o patients had reached an acceptable diastolic blood
pressure, compared to 32 percent in 2004. Likewise, the number o patients
who met their target ldl cholesterol levels rose by29 percentage points (rom
25 to 54 percent).
CerrejnPubliC HoSPitalS: uniDaDMvil De SaluD (uMS)
The department o La Guajira contains the countrys largest indigenous popula-
tion. Many rural residents historically ace barriers to medical accessa result
o geographic isolation, language barriers and high costs, among other actors.
Aware o these obstacles, the mining company Cerrejn acquired a mobilehealth and dental services unit to acilitate and improve health services or
people residing in the municipalities o Barrancas, Hatonuevo and Albania.
The Unidad Mvil de Salud (ums)launched in July2008operates a
mobile medical assistance program that provides individual, comprehensive
diagnoses and develops activities or promoting health and the prevention o
disease. Cerrejn coordinates the programs, maintains the ums vehicle and
provides medical supplies while regional hospitals are responsible or nding
the necessary doctors, nurses, lab technicians, and community health pro-moters. By the end o2008, ums had launched services in 30 communities
within the three target municipalities.
The ums developed as a collaborative agreement among Cerrejn, munic-
ipal secretaries o health and public hospitals, including Nuestra Seora del
Pilar in Barrancas, Nuestra Seora del Carmen in Hatonuevo and San Raael in
Albania. The support o the department-level Oce o the Secretary o Health
urther supports the ums mission.
The ums vehicle unctions as a mobile primary care center and oersgeneral medicine, gynecological and dental services. Medical sta rom public
hospitals (doctors, nurses, and paramedics) provide basic health services in the
areas o childhood care, adolescent medicine (10 to 29 years old), womens
health (pregnancy and amily planning), and adult medicine.
To guarantee that the neediest populations are being served, the ums
assesses its target communities on a monthly basis. A regional hospital then
sends a health promoter to each community to identiy patients, make
appointments and set-up educational and other activities in anticipation o thearrival o the ums.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
13/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
13
The umsrelying on $70,000 annually or upkeepis growing quickly. It
went rom serving 239 patients at its launch to serving 11,459 children, adults
and seniors by December 2009. In 2010, ums services ocused on primary
care (32.0
percent o interventions), oral hygiene (22
.5
percent), dentalservices (14.5 percent), nutrition, optometry (4.2 percent), child development
(4.7 percent), and amily planning (2.0 percent). In addition, 4.5 percent
o the women received pap smears to screen or cervical cancer; 10.0 percent
o these then received an additional ultrasound scan. Beyond that, the
ums provided 568 laboratory tests along with prenatal care or 40 women,
high blood pressure and diabetes treatment or 82 people and vaccinations
or 236 patients.
Besides strengthening ties to the community and its leaders, improvingpatient-doctor trust and building a collaborative relationship with the regions
institutional hospitals, the ums has yielded other impressive achievements.
The training o hospital doctors and nurses resulted in eective and timely
diagnoses, and educational campaigns taught people how to apply or govern-
ment health coverage to obtain medication. Epidemiologic data show that
illnesses relating to a lack o primary health caresuch as poor maternal and
child healthdecreased.
Although on a lesser scale, specialized medical services such as gynecology,ophthalmology, pediatr ics, orthopedics, and surgery (or 0.6 percent o
patients) were also oered. The campaign or early detection o cervical
cancer through pap smears stands out: it diagnosed 95 positive cases,
representing 9.45 percent o the women tested, who were then oered
additional treatment.
work- dco Mr
o soc proco d ro od oc
ro cod romo rr kod
mo cororo o d o
mrzd comm d o o ddr m,
rr r om.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
14/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
14
ProPalMuniCiPal governMentS:SaluD y SaneaMiento bSiCo
Recognizing the poor living conditions o the communities where its plants are
located, Propal, a leading paper manuacturing company, launched a multi-
pronged eort to promote social development and improve the standard o
living. This included the creation o the Fundacin Propal to administer social
development projects. Fundamental to the Propal initiative is its belie that
greater results can be achieved in collaboration. To that end it works through
community participation and inter-institutional partnerships with the govern-
ment o Cauca department, city governments, international agencies, and
other local companies. Funding comes rom this broad range o sources.
Launched in 1993, Fundacin Propals Salud y Saneamiento Bsico
program includes a medical center, community health projects and basicsanitation. This program expands social inclusion by oering otherwise scarce
or non-existent quality care, including specialized medicine, to communities
that are vulnerable due to socioeconomic conditions (in the bottom two-ths
o the income hierarchy), race and ethnicity (Aro-Colombians and indigenous
populations), and/or social circumstances (mainly single, emale-run house-
holds). In Cauca department, Salud y Saneamiento Bsico ocuses on the
municipalities o Puerto Tejada, Gauchen, Villa Rica, and Caloto.
The medical center brings comprehensive general and specializedmedicineincluding diagnostic imaging, mammograms, etal monitoring, and
specialized lab workto the communities. At the same time, the community
health project ocuses on education campaigns regarding basic public health
and preventable illnesses. The basic sanitation componentdesigned and
administered with support rom Cementos Argos and Pavcois dedicated to
making drinking water widely available.
Although the program is airly new, results are already available. From
January to September 2010, the medical center recorded 113,800 healthconsultations. Services or most patients were paid or by the subsidized
insurance regime, but 835 people who have yet to be aliated to it received
care completely ree o cost. (By 2015, the subsidized regime is expected to
include all those who cannot aord to enroll in the contributory regime.) In
turn, the community health project completed an average o our days o
service per month, oering medical attention in the orm o pap smears, water
fuoridation, deworming, and medication dispensation. Additionally,
prevention and health promotion campaigns reached 4,962 people, includingpregnant women, the disabled, older adults, and children under age two. An
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
15/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
15
additional 2,783 school-age children and adolescents also took part in the
education program. The basic sanitation project has yielded improvements in
11 water systems (beneting 180 amilies) and provided nine educational
centers with sanitary kits.
the thRee CasesiMpaCt anD sCalability
The experience o these joint ventures demonstrates the importance and
power o collaborative action between the private, or-prot sector and govern-
ment entities to improve health care or vulnerable communities. Over time,
the three programs have expanded their coverage to new populations and
geographic areas, thanks in large part to their strong working relationships
with local governments. While ocused on primary care, these programsventure as well into specialized medicine, mainly or illnesses o high inci-
dence and high mortality rates in Colombia, such as heart disease and cervical
cancer. They also serve remote locations with ongoing attention to health care
needs, or example providing screening tests such as mammograms and
laboratory testsnormally oered only in the largest citiesto populations
marginalized by geographic isolation. In this sense, they respond to the
non-communicable chronic illnesses increasingly aecting the Americas and
overwhelming traditional basic care programs.In spite o the successes achieved in making care available to vulnerable
communities, obstacles to access remain. Even with these programs, geo-
graphic isolation remains one o the greatest impediments or indigenous
groups, Aro-Colombians, the rural poor, and the elderly. Other challenges
include communication diculties due to linguistic and cultural dierences
(in the ums case, 44 percent o the population served is indigenous) and
limitations in the government-subsidized Mandatory Health Plan. Govern-
ment-subsidized health insurance is restr icted to primary-level interventions,excluding such secondary-level care as treatment or complications o chronic
conditions like diabetes and hypertension or visual and mental health care,
which disproportionately aect the elderly. While recently enacted laws
(Sentencia 760 rom the Constitutional Court andLey 1438 o2011) have
mandated the unication o the benets package or both regimes, it remains
to be seen when the social security system will, in practice, begin to provide
coverage or these diseases.
Further, i these programs are to bring about ar-reaching changes inColombias health system, they must achieve scalabilityunderstood here as
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
16/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
16
the capacity to expand a process without diminishing the quality o the service.
Some have already begun to do so. Beore De Todo Corazn was implemented,
patients received only minimal health services in their local communities. Spe-
cialized medicine such as cardiology services was available only in cities, which
meant that patients would have to travel to receive medical care. But ollow-
up care was oten inaccessible as patients oten lacked the nancial means to
travel or additional doctor visits. This program directly addressed that barrier.
Patients could access cardiologists and nutritionists, specialized medical labo-
ratories, electrocardiograms, and drug dispensation in their own communities.
Since starting with 4,000 patients in 2004, De Todo Corazn has gradually
grown with annual increases o50 percent. Without private unding or oun-
dation support, the programs structure is one that can be replicated in both
urban and rural areas, either in Colombia or elsewhere, where geographic andother barriers result in inadequate care or vulnerable populations. One lesson
learned is the importance o enlisting the participation o community leaders
who live in the same areas as the patients. Another key practice is to pool
patients according to their place o residence, which acilitates the work o
health proessionals in providing ollow-up medical attention.
Similarly, other companies or the governmenteither in Colombia or in
countries with geographic and economic conditions similar to those o rural
La Guajiracan replicate the Unidad Mvil de Salud program. In contrast tothe De Todo Corazn program, the ums provides health care services in
dispersed communities where small population sizes oten do not justiy the
construction o permanent health centers. The mobile clinic provides a means
o taking health care straight to these residents homes. What is needed,
though, is an economic evaluation o the model to determine i it can be
easibly and justiably implemented elsewhere in the country.
For Fundacin Propal, Salud y Saneamiento Bsico has expanded the
reach o its community health projects in conjunction with municipal govern-ments. But it is also exploring options to augment service delivery through a
mobile clinic similar to the ums model launched by Cerrejn.
In each o these cases, however, the programs depend on a corporation to
cover essential operating expensesa worthy expense given the positive
community reaction to these initiatives. In the case oDe Todo Corazn the
necessary nancial resources to run the program are wholly underwritten by
Mutual ser and Pzer, since the subsidized government insurance plan does
not cover the targeted diseases. Cerrejns Unidad Mvil de Salud began witha $169,000 investment o corporate unds to buy the vehicle, supplies and
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
17/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
17
medical equipment, and each year Cerrejn invests an additional $70,000 to
pay or vehicle maintenance, supplies, health proessional ees, a driver,
security guards, and uel. The nancing mechanism or the Salud y
Saneamiento Bsico program is slightly more diversied, with unds being
generated through a combination o company resources and reduced-rate
services to patients, but Fundacin Propal must still cover the expenses o a
large sta o general practitioners, specialists and assistants.
I, in shiting priorities or or any other reason, these companies were to
decide to ocus on another area or reduce their budget, the operation o the
programs would be jeopardized. Thus, broad-based nancing is a major
obstacle to scaling up interventions. Initiatives designed to expand access to
marginalized populations must seek diverse and sustainable sources o unding.
While or-prot companies like Cerrejn, Propal and Pzer are making animpact, this is not common or Colombia. In general, the countrys private
sector shows a growing interest in social inclusion, but with a greater ocus on
education and the environment. O the 15 health-related initiatives identied
in Colombia as part o this study, only three companies (15 percent) are part o
the health industry, despite health companies rising importance or the
national economy. An additional issue is how to design public-private partner-
ships so that activities extend beyond social responsibility. Working-level
discussions between the Ministry o Social Protection and groups involved insocial responsibilityincluding Colombia Incluyente and the Colombian
Business Council or Sustainable Developmentcould help promote greater
knowledge among corporations about the health needs o marginalized com-
munities and how to address them, spurring their involvement.
None o these case studies utilizes telemedicine or other eHealth initiatives
to improve access. But as seen in India and other emerging economies, the
eective harnessing o existing technologies can overcome some o the geo-
graphical and nancial obstacles to health care provision in remote communi-ties. Wireless networks can reach much deeper into a country than any other
technology to collect health data, support diagnoses and treatment, and
advance education and research.11 They make medical consultation, para-clin-
ical analysis and interpretation o imaging data possible without requiring the
physical presence o specialists. In so doing, they improve the local capacity or
medical response and ampliy the portolio o services available to these
populations. In turn, this reduces the need or reerrals, cutting costs, elimi-
nating the need or travel, and ultimately improving patients quality o lie.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
18/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
18
Mexico:a push tOwaRD univeRsal COveRage, but
wiDespReaD aCCess yet tO be ReaCheD
Mexicos health care dynamics have changed dramatically in the last decade.
Only10 years ago, nearly10 million Mexicans lacked any type o medical care,
and more than 50 million people were not covered by social security. For
those that did have insurance, coverage was regressive in that the poor aced
the greatest health care costs in proportion to their income. Compared to its
Latin American neighbors, Mexico spent below the regional average on health
care in 2003about 6.1 percent ogdp. Among other things these low levels
o unding prevented Mexico rom addressing the shiting burden o disease tochronic, long-term illnesses.12
But a ar-reaching reorm o the health care systempassed into law in
April 2003 and implemented in January2004established a new System or
Social Protection in Health (ssph). The ssph, which includes the Seguro
Popularpublic health insurance program, sought to ensure that all had the
right to health care as recognized in the Mexican Constitution. In the rst hal
o2011, nearly50 percent o the Mexican population is expected to be
aliated to Seguro Popular. The ssph has also improved public health centersand guaranteed quality servicesthrough new accreditation methods and
deployment o health quality indicatorsto those that historically lacked
access to health care.
Nonetheless, a lack o access to care and medication persists in highly
marginalized urban and rural areas today. This gap in Mexican health care
reinorces the exclusion o marginalized groups and thus the overall develop-
ment o Mexican society. Here, the private sectora signicant, untapped
resource in the delivery o carecan play an important role in the provision ooutpatient and hospital care or those aliated to Seguro Popularbut who
cannot access public health services.
OveRview Of exaMples
Given the impressive successes oSeguro Popularbut also the challenges that
exist in reaching certain marginalized segments o the population, our
research looked at nine examples o private organizations seeking to ll thegaps that continue to exist today. Again, these are simply a representation o
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
19/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
19
eorts across geographic, thematic and industrial lines o private-sector
initiatives to increase access or marginalized groups in Mexico. O these nine
cases, three were selected or urther research based on geographic diversity,
the method used to support access to health care and intended beneciaries.
Each program is described in greater detail below.
In all three examplesas is the case or private organizations overallthe
strategies to expand health care access can be thought o as one part o a
nationwide strategy. Each also responds to an unortunate reality in Mexico:
the unequal distribution o disease, determined by a populations isolation and
level o poverty. For example, in areas with a high concentration o marginal-
ized groups, inectious diseases are the leading cause o inant mortality and a
lack o medical services and trained personnel result in high rates o maternal
mortality. This is not the case among middle- and high-income groups.Each case study shares a common goal: acilitating access to care or
groups who traditionally ace barriers. Target communities are selected i they
either all outside o the social welare system or the services oered by the
Secretary o Health, or i they lack the means to pay or conventional health
insurance. These examples were chosen because they acilitate access to
health care services or clearly identied populations that would otherwise
have great diculty in obtaining such access.
The rst case is Sistemas Mdicos Nacionales, S.A. de C.V. (simnsa), aprot-driven company established in 1992 that sells health insurance to
persons living in Mexico but working in the United States. It is the rst
Mexican health insurance rm authorized to do business in Caliornia. The
target clientele is Mexican workers in Caliornia who purchase hmo or ppo
plans either directly (supplemented by their employers) or through unions in
San Diego. These workers all in the middle-income range (with earnings
above the lowest-income levels in Mexico), but still cannot aord U.S. health
insurance plans. With simnsa coverage, they gain access to medical servicesin Mexican cities.
The second case is the initiative oFundacin Adelaida Lafn, an ngo that
runs a community clinic closely linked to Muguerza de Monterrey Hospital
now a part o the Christus Muguerza Group health care systemin the state
o Nuevo Len. Since its ounding in the 1930s, the hospital has recognized
the need to provide care or those o limited means and maintained a reserved
area or such patients. At the end o the 1990s, administrators expanded on
this service and began to oer care in a community clinic located in an inner-city neighborhood o Monterrey. The clinic is run byFundacin Adelaida
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
20/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
20
Lafn, which also serves an indigenous community in San Luis Potos.
For both simnsa and Fundacin Adelaida Lafn, only limited coordina-
tion is carried out with public services. At a national level, no ocial body
exists at the Ministry o Health to regulate, coordinate or promote public-pri-
vate collaboration. This means that it then alls on state-level Secretariats o
Health to create any alliances with the private sector. But as discussed later in
this section, many opportunities exist or greater collaboration.
The third case is Fundacin Mexicana para la Planeacin Familiar
(Mexam), a non-prot civil society organization ounded in 1965 and
dedicated to promoting comprehensive amily planning. It provides
inormation along with educational and clinical services in sexual and
reproductive health to disadvantaged groupsmainly women and school-age
adolescents and youth. Mexam activities are carried out throughout thecountry but always in areas where approximately25 percent o the population
is considered marginalized.
the thRee CasesexpanDing aCCess
As in the case o Colombia, we dene access to health care services based
on utilization and the number o people receiving particular services.
However, this data does not allow or an accurate assessment o the levelo quality o each service.
SiSteMaS MDiCoS naCionaleS, S.a. De C.v. (SiMnSa)
Many low-wage documented Mexican workers who either reside in the U.S. or
requently travel between the two countries cannot aord to pay the high
costs o U.S. health insurance. The result is oten lack o access to preventative
care or debt-burdening payments at times o immediate need to critical health
care services. The Sistemas Mdicos Nacionales, S.A. de C.V. (simnsa) soughtto change this reality by oering discounted insurance policies to rms o
50 or more workers in the San Diego area.
The company or union can choose to buy an individual or amily plan.
According to simnsa, the company makes the decision and asks the worker to
pay a portion o the cost. Commonly, the employer agrees to pay or the
individual portion o coverage, while the worker assumes responsibility or the
amily portion. An individual plan costs $1,400 per year, while a amily plan
costs $3,900 annually. This ratealthough still costlyis more aordable orthe average plan participant whose income ranges rom $5 to $7 per hour.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
21/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
21
For these workers, the top health concerns are in the areas o reproductive
health and work-related injuries, but chronic illnesses are a growing health
need. In turn, the simnsa insurance plan covers services such as outpatient
treatment, prescriptions, hospitalizations, surgeries, laboratory tests, mental
health services, immunizations, cancer screenings, dental and optometry
services, and prenatal, labor and neonatal care.
All services, with the exception o emergency medical attention, are
provided in our cities on the Mexican side o the U.S.-Mexico border,
relying on two main hospital units and a network o about 200 doctors.
To stay competitive, simnsa partnered with Health Net, one o the largest
publicly-traded health insurers in the United States, in an agreement where
Health Net-aliated providers oer emergency services in the United States.13
Plan participants can still enroll in Seguro Popularwhen living in Mexicobut many remain with simnsa due to lack o knowledge about their
eligibility or low condence in the reliability or quality o services oered
under Seguro Popular.
In 2000, simnsa received approval to operate as a licensed hmo in the
state o Caliornia, although it had already been operating there or years (the
relevant legislation, the Knox-Keene Health Care Service Plan Act o1975,
did not have provisions or licensing oreign health plans). At the time, it
provided care to approximately10,000 members rom over 100 employergroups. In June 2004, simnsa had grown to 14,098 aliates. By October 2007,
the simnsa network had grown to about 20,000 members. O these, 17,000
obtained coverage directly rom simnsa or in Caliornia through its arrange-
ment with Health Net. The remainder was covered through U.S. insurance
companies that buy the service rom simnsa.
funDaCin aDelaiDa lafnMuguerza
De Monterrey HoSPitalIn Monterrey, as is the case in many areas o Mexico, the poor population is
oten dependent on the inormal economy. Many lack access to services
oered by ormal sector social welare institutions, and while they may be
eligible or Seguro Popular, the public insurance plan does not cover all o
their needs.
This creates huge disparities in health care access and is the principal
reason that the Muguerza de Monterrey Hospital in Nuevo Len launched and
backs Fundacin Adelaida Lafn. The community clinic serves the residentso a poor Monterrey neighborhood, who oten work in the inormal economy
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
22/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
22
and can only access the minimal public services available. Seguro Popular,
which has still yet to reach its nationwide coverage goal, remains unavailable
or many in this zone.14
The Fundacin also runs a second clinic in San Luis Potos that serves an
estimated 25,000 people rom poor, indigenous rural communities where most
o the heads o households work in subsistence arming and earn small, irreg-
ular incomes. Both clinics are dedicated to both improving health care as well
as developing initiatives that support the communities overall social and
economic development.
The Fundacins health care centers are primary-level acilities that oer
services 24 hours a day in amily medicine, pediatrics and gynecology. Patients
have access to the ollowing: diagnostic testing through x-rays, ultrasound and
laboratory tests; emergency services; general surgery; psychology; nutrition;and speech and physical therapy. The San Luis Potos clinic serves clients
whether or not they are aliated to Seguro Popular. However, no relationship
exists with the state Secretariat o Health since the public sector perceives the
eort as competition rather than as a potential collaborator.
A primary care consultation costs about 50 pesos (about $4), compared to
150 to 200 pesos at private institutions ($12 to $16). The cost o an x-ray or pap
smear is about the same. The low ees at the clinicwhich do not vary
according to the patients socioeconomic levelare structured to be aord-able, while still covering about 75 percent o operating costs. Muguerza
Hospital covers the remainder. Patients that cannot aord to pay are reerred
to the social service oce and may be exempted rom payment. In return, the
patient must commiteither personally or through a amily memberto
volunteer at the health care center or in the community as a orm o compen-
sation. The Christus Muguerza group in turn benets through increased brand
recognition and positive brand association.
funDaCin MexiCana Para la PlaneaCinfaMiliar, a.C. (MexfaM)
The ounding oFundacin Mexicana para la Planeacin Familiar, A.C.
(Mexam) in 1965 resulted rom a need to create greater awareness o and
access to amily planning options in the most marginalized areas o the
country. More than 40 years later it continues to oer new services designed
to respond to Mexicos changing health needs.
Mexam serves three primary constituencies: disadvantaged groups(low-income individuals, women, adolescents, and youth); marginalized people
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
23/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
23
without access to social welare services; and proessionals in the health and
education elds (youth and community advocates, educators, doctors, nurses,
social workers, and psychologists). It operates in 19 o Mexicos 32 states
(including the Federal District), in which 25 percent o the countrys most
marginalized people reside.Activities are concentrated on our programs. The Programa Comunitario
Rural trains community advocates (promotores comunitarios) on issues o
amily planning, contraceptive use and other health issues. In turn, the
promotores lead community discussions, participate in health airs, conduct
home visits, and distr ibute posters and brochures at strategic community
locations. The Programa Comunitario Urbano is similar to the Programa
Comunitario Rural and is implemented in outlying urban areas, poor inner-
city neighborhoods and squatter settlements. The main dierence betweenthe two programs is that the urbanpromotores link up with existing initiatives,
conduct the training sessions in schools and distribute contraception at
medical clinics, whereas the ruralpromotores lead the initiatives and work in
more community-based settings.
The other two initiatives incorporate service delivery at clinics. The
Programa Gente Joven targets youth and carries out its activities through
workshops and cultural and academic activities designed to improve their
physical, emotional and social well-being. It includes Centros de ServiciosMdicos Gente Joven, which are youth-ocused acilities that serve the
program objectives. The Programa de Centros de Servicios Mdicos includes
Mexam clinics that provide general and specialized medical care in seven
areas related to reproductive health: gynecology, pediatrics, urology, gastroen-
terology, dermatology, internal medicine, and surgery.
The number o services provided by Mexam continues to rapidly expand.
From 2006 to 2008, Mexam saw a 34 percent increase in the number o its
beneciariesrom 3,278,900 to 4,394 ,135. These numbers include peoplewho received medical services, participated in a contraceptive consultation or
t rod cor rodd sm or
soc proco h (Seguro Popular)
r oor or r orzo
o rod cc o rc or mrzd
oo comm ck c.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
24/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
24
distribution program or participated in a training or inormation session. In
2008, Mexam provided contraceptive counseling to 467,000 individuals,
screened 131,000 people or breast and cervical cancer, trained 157,000 youth
through its Programa Gente Joven, oered 18,571 people services related to
hiv/aids testing and prevention, perormed 10,000 pediatric consultations,
and delivered 2,392 babies.
Like its services, Mexams operating budget generally continues to grow,
albeit at a slower pace than its increase in services. However, rom 2006 to
2007, net revenue decreased by12 percentrom $11,587,516 to $10,342,645.
The majority o these unds came rom oundation grants and philanthropic
donations, subsidies, and interest earned on income. Mexam also earns
some revenue through the sale o contraceptives and other medications at its
clinics and centers.
the thRee CasesiMpaCt anD sCalability
Despite the implementation in recent years o a national health plan striving
or universal coverage, major inadequacies and challenges persist. Isolated
communities, highly marginalized sectors and/or indigenous communities
continue to be excluded rom social services. Even under Seguro Popular,
coverage remains low in certain areas (or example, 39 percent in the state oNuevo Len in 2008). Furthermore, even under a policy o social inclusion, it
will be a challenge to achieve and maintain universal coverage (public or
private) that provides care or a broad number o illnesses while doing so with
high-quality service delivery.
All three cases described in this paper have improved the health and
overall quality o lie o their program beneciaries, although through distinct
methods and with diering target populations. The successul experience o
the Fundacin Adelaida Lafn clinics is attributed to the support (nancial,human, and technological) received rom the Muguerza de Monterrey
Hospital and its collaborative work with local communities. Similarly,
Mexams success lies partly in its community advocates and education cam-
paigns in local neighborhoods, as well as its ability to consistently update its
methodologies in response to changing health needs. simnsas success, in
contrast, arose rom its ability to identiy and market to a specic market
niche: documented Mexican workers employed in U.S. border communities
who are unable to pay the high costs o U.S. health coverage.While these programs have signicantly expanded the health care options
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
25/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
25
or some o Mexicos neediest people, the true test or them and or Mexicos
overall health care will be whether they can meet continued obstacles to
access and expand their operations. As in Colombia, nancing is precarious or
these three programs. Lacking broad corporate support, Mexam relies on
grants and donations, but has recently broadened its ocus to research and
other activities in order to attract greater nancing. In the case osimnsa and
Fundacin Adelaida Lafn, which combine high patient volumes with low
costs, nancing o operations largely comes rom the beneciaries themselves,
showing how the private sector can serve marginalized groups in a sel-sus-
taining business model. And unlike the programs in Colombiatwo o which
are administered by companies outside the health sectorthe initiatives in
Mexico are largely run by oundations or businesses that specically operate in
the health industry, meaning they may have a greater long-term stake increating models to expand access to health services.
Beyond nancing, both simnsa and Fundacin Adelaida Lafn ace
distinct constraints to access. simnsas activities and strategies are restricted
to a specic geographical region and to only those who can aord to pay the
reduced health insurance rates. Its principal challenge is in increasing
coverage and nding ways to oer services to non-aliated populations.
In the case o the Fundacin Adelaida Lafn clinics, obstacles to access
arise when individuals lack sucient resources to pay even the nominalservice ees and do not qualiy or exemption through social service.
Additionally, duplicating or expanding the Fundacins network o low-cost
clinics to other areas with high concentrations o marginalized groups
would require the support o large hospital rms, many o which are generally
not receptive to such projects and partnerships. Nonetheless, the Christus
Health Group may have an answer, as going orward it plans to establish
a Fundacin clinic in each municipality where the consortium opens a
highly special ized hospital. In this way, as the or-prot hospitalnetwork grows, so will the number o low-cost Fundacin clinics.
At the moment, plans to open highly specialized hospitals are concentrated
in the northern states o Nuevo Len, Coahuila, Chihuahua, and Tamaulipas
with a project in the works to also open a hospital in the southern state
o Chiapas. The model would appear to be replicable as long as patients
can continue to und the majority o operating costs and at the same
time the clinics strengthen brand association o the new hospitals.
Collaborations between the Fundacin and the public sector, especiallymunicipal governments, do exist, but a stronger working relationship would
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
26/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
26
acilitate replication. In San Luis Potos, or example, the clinic treats patients
covered bySeguro Popular, but no ormal agreement exists. There, as in the
city o Monterrey, it would be conceivable to sign agreements where the
private clinics would provide care to people covered bySeguro Popularor
specic health issues and receive payment or that treatment through the
System or Social Protection in Health.
For its part, simnsas endeavor could be expandedeither bysimnsa itsel
or another organizationinto the main cities along the U.S.-Mexico border.
Doing so would mean extending health care access to a sector o the popula-
tion (and their amilies) that, while not the most indigent, cannot easily
acquire private health insurance due to an inability to pay or an absent culture
o being insured. Given the prole o workers enrolled in simnsa, the strategy
seems to be easible in the main border cities. What is more, growth in themedical tourism industry could trigger a spike in demand among workers in
the United States. simnsa recently began to negotiate with other rms to
promote the sale o its policies in the United States and to strengthen its
capacity to respond to Mexicos health needs.
simnsa could also potentially engage in collaborative eorts with the
public sector. Under the ramework o the ederal Seguro Popular, simnsa
could work out an agreement by which its members receive care at health
acilities run by border states Secretariats o Health. These publicly-runmedical centers would be able to compete with the private entities now under
simnsa contract.
Mexam, which is now active in more than hal o Mexico and has long
been recognized or its work with marginalized groups, has already demon-
strated a notable capacity or expanding its strategy and services. It has also
historically maintained a broad partnership with the public sector to develop
programs and public health policies pertinent to reproductive health at the
local, state and ederal levels. When it was ounded, Mexams servicesincluded amily planning, maternal and child health, and sexual and reproduc-
tive education. Forty-ve years later, its services have been expanded to
include raising nutrition awareness, building latrines in marginal zones,
treating parasites, organizing amily vegetable gardens, and implementing
sanitation projects. It could achieve even greater coverage and expand to state
health care domains and medical acilities where operations do not currently
existboth by pursuing some o the strategies it has ollowed in the past and
by creating new structures o collaboration with the government. This couldentail joint eorts in administration o the health care system and expansion o
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
27/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
27
coverage by the System or Social Protection in Health.
All three o these entities ace common challenges o access and scalability,
providing valuable lessons or other organizations in Mexico and beyond, which
seek to improve health care access and overall social inclusion. First, private
entities should maintain regular contact with health ocials and public
institutions to coordinate similar or complementary eorts. Second, the public
sector should view corporations and ngos as a source o support and collabora-
tion rather than as competitors or patients or clients. Third, the broad
coverage provided by the System or Social Protection in Health (Seguro
Popular) presents an opportunity or private organizations to provide access to
services or marginalized populations in communities lacking health acilities.
Legal and administrative opportunities exist or striking partnership agree-
ments between the public and private sectors. Fourth, even with SeguroPopular, eorts are needed to provide access to care or people o limited
resources. Finally, private organizations should conduct systematic evaluations
to be able to then share successul experiences and lessons learned, as well as
the causes o unsuccessul eorts. Such evaluations should also look at the
quality o service both in terms o its technical aspects and o meeting the
needs o those served.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
28/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
28
ConclusionsRegionally, and specically in Mexico and Colombia, it is clear that new
practices are increasingly allowing marginalized populationsalbeit through
targeted interventionsto access primary health care services. But the case
studies presented demonstrate that challenges remain or eectively
addressing systemic challenges o society-wide health care inclusion. Heres
what we ound:
First,even in countries with health care models that seek to broadlyexpand access or even achieve universal access, signifcant gaps in
access still exist or certain populations. The private sector can help to ll
this void through health care nancing, direct service provision, low-costmedical treatment, eHealth/mHealth, and prevention programs and education.
The public systemwhether through Seguro Popularin Mexico orLey 100 in
Colombiadoes not reach the entire population due to insucient allocation
o unds, the physical distribution o health care providers, lack o knowledge
and awareness o the benets available, and social stigma, among other
reasons. In act, or geographically isolated communities, the urban or rural
poor, or indigenous and Aro-Latino populations, inclusive public policies can
actually hamper their ability to receive quality health care services i suchpolicies then yield an attitude o complacency rom the health care industry.
Second,cross-sector collaboration increases an initiatives scal-ability and sustainability. Involvement o the public sector, hospitals
and community leaders in the design and implementation o a
targeted health program will lead to greater buy-in o the desired
outcome and results. This is also true insoar as the need to bring together
multiple stakeholders to provide the unding or a program to ensure itslong-term sustainability and scalability. As seen in the case o the Salud y
Saneamiento Bsico program run byFundacin Propal, the eective engage-
ment o local and regional government along with other businesses and even
multilateral agencies will increase the potential longevity o an initiative.
Much o the success o the Fundacin Adelaida Lafn and Mexam programs
is a result o their community-wide collaboration both in terms o their
nancing and programming models. At the same time, broad-based collabora-
tion also helps to ensure that an intervention is responding to some o themore pressing local health needs.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
29/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
29
Third,the private sector has yet to ully appreciate the potential orproft when investing in health care initiatives that reach excluded
groups. None o the examples involves or-prot service provision to margin-
alized populations. In Colombia, companies like Cerrejn and Propal
launched their health care eorts to respond to the needs o the local popula-
tion where corporate operations exist. But neither company is in the health
care eld. In act, the majority o health investments come rom businesses
that traditionally have worked in isolated or vulnerable communities. More
can be done by health care companies to better serve marginalized groups in
a way that not only responds to corporate social responsibility goals but also
directly or indirectly drives prots. The PzerMutual ser program is one
example o a program that indirectly benets the companies through positive
brand association. Companies in the health industry can also expand theirmarkets by nding ways to provide low-cost services to populations who have
the potential to become part o their consumer base. A rst step could be to
conduct a broad search or services that the poor want and can be adminis-
tered at low cost with potential nancial returns or the rm.
Fourth,health outcomes are oten measured in terms o access tocare rather than access to quality care. But both indicators are critical to
determining whether an intervention is in act improving the overall care o
the targeted population. Each program analyzed has shown great increases inthe number o patients reached or number o services used. But the unda-
mental question o how these interventions have aected the overall health o
the population remains. This is what matters or creating the opportunities
that will lead to greater socioeconomic mobility and overall social inclusion.
Fith,health delivery interventions have greater society-widebenefts when combined with public education eorts. While huge
advances have been made in reducing inectious diseases and inant mortality,health care systems and providers are acing a growing burden o chronic,
non-communicable diseases such as diabetes, cardiovascular and respiratory
disease, and cancer. Education ocused on improved diet and health practices
is critical or increasing awareness about the risk actors or these diseases.
Each o the case studies presented (with the exception o the simnsa insur-
ance regime) incorporated education as a key component o the programs.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
30/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
30
RecommendationsFirst,greater utilization o inormation and communications tech-nology (ICT), through eHealth and mHealth initiatives, can expand
access to quality care, reduce inefciencies and cut costs. India is a
prime example o howicts can expand health care access, but this approach
has yet to catch on throughout Latin America. In this, partnership across
sectors and providers is crucial to generate impact, sustainability and scal-
ability. Companies are using video and mobile platorms to provide consumers
with inormation; to connect clinics, physicians and patients otherwise sepa-
rated rom one another; and to track population migration and the spread o
disease. Better optimization oict
s will enhance access but will lead to evengreater eciency gains in the quality o care that is delivered, especially in
remote areas. For example, eHealth and mHealth oer the ability or highly-
skilled doctors located in urban areas to remotely diagnose and treat patients.
Second,a regional clearinghouse o or-proft models that servemarginalized populations can be an eective strategy or consoli-
dating eorts. This study is not wholly comprehensive o the types o health
interventions in the region, but it is representative o the eorts being carried
out in Mexico and Colombia. Here, individual eorts are producing importantlessons learned that could be good reerence points or the larger health
community. But a region-wide platormboth online and through working-
level discussionsdedicated to or-prot models that address the primary
health needs o excluded groups could lead to identication o a series o
shared, cross-cutting best practices. One model or this is the Center or
Health Market Innovations.
Third, regular dialogue between health ministries or local depart-ments and the private sector is necessary to harmonize health caredelivery eorts. As in the area o education, which is also studied in the
Americas Society Social Inclusion Program, a certain level o distrust exists
between the public and private sectors. Greater condence in working
together is seen at the local or state/department levels, but still, the two
sectors could more eectively address the primary health care needs o
excluded groups with better triangulation o: a) their service delivery eorts;
b) the on-the-ground policy dynamics; and c) the actual health needs as shownby national health data. This can only be achieved through regular dialogue.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
31/32
Addessng sysemc cAllenges scAl nclusn n e Al cAe:
nAves e PvAe sec
31
In the end, access to quality health care is a undamental prerequisite or
an individuals social mobility and labor productivity, and or societys ultimate
economic growth and competitiveness. Put in a global context, this is precisely
why three o the eight Millennium Development Goalsreduce child
mortality, improve maternal health, and combat hiv/aids, malaria and other
diseasesare ocused on these critical health improvements.
-
7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care
32/32
enDnoteS
1 Julio Frenk, Assessing Mexicos Health System Reorm (Keynote Remarks, Health Care in the
Americas: Public-Private Eorts to Increase Access, Americas Society, New York, NY, December 8, 2010).
2 Pol De Vos, Wim De Ceukelaire and Patrick Van der Stuyt, Colombia and
Cuba, Contrasting Models in Latin Americas Health Sector Reorm, Tropical
Medicine and International Health 11 (10) (2006):1604-1612.
3 United Nations, The Millennium Development Goals Report 2010(New York: United Nations, 2010), 26.
4 World Health Organization, Trends in Maternal Mortality:1990 to 2008
(Geneva, Switzerland: World Health Organization, 2010).
5 PAHO Health Inormation Platorm, Basic Health Indicators Most Requested: Indicator Series,
http://ais.paho.org/phip/viz/mr_indicatorserietable.asp (accessed February 17, 2011).
6 Latin Americas Bill o Health, Americas Quarterly4 (3) (Fall 2010):55-59.
7 Joel Selanikio, The Mobile Revolution in Health Care, Americas Quarterly4 (3) (Summer 2010):64-
65; Donika Dimovska, Filling the Gap, Americas Quarterly4 (3) (Summer 2010):66-71.
8 Luis Jorge Garay, Crisis, exclusin social y democratizacin en Colombia
(working paper, Universidad Nacional de Colombia, 2003).
9 Cristina Torres, Descendientes de aricanos en la Regin de las Amricas y equidad enmateria de salud, Revista Panamericana de Salud Pblica 11 (5/6) (2002):471-479.
10 Luz Dary Salazar lvarez, El envejecimiento en Colombia: una construccin social 1970
2000, Red Latinoamericana de Gerontologa, http://www.gerontologia.org/portal/
inormation/showInormation.php?idino=1649 (accessed February 17, 2011).
11 David Aylward, Beatriz Leo, Walter Curioso, and Fabiano Cruz. Can You
Heal Me Now?, Americas Quarterly4 (3) (Summer 2010):90.
12 Felicia Marie Knaul and Julio Frenk, Health Insurance in Mexico: Achieving Uni-
versal Coverage through Structural Reorm, Health Affairs 24 (6) (2005):1467.
13 Health Net is the biggest health insurance company in the United States, oering its members a variety
o plans. It oers many individual and amily plans. It covers people working in small companies and
people who are sel-employed or temporarily out o work. There are ways or choosing dierent optionsor each amily member. Health Net has a broad range o associates that in turn count on providers
practically throughout the United States, especially in Arizona, Caliornia, New Jersey, and Oregon.
14 In 2008, the Seguro Popularcoverage in select states reached 39 percent in Nuevo Len, 50
percent in Baja Caliornia and 55 percent in San Luis Potos. Even when Seguro Popularreaches its
nationwide coverage goal, a clinic similar to that o Fundacin Adelaida Lafn is likely to remain
necessary since people may not afliate themselves and all services may not be covered.