Health Sector Reform in Chile: civil society in action.

The Pan American Health Organization hosted the International Workshop "Genero y Salud Sexual y Reproductiva en las Reformas de Salud en America Latina y Chile" (Gender and Sexual and Reproductive Health in Health Sector Reform in Latin America and the Caribbean) April 29-30, 2002, in Santiago, Chile. This important event included the participation of several experts from throughout the region in an effort to open debate on the challenges and priority issues involved in achieving equity in health -- with a special focus on gender equity -- in the processes of Health Sector Reform currently underway.

Coordinated by PAHO's office in Santiago and the Regional Office of the Women, Health and Development Program, this international event coincided with the celebration of PAHO's 100th anniversary. The workshop also provided an opportunity to present the Equity, Gender and Health Sector Reform Project in Chile. This PAHO initiative promotes the inclusion of gender perspective in all the aspects of health policy.

Several other institutions also participated in the organization of the event, including Chile's Servicio Nacional de la Mujer (SERNAM, National Women's Service), the Chilean Ministry of Health and the UN Economic Commission for Latin America and the Caribbean (ECLAC). Funding for the workshop was provided by the Ford Foundation and the PAHO/WHO Regional Office.

Identifying Priorities

As the variety of institutions involved in the event reflects, the topic of equity in Health Sector Reform is a significant issue for a wide range of sectors. Indeed, the primary conclusion from this stimulating event was the need to stress equity as the only possible path toward true justice in health that focuses on the priorities of individuals and ensures the same level of health for all, free from discrimination based on gender, age, socio-economic level or any other characteristic.

But this laudable goal demands a new economic ethic based on solidarity and the recognition of the right to health as both a social asset and a civil right that must be guaranteed by the state. The current health care systems are not based on these principles, especially the profit-driven private system.

At the same time, bearing mind the historical power inequities between women and men and the considerable impact of this inequity on women's health, gender must be taken into account as a primary determinant of health in the formulation of Health Sector Reform objectives. The failure to apply a gender perspective to health policy reinforces discrimination against women, which in turn makes it more difficult for women to access health care resources and services and to pay for this care.

The participants also stressed the need to draw attention to the role that women traditionally have held in regard to the production of health within their homes and the nation. Women have always been responsible for ensuring their families' health, yet this work is neither recognized, remunerated nor included in the calculations of national accounts. At the same time, while the majority of health care workers are women, their contribution to the sector is overwhelmingly limited to lower-paid and less prestigious jobs. Few women health care workers occupy decision-making positions.

Clearly, the incorporation of gender perspective in all state policies and programs is urgently needed, including permanent efforts to gather information on the impact of gender inequity on women's health and lives.

Another indispensable step for improving gender equity is the incorporation of sexual and reproductive rights into the basic contents of the reform processes. However, real exercise of these human rights will also require laws to guarantee them since the cultural changes that favor the social recognition of sexual and reproductive rights are exceptionally slow processes. Health policy reform will fall short if, for example, it punishes women for their reproductive potential, fails to address unsafe abortion as a priority public health concern, or ignores the autonomy of adolescent women and men over their own sexual and reproductive lives and health. In fact, most public policies throughout our region turn a blind eye to these key issues.

The participants at the PAHO event also agreed that the reform processes require a broad, intersectoral and multidisciplinary perspective. We cannot expect the health sector to act alone since people's health is influenced by a variety of social, cultural, political and economic factors. Strictly biomedical criteria is insufficient and biased, and therefore, this perspective alone will not provide an accurate analysis of the health of a population.

Proactive social participation in which citizens exercise their civil rights, including the right to monitor the government policies, was also identified by the workshop participants as an essential element. This participation must be supported by accurate information on the systems' processes and policies that that is transparent and intelligible enough for civil society organizations to use in their lobbying efforts.

Finally, in regard to the ISAPREs -- the private system that operates in Chile -- the participants characterized this subsystem as profit-driven and market-oriented; ISAPREs provide health care but do not necessarily ensure the right to health in equitable conditions. In response, the participants demanded the strengthening of regulatory systems to combat abuses and discrimination in service prevision, especially those related to maternity.

No Policy is Neutral

Elsa Gomez, of PAHO's Women, Health and Development Program in the Division of Health and Human Development, opened the workshop with the Inaugural Address "Sexual and Reproductive Health and Health Sector Reform in Latin America." She stressed that as long as health policies fail to recognize the existence of gender inequalities, no policy can be considered gender-neutral. Unless these gender inequalities are not confronted openly, they will continue to be reproduced or even exacerbated.

A gender perspective reveals how the relationships between women and men affect the overall well-being of society. The differences between women and men are not the problem in and of themselves, but when they are associated with women's systematic socio-economic disadvantage. A gender perspective is also essential to ensure the efficiency and sustainability of the reform processes.

Ms. Gomez outlined four categories of gender inequities in health: health status and its determinants; access to resources and appropriate services; health care financing; and participation in health care management.

Equity in health status is achieved when there are no remediable differences between women and men in regard to opportunities for health or in how they become ill, suffer disabilities, or die from preventable causes. For example, statistics show that living in conditions of poverty has a much greater impact on women than on men in terms of survival and health status. Among upper-income levels, women's life expectancies are longer than men's by various years. This difference is substantially reduced in the lower-income levels, where women and men's life expectancies are nearly the same. In some countries, however, the life expectancies of poor women are lower than those of men who live in the same conditions.

Gender equity in access to services means that allocation and availability of resources are determined by need. In other words, women's greater use of health care services is explained by their greater need, which is determined by their reproductive functions and because they live longer and therefore become ill more often. However, statistics reveal that women use health services more often in only certain circumstances. In Chile, for example, men use emergency care services much more often than women, while women tend to use preventive services more often than men, except at the lowest income levels. However, when preventive behavior is examined in relation to the type of health care system to which the women belong, we find that those in the public system consistently and frequently use preventive services, where as in the private system, only women from higher income levels use them.

Equity in terms of financing health care demands that women and men contribute according to their economic capacity and not according to their health care needs or risk (which currently the case with the private system). Above all, the social cost of reproduction must not be shouldered by women (or by women and their partners) alone, but by all of society. In Chile, however, women of reproductive age pay twice and even three times as much as men for private health insurance.

In terms of health care management, gender equity includes not only the issue of equal pay for equal work, but also the equal distribution of responsibilities among women and men, the recognition and registration of the economic contribution of women's unpaid work in health care (both preventive and curative), the recognition of women's underrepresentation in local and national power structures, and the fair distribution of the real cost of providing health care among the family, the community, government and the market.

Ms. Gomez summarized women's current disadvantages in the following terms:

* greater need for services;

* fewer resources to pay for these services;

* greater out-of-pocket spending on health care;

* disadvantaged position in health care management; and

* greater demands on women to provide care when public services are reduced.

As a result, the challenges are to:

* eliminate the avoidable differences between women and men's health status;

* allocate resources according to need;

* demand equal pay for equal work; and

* achieve an equal division of responsibilities and power.

In addition, she reminded the participants that close attention must be paid to the definition of priorities in all reform processes, especially in regard to the explicit incorporation of sexual and reproductive health services. The emphasis placed on preventive care and health promotion should also be examined closely: sexual and reproductive health care needs may be underestimated if the focus is placed on injury (as is the case of systems that use disability adjusted life years, or DALYs).

Finally, Ms. Gomez explored the possible mechanisms that might be used to respond to the impending crisis of health care services not yet unprepared to deal with the increase of chronic illnesses due to the aging of the population. As a result of changing gender roles, women will not necessarily be available in the home to care for ailing family members, and this reality will have a dramatic impact on the sustainability of health care. Women also may be forced to continue to assume the responsibilities for home care at a considerable cost to their own physical and mental health.

Targeting All Levels

The first panel of the event was entitled "The Impact of Health Sector Reform on Sexual and Reproductive Health." The attempt to introduce the Chilean model for Health Sector Reform in Colombia was described by Colombian economist Cecilia Lopez, who has been Minister of Planning, Vice Minister of Agriculture and Director of Social Security in Colombia, as well as past Director of the regional economic institution PREALC in Chile. Dr. Lopez explained that today's challenge is to implement cutting-edge reforms designed specifically to meet the structural needs of social development in Latin America and to assure universality, solidarity and efficiency.

As with all sectoral social policy, health reform is conditioned by macroeconomic policy, she argued. Therefore, health reform is an economic policy issue directly related to the structural problems of social development in the region. As a result, advances in health policy must face issues of power relations in our societies as well as economic and social elements, such as strengthening fiscal policy and economic democracy. However, Dr. Lopez argued, economic and social elites in the countries of the region are totally disinterested in social change and represent an obstacle to democratic advancement.

In conclusion, Dr. Lopez emphasized that gender equity is a principle of social equity and a category of analysis essential for understanding the obstacles to development.

Next, Nieves Rico of the Economic Commission for Latin America and the Caribbean (ECLAC) addressed "Sexual and Reproductive Rights in Latin America," analyzing the need for information to facilitate the incorporation of a gender perspective in public policy. She questioned the information currently being used by policy-makers to define priorities in sexual and reproductive health and raised ethical, technical and political arguments for incorporating these priorities into the agenda of the reform. Ms. Rico identified the limited or nonexistent information on sexual and reproductive health, the invisibility of this important aspect, resistance to incorporating this topic, and ideological opposition as the most serious challenges.

She also explained that debate on sexual and reproductive rights is generally based on fragmentary empirical evidence and broad conceptual principles. In conclusion, Ms. Rico recommended:

* strengthened ties between sexual and reproductive health researchers and those who use this information;

* linking Health Sector Reform to national and international legislation on gender equity, population and sexual and reproductive rights;

* developing democratic and participatory strategies within the institutions and establishing intersectoral and inter-institutional agreements to advance sexual and reproductive rights; and

* developing organized civil society's analytical capacities in economics.

Silvina Ramos from Argentina's Centro de Estudios de Economia y Sociedad (CEDES, Center for Social and Economic Studies) referred to "Health Sector Reform and its Impact on Sexual and Reproductive Health in Argentina." According to this expert, very little is known about the impact of the reform in her country due to the complexities of the health sector and the characteristics of the process itself, which is being implemented silently and without public debate.

However, Ms. Ramos explained, longstanding social inequities in health can be observed in disparities in coverage, access and mortality rates. There are also differential risks in reproduction and inequitable access to sexual and reproductive health care, in addition to changes in regulations. In 1994, a constitutional reform incorporated some international instruments ratified by Argentina, such as the CEDAW, even though this convention is not implemented in practice. Between 1995 and 2000, reproductive health laws were approved, and reproductive health programs were implemented.

Today in Argentina, sexual and reproductive health and rights are characterized by gender, socio-economic and generational inequality. The country's health care system is divided into three subsystems -- public, private and social security -- which have marked differences in terms of financing and provision of services. In addition, the public system is fragmented and offers inconsistent coverage and quality.

The final speaker on the panel, Dr. Virginia Camacho from the Safe Motherhood Program of the PAHO/WHO Regional Office, addressed "Health Sector Reform and Safe Motherhood." The Safe Motherhood Program aims to reduce maternal mortality in the Latin American and Caribbean region. Today, maternal mortality is estimated at an average of 190 maternal deaths per 100,000 live births, with serious differences between and even within countries.

Dr. Camacho recognized that very few successful Health Sector Reform experiences are known, despite the cases of Bolivia, Ecuador and Peru where basic health care packages do seem to met the needs of a population that has very little access to health care. Nonetheless, she also stressed that the paradigm of sexual and reproductive health and its relationship with the processes of Health Sector Reform is a very complex issue, and as a result:

* sexual and reproductive health is often part of the public agenda, but it is incomplete;

* implementation of sexual and reproductive health policies is inconsistent;

* ensuring quality of care and access to services for the poorest sectors is an ongoing problem;

* the concept of sexual and reproductive health is manipulated ideologically;

* emphasis has been placed on financing, reorganization and decentralization, but without clear objectives in terms of health outcomes;

* the vertical nature of the programs persists, even when family planning or mother-child programs have been converted into comprehensive reproductive health programs;

* the implementation of intersectoral perspectives is indispensable for the articulation and processes of the reform; and

* the ICPD Programme of Action's recommendations should be taken into account, including linking reproductive health care policies to plans for the reduction of poverty, the reduction of inequities, the fulfillment of unmet need, training for providers and related issues.

A Closer Look at Chile

The second panel of the workshop was dedicated to "Gender and Sexual and Reproductive Health in Chile's Health Sector Reform."

The first speaker, Health Ministry representative Patricia Frenz, analyzed "Sexual and Reproductive Health in the Health Objectives and the System of Universal Access with Explicit Guarantees." The Plan AUGE, as this system is known in Spanish, was recently presented to Parliament by the executive branch.

This governmental proposal, the cornerstone of Health Sector Reform in Chile, seeks to address: user dissatisfaction with the current health care systems; inequality in health and access to health care; discrimination against women, the poor and the elderly; changes in the country's epidemiological profile and health care needs; and the growing costs of health care and its financial impact on the households.

With regard to gender equity, Ms. Frenz indicated that the Plan AUGE intends to eliminate discrimination against women by ensuring explicit guarantees and quality of care.

Next, Fanny Berlagoscky spoke on behalf of the Latin American and Caribbean Women's Health Network and the Red Foro de Salud y Derechos Sexuales y Reproductivos (Forum Network for Sexual and Reproductive Health and Rights). Her presentation on Gender and Sexual and Reproductive Health in the Proposed Health Sector Reform under Debate: Observations and Proposals from Civil Society" posed a number of questions: Is there really a need for Health Sector Reform in Chile? Will the current proposal really decrease the inequalities in access? While the AUGE claims to include new health care services, she explained, the list does not include anything new but rather reprioritizes services that already exist. If the plan is structured as a package of basic services, the reform would actually be a setback in terms of the progress of Chile's health care system.

Ms. Berlagoscky insisted that the reform proposals must take into account fundamental principles of sexual and reproductive rights that the women's health movement has long championed. However, the government's current proposals do not include these basic principles. In order to remedy this situation, the reform should:

* be founded on a comprehensive vision of women's health;

* introduce gender as a variable in all analyses with the understanding that gender influences health;

* discourage use of women by the health care services, but rather encourage quality of care that treats women with dignity; and

* ensure the fulfillment of family planning service guidelines, including voluntary sterilization and the restoration of therapeutic abortion.

Ms. Berlagoscky also demanded that the reform proposals take into account the research carried out over the past 15 years by the women's health movement and the proposed Law on Sexual and Reproductive Rights, currently being reviewed by Parliament.

Patricia Silva, a lawyer with the Servicio Nacional de Ia Mujer (National Women's Service) closed the second panel with her presentation on "The ISAPREs and Women's Reproductive Health in Chile: The Urgent Need for Regulation." Chile's private health insurers, known as ISAPREs, are for-profit entities that consider women's reproductive potential a "risk." The resulting gender bias is evident in health plans that are much more expensive for women than men, effectively punishing women for the biological function of maternity.

According to this specialist, it is particularly serious that important topics such as access to family planning, abortion and related issues are often ignored in public policies and eliminated from public debate. She argued that that sexual and reproductive health is not a neutral issue, but is clearly linked to patriarchal norms and values in Chilean society. In this context, women are still exclusively responsible for reproduction and child-rearing, with the resulting burden in terms of workload and the impact on their physical and mental health. At the same time, they do not enjoy autonomy in decision-making with regard to issues of sexuality and reproduction.

At the workshop's conclusion, participants debated how to address the inconsistencies between the discourses of government officials and the actual contents of the documents describing the reform. There are a number of important gaps, such as the failure to detail the contents of family planning programs; the failure to include unsafe abortion as a priority public health problem; and the difficulty in accepting adolescents as individuals with sexual and reproductive rights.

In addition, some participants questioned the value of the sort of reform being proposed in Chile, in that it only appears to offer a basic package of services. Others suggested that the reform is actually a step backwards for women who may be better served by the Ministry of Health's 1997 Women's Health Program.

Neither does the reform seem to defend the public health system, argued the workshop participants. In this respect, the government must open debate on the ISAPREs, which have manipulated the market of health care to their own advantage.

Finally, the participants insisted on the need for a more transparent and participatory process, with a proactive civil society that can present proposals and have an real impact on the Health Sector Reform. In this effort the commitment of health workers' unions and the users of the health systems is especially important.

The following report on the Pan American Health Organization's International Workshop "Genero y Salud Sexual y Reproductiva en las Reformas de Salud en America Latina y Chile" (Gender and Sexual and Reproductive Health in Health Sector Reform in Latin American and the Caribbean) was prepared by Revista Mujer Salud editor Adriana Gomez.