Document(s) 6 de 14

Introduction

This chapter will describe the fundamental features of the health services system (HSS) in Argentina, with emphasis on its organization, financing and service delivery. The first part will cover the structural features of the system and the dynamic processes that it has undergone in recent years, in order to provide a general understanding of health needs and available resources. It will also give a socio-demographic and epidemiological profile of the population; provide information on health expenditure by source of financing and the proportion of the population covered by each subsystem; and describe the institutions in charge of financing and providing health services, including the evolution of inpatient and outpatient facilities in the three subsystems that make up the HSS.

The second part of this chapter outlines two organizational models of the system. The first was in effect during the 1960s and 1970s, and went into a deep crisis at the beginning of the 1980s. The second is the result of changes that occurred because of that crisis, which have profoundly changed the relationship between financing institutions and health care providers, to the extent of lending support to the hypothesis that a new model is under construction.

Structural Features

Socio-demographic features

According to the 1991 Population and Housing Census, the total population of Argentina is over 34 million, 85% of them living in urban areas. Indeed, almost 50% of the population is concentrated in the Federal District and the Province of Buenos Aires. Trends in certain socio-demographic indicators can be seen in Table 1.
 

Table 1. Socio-demographic indicators, Argentina, 1970 and 1990.
	1970	1990	% increase
Urbanization ratea	80.30	87.20	8.59
Literacy rateb, d	92.90	95.00	2.26
Life expectancy at birthb, d (years)	68	71	4.23
Infant mortality ratec, f (neonatal and post-neonatal per 1 000 live births)	62.00	22.30	-64.03
Mortality ratec, d	9.36	7.69	-17.84
Birth rateb (gross for 1 000 inhabitants)	23.00	21.00	-8.70
Fertility rateb	3.10	2.80	-9.68
Sources:     a Lindenboim (1997).        d Anuario Estadístico de la República Argentina, 1979-80. b World Bank (1993).    e UNDP (1993). c MSAS (1996).            fMSAS (1985).

Of the total population, 46% are under 25 years of age, 40.8% are between the ages of 25 and 59, and the remaining 13.1% are 60 or older. The economically active population (EAP) is 12.2 million, of which 54.2% are employed in the service sector, 13.2% in farming, 10.9% in construction, and 21.7% in industry. The EAP has remained at about 36% or 37% during the last 6 years. In contrast, unemployment has increased steadily from 6% between 1989 and 1991, to 17% in 1996, according to the national household survey and the biannual survey (INDEC 1996) of the Instituto Nacional de Estadísticas y Censos (INDEC, national institute of statistics and censuses).

Over 6 million Argentineans, or over 19.3% of the total population, are defined as living in a situation of structural poverty, that is, in households unable to satisfy their basic needs. Of the poor population, 23% are women of reproductive age and their children (INDEC, National Population and Housing Census, 1991.) With regard to the epidemiological profile of the population, the main causes of death are heart disease (22.7%), malignant tumors (14.8%), and cerebrovascular diseases, as can be seen in Table 2.
 

Table 2. Principal causes of mortality, Argentina, 1980 and 1994.
	1980		1994		% increase
	Mortality rate (per 10 000 inhabitants)	%	Mortality rate (per 10 000 inhabitants)	%
Cardiovascular disease	25.8	29.9	22.7	29.5	-1.34
Malignant tumor	13.9	16.1	14.8	19.3	19.88
Cerebrovascular diseases	8.0	9.3	7.2	9.4	1.08
Other	38.6	44.7	32.2	41.8	-0.06
Total	86.3	100.0	76.9	100.0
Source: MSAS (1996).

Expenditures

According to World Bank figures, public expenditure on social programs has been growing under the Convertibility Plan, both in absolute and relative terms. Consolidated public social expenditures increased from 16.4% of gross national product (GNP) during the period 1984-1988, to 17.3% during the first Menem administration (1989-1994), to reach US $51.4 billion or 18% of GNP in 1994 and 18.3% in 1995. Consequently, overall social spending as a share of total public expenditure rose significantly from 49.5% during the period 1984-1988 to 67.2% in 1994. Of the total amount devoted to social expenditures, 11% - or 2.15% of GNP - was destined to finance health services supplied by the public sector. The sources of financing for the other subsystems within the HSS, and their relative share of the total expenditure on health between 1970 and 1995, are shown in Table 3.
 

Table 3. Distribution of health expenditure, 1970-95.
Year	Public sector (%)	Obras sociales (%)	Out of pocket (%)	Total expenditure (US$ millions)a	% of GNP	Per capita
1970	19.5	22.8	57.7	9 755.0	7.75	417.6
1980	30.1	35.8	34.1	10 779.2	6.73	381.8
1985	22.7	39.2	38.1	11 910.3	8.24	389.8
1991	20.2	32.4	47.4	13 188.0	7.29	404.2
1995	23.6	34.9	41.5	19 230.0	9.00	565.5
Source: Cetrangelo, O. et al. (1992), World Bank (1995)a. In the total expenditure column: US$ (millions). Values are adjusted according to combined price indexes (consumer and national wholesale non-farming) at prices of March 1992.

These values must be compared cautiously, however, because they come from different sources. Nevertheless, the data do illustrate certain trends. For example, the 1970 distribution reflects the situation before the obras sociales system became generalized. Consequently, a larger proportion of spending came directly out of the pockets of consumers. The values for 1980 reflect the stage of higher coverage by obras sociales, with a significant drop in out-of-pocket spending. The values for 1985 and 1991 show a reversal of the trend as a result of the financial crisis in the obras sociales. Private spending increased either directly or through the purchase of private insurance or additional insurance (co-insurance), or to cover extra-billing by physicians at the time of providing services.

It must also be pointed out that public expenditure on health decreased between 1980 and 1994 in nominal values, as a percentage of total expenditures, and as a percentage of GNP. The values for 1995, obtained from estimates made by World Bank officials, show a recovery in public expenditure; however, these figures have not been accepted by other analysts, who go so far as to double the out-of-pocket estimates issued officially (Tafani 1996).

The breakdown of health expenditure shows that most of the public spending came from the provincial governments and the Federal District (see Table 4).
 

Table 4. Estimated health expenditure - 1995.
		US$ (millions)	% of total
Total		19 230	100.00
Public Expenditure
	National	410
	Provincial governments and Federal District	3 370
	Municipalities	760
	Subtotal	4 540	23.61
Social Security Expenditure
	Obras sociales(ANSSAL)	2 560
	PAMI	2 380
	Provincial and municipal obras sociales	1 380
	Autonomous obras sociales	390
	Subtotal	6 710	34.89
Family expenditures
	Indirect	3 760
	Direct	4 220
	Subtotal	7 980	41.50
Source: Local office of World Bank.

Population coverage

These values must be taken as estimates, however, because the state agencies themselves claim not to know the actual number of obras sociales beneficiaries and no precise information is available on private insurers. Also, the total value is not exact due to an overlap in coverage between obras sociales and private insurance, and even between different obras sociales.

The difference between the total population and the population covered by either compulsory or voluntary insurance is considered to be the population covered by the public subsystem, which is open to the whole population. However, some analysts consider that 5% of this number consists of high income-earners who pay for health services directly out of their own pockets.

Subsystems

The division of health services into three subsystems, public, private, and social security, has a dual basis. It is based on the ownership or jurisdiction of the respective health care services, and on the source of financing and the mechanisms that link payers and providers. Statistical information is collected and elaborated on the basis of the three subsystems, as reflected in the description given in the first part of this section.

The transformations that have taken place in organization of the health care system are basically linked to the relationship between the financing and provision of services. To facilitate a schematic presentation of these transformations, I will consider the three subsystems, but use a single classifying criterion, namely source of financing. Thus, the public system is one in which resources came from taxes, the social security system is financed by compulsory contributions, and the emerging private system is funded through voluntary insurance schemes. The relationship between financing and provision is integrated in the case of the public system and contractual in both the compulsory and voluntary insurance subsystems.

The three subsystems identified above are based on the classification used in a report issued by the Organisation for Economic Co-operation and Development (OECD 1992), which contains a comparative analysis of health care reform in a number of European countries. The categories applicable to Argentina are as follows:

• Compulsory insurance model: Resources are collected and managed by the obras sociales, and feature provision of services by contract: compulsory health insurance that involves direct payments, under contract, from the insurers or third-party payers to the providers of services rendered to insured persons. In this model, the providers are often independent and the contractual payments to them are by capitation or on a fee-for-service basis.

• Public integrated model: This model corresponds to services financed and provided by institutions dependent upon different state organizations. Resources come out of general taxation and payments to providers are by salary and prospective budget. Government is the principal insurer and the major provider. Benefits are supplied to patients in kind, often free of charge.

• Voluntary insurance model with provision of services by contract: This model corresponds to institutions engaged in organizing voluntary health insurance with direct payments, under contract, from the insurance company or third-party payers to the providers of services rendered to insured persons. Under this model, the providers are often independent and the contractual payments made to them on a fee-for-service basis.

Social security

Obras sociales are group insurance schemes based on the occupation of their beneficiaries. They function as sickness insurance funds, financing health care services for employees and their immediate families. Those under national jurisdiction were legally constituted by Law 23.660 of 1989 and its regulating Decree 576/93. These dispositions have undergone partial modifications through decrees sanctioned in 1993 and 1995, the main aspects of which were discussed in the previous section. The obras sociales under provincial jurisdiction are ruled by specific laws.

Obras sociales are semipublic, because their creation requires authorization by the state, which has the means to intervene in their administration. They must pursue public ends and they exercise public authority, as expressed in the compulsory nature of their affiliation and their right to apply sanctions.

The 281 obras sociales at the national level are the central agents of the health insurance system and cover 48.21% of the population ensured under the compulsory insurance system (Local Office, World Bank). They are subject to national jurisdiction through the Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration). The 23 provincial obras sociales cover 29.41% of the population, mainly employees of the provincial public sector and their dependents. Their source of financing is income?related contributions by employers and employees. In the case of obras sociales under the national regime, contributions amount to 8% of payroll. Provincial contributions vary between 7% and 12.5% of payroll. The Instituto Nacional de Seguridad Social para Jubilados y Pensionados (INSSJYP, national social security institute for retirees and pensioners) is under a special regime, and is commonly known by the initials corresponding to its Programa de Atención Médica Integral (PAMI, comprehensive health care program). It covers some 22.4% of the population under the compulsory insurance system, and its resources come from contributions from active and retired workers, varying between 3% and 6% of their earnings.

The fundamental features of the social security system are its compulsory nature and its organization according to the beneficiaries’ occupation. Contributions from both employers and employees are channelled to the respective obra social, trade union, and so forth. Despite the existence of a large number of institutions, both beneficiaries and resources are concentrated in a relatively small number, meaning that many are not financially viable. Out of 281 institutions, 30 account for 73% of the beneficiaries and 75% of the resources.

Thus, the average revenue per beneficiary varies widely among obras sociales. Some of them have incomes of less than US $5 per beneficiary per month. Others take in over US $80 per beneficiary per month.

The Fondo Solidario de Redistribución (FSR, solidarity redistribution fund), administered by ANSSAL, was instituted by Law 18.610/70 with a view to reducing this kind of imbalance between obras sociales. It was unable to fulfill this function, however, for reasons generally attributed to political pressure, and contributes only 0.9% of the total resources of the system. Extreme politicization transformed the subsidies distributed by the Instituto Nacional de obras sociales (INOS, national institute of obras sociales) and ANSSAL into resources destined to co-opt or reward the political clientele.

Given the sharp differences in average income levels across obras sociales, there are wide disparities in the comprehensiveness of the services that they provide. Expenditure on health services in the higher-income obras sociales is six times that in the lower-income group; the annual number of consultations per beneficiary varies between 1.9 and 8.4, and expenditure on pharmaceuticals by "rich" obras sociales is 13 times that of "poor" ones.

In spite of their large total expenditure, the services provided by the obras sociales have become targets for criticism on several counts. The health care orientation is fundamentally curative, featuring highly specialized services, technology that is not always suited to the demand profile, and heavy reliance on inpatient care facilities. In general, the financing organizations have not participated in the development of service systems, confining themselves to covering the range of services supplied by the marketplace, with no other limit than their own financial capability.

Public services subsystem

The services of the integrated public subsystem are financed through resources from the national budget, and managed by the national, provincial, and municipal governments. The Ministerio de Salud y Acción Social de la Nación (MSAS, ministry of health and social action) is the organization in charge of regulating the entire health services system. Its functions are to set norms, regulate, plan, and evaluate all aspects of health care, including promotion, prevention, treatment, assistance, and rehabilitation. It directly manages five specialized hospitals and special programs such as immunization, maternal and child health care, AIDS, and sexually transmitted diseases (STDs). It participates, through the Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration), in the definition of policies concerning the obras sociales.

Each provincial government is responsible for the health of the province’s inhabitants due to a constitutional power not delegated to the national government or the municipalities. This power is exercised through their respective ministries of health, which in most cases have a centralized structure and a specific budget. In some provinces, the municipalities manage health centres dispensing primary care services and may even have hospitals under their jurisdiction. These services are financed by resources from the municipal budget, and subsidies or transfers from the provincial or national government. The provinces play a considerable role in the health services sector, as more than 75% of public expenditure on health comes out of their budgets. Over the last decade, they have expanded their range of action and organized the sector in accordance with their own criteria and methods.

Figures on health care expenditures by level of government are given in Table 4. In provincial jurisdictions, the expenditure on hospitals amounts to more than 85% of the total. The remainder corresponds to primary care and special programs.

The public hospital is the cornerstone of the public services subsystem. It provides care to the poor who have insufficient or no medical coverage; subsidizes the obras sociales by providing services to their beneficiaries without charge; and occasionally serves higher-income-earners who are attracted by the reputation of a particular institution or its medical personnel. The public hospital is also responsible for providing essential health emergency services; training professionals to the graduate and postgraduate level; and biomedical research.

Nevertheless, the public hospital today epitomizes all the contradictions in the health care system as a whole. It exhibits serious structural deterioration and managerial inefficiency; a high degree of administrative centralization at the provincial level; rigidity in its staffing structure and labour relationships; no adequate system of incentives; inadequate information systems on which to base decision-making and control; serious deficits in facilities and equipment maintenance; and a system of management ill-suited to its size. Its budgets, in most jurisdictions, follow the traditional pattern of assigning resources by function or by set of practices. Hospital budgets are often subject to political pressure.

Current methods of financing are characterized by the following features:

• use of a global budgeting system, with no mechanisms for planning, implementation, or control;

• wages and salaries for hospital personnel, representing about 85% of hospital expenditure, come directly from central administration; and

• no identification of patient coverage, which makes it impossible to determine whether a given service is accessible to the uninsured population or to evaluate the extent to which the hospital is fulfilling its mission to provide services to the poor.

Private insurance

Voluntary insurance plans (empresas de medicina pre-paga) are provided by over 200 organizations, cover more than 2 million people, and pay out more than US $1.5 billion annually. The 72 largest companies account for about 70% of the market, cover 1 740 million beneficiaries and report earnings of US $1.13 billion. They are profit-making organizations that seek clients from among the higher-income segment of the population. The coverage they supply is limited, and different plans are priced according to the level of risk they cover. Contracts establish the period of coverage and preexisting conditions are not covered.

In addition to the private plans, there are more than 3 000 mutual aid societies providing health care services to one million beneficiaries for an amount estimated at US $500 million.

Private profit-seeking insurance companies evolved out of initiatives by groups of professionals or private hospitals, and some of them have reached a significant size. According to the Ministerio de Trabajo y Seguridad Social de la Nación (MTSS, ministry of labour and social security), the majority are organizations designed on a business model with professional management (MTSS 1995). They base their offer on levels of excellence in given areas, and on efficiency, image, and marketing.

According to an evaluation by the World Bank (1995a), existing private insurance schemes constitute a very heterogeneous system with an enormous number of organizations, extremely high operating costs, and little transparency in the areas of competition and consumer protection. There are currently no effective mechanisms to protect users from bearing the brunt of increasingly fierce competition. Its flexible structure undoubtedly allowed the private insurance system to function dynamically as a marginal entity within the health care system in its initial stages. However, this flexibility may now represent an obstacle to maintaining and developing an integrated, transparent, competitive, and universal market.

On the other hand, domestic and international economic conditions in recent years have favoured the appearance of foreign capital in the field of private insurance services. Several of the most important health insurance companies have been sold to American, Swiss, or Latin American companies. Financial groups that entered the market of the Administradoras de Jubilaciones y Pensiones (retirement and pension fund administration firms) and later organized the Administradoras de Riesgos de Trabajo (occupational hazard administration firms), are now looking to expand into the health insurance market via the deregulated obras sociales.

To date, regulatory intervention by the state has been minimal. No regulations exist to govern exclusion or refusal to cover pre-existing conditions. Nor are there any standards with regard to minimum capital, reserves, or reinsurance that insurance services must meet to protect the covered population. All these concepts are part of the debate associated with deregulation of the obras sociales and, at present, the future standards for regulating these enterprises are being discussed in congress.

Organization and provision of health services

The Ministerio de Salud y Acción Social de la Nación (MSAS, ministry of health and social action) is the organization in charge of standardizing, regulating, planning, and evaluating health care activities in the country. It is also in charge of producing epidemiological statistics. Through the Programa Nacional de Estadísticas en Salud, national health statistics program), it collects the scant information available on health services distribution. This program has recently published the Guía de Establecimientos Asistenciales en la República Argentina (MTSS 1995), a guide to health care establishments in the country that traces the supply of services and its evolution over the past 15 years.

Institutions with and without inpatient services

Between 1980 and 1995, inpatient care institutions increased by 10% while ambulatory facilities increased by 100%. A considerable number of these establishments are owned by the private sector, which doubled its facilities from 4 039 to 8 873 during the same period. At the same time, the number of facilities that depend on the obras sociales decreased from 364 to 222, while the number of public facilities increased from 4 648 to 6 971. By 1995, 98.5% of the total number of institutions were either publicly or privately owned, with private sector ownership accounting for 55.2% of inpatient and ambulatory facilities.

A considerable change has also occurred in the distribution of each kind of service. Whereas in 1980, the number of ambulatory facilities was double that of inpatient facilities, the proportion has now grown to 4 to 1. This is particularly noticeable in the public sector, where a 3 to 1 ratio in favour of outpatient facilities has now changed to almost 5 to 1, bearing evidence of the emphasis on primary care centres. At the municipal level, ambulatory facilities have increased from 19.8% to 30.8% of the total number of institutions.

Moreover, in spite of the increase in the number of public facilities in both categories, the sector’s proportion of outpatient facilities has fallen from 57% to 45% while its proportion of inpatient facilities has fallen from 39% to 37%. The private sector has taken up the slack, increasing its share of outpatient facilities from 38% to 54% and inpatient facilities from 57% to 61%. The private sector has thus increased its share of inpatient facilities and surpassed the public sector in terms of ambulatory institutions. The proportion of public and private ownership for all facilities can be seen in Table 6.
 

Table 6. Hospitals and health centres by subsector, Argentina, 1980 and 1990.
Subsector	1980		1990
	n	%	n	%
Public	4 648	51.35	6 990	43.46
Social security	364	4.02	222	1.38
Private	4 039	44.63	8 873	55.16
Total	9 051	100.00	16 085	100.00
Source: compiled by author from various sources.

Beds

The number of beds (public, private and obras sociales) increased by about 10 000 units between 1970 and 1980, and by a similar number between 1980 and 1995. In the first period, the increase occurred in private and social security institutions; in the second, it occurred exclusively in the private sector, as beds owned by the public sector and the obras sociales steadily decreased. These data are illustrated in Table 7.
 

Table 7. Beds in hospitals by subsector, Argentina, 1970, 1980, and 1995.
	1970		1980		1995
	n	%	n	%	n	%
Public sector	96 688	73.0	91 034	62.48	84 176	54.05
Private sector	30 095	22.5	46 611	32.00	67 198	43.15
Obras sociales	4 977	3.7	8 045	5.52	4 375	2.80
Total	131 760	100.0	145 690	100.00	155 749	100.00
Source: compiled by author from various sources.

The following are among the causes cited to explain the decrease in the number of public sector beds:

• the adoption of an orientation toward a health care model based on primary care;

• declining budgets in the public sector due to the fiscal deficit and the measures adopted to overcome it; and

• more judicious use of the sector’s financial resources by introducing focused and demand-driven policies.

With regard to the obras sociales, one must remember that they lost a considerable number of their members due to layoffs in the metalworking sector and the dismantling of a large number of railway branch lines. These events affected two of the trade unions that had developed services of their own. To this must be added the newly introduced permission to contract with the private sector under conditions such as capitation, which allowed the risk to be transferred from the payer to the provider, thus converting the maintenance of facilities into a fixed cost with limited strategic value.

Human resources

As there is no continually updated national register of health professionals in Argentina, one cannot be certain of the actual number of physicians. Nevertheless, the Asociación Médica Argentina (Argentine medical association) estimates the number of physicians at 87 000, giving a national ratio of one physician per 370 inhabitants. In 1958, 1959, and 1980, the estimated numbers of doctors were 24 000, 54 000 and 69 000 respectively. Physicians are distributed unevenly between the capital and the provinces, and between rich and poor provinces. According to the 1980 census, there were 47 doctors per 10 000 inhabitants in Buenos Aires, whereas there were between 15 and 20 doctors per 10 000 inhabitants in 10 provinces, between 10 and 14.9 in other provinces, and fewer than 10 in the four north-eastern provinces.

In 1980, the health sector employed some 290 000 persons, or about 2.9% of the economically active population (EAP). Official estimates for 1985 indicate that the workforce had increased to about 400 000 persons, or 4% of EAP. The distortion in the distribution of the workforce is evident in the fact that at that time there were 90 000 physicians and only 41 000 nurses working in the health care services. The complete distribution is given in Table 8.
 

Table 8. Human resources in health care, 1985.
Profession	Number
Physicians	90 000
Dentists	22 000
Pharmacists	29 000
Biochemists	9 500
Midwives	4 000
Physiotherapists	13 000
Psychologists	25 000
Nurses	16 000
Nursing assistants	25 000
Technicians	90 000
Administration employees	95 000
Source: OPS/OMS (1990)

Transformations in the Health-Service Systems - Organizational Models

Organization of the health services system between the 1960s and 1980s

This analysis will consider only two subsystems in the organization of the health services system in Argentina, because the practice of private insurance only began to intensify in the second half of the 1970s, as a complement or supplement to the social security system. The health services systems (HSS) was composed of a model financed by compulsory social security contributions (obras sociales), with the provision of services by contract, and a model financed

through taxation (public health system), offering a comprehensive range ofservices. The first covered close to 75% of the total population, made up of salaried workers and their dependants, and the second covered about 20% of the population, mainly persons with low incomes and with insufficient or no social security coverage. A small percentage of the population paid for their health care directly and the middle-income segment of the population was covered by various forms of private insurance, as a supplement to social security.

Providers have been classified as follows: public medical centres with salaried doctors; public hospitals with salaried doctors; independent general practitioners and specialists; and private for-profit hospitals, usually employing physicians on a fee-for-service basis. The obras sociales paid the association representing independent professionals and private hospitals for services provided to their members. Public services received global budgets and paid their doctors full- or half-time salaries.

Relationship between third-party payers and providers

The contracting methods were regulated by the Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration) or its predecessor Instituto Nacional de Obras sociales (INOS, national institute of obras sociales). Contract terms and conditions, and forms of payment for services, were established at the national level and applied uniformly throughout the country. By law, the amounts charged for each service had to be established periodically through formalized agreements between representatives of the providers and the obras sociales, with state arbitration in case of conflict. In practice, it was the state that determined the amounts, which were recorded in the Nomenclador Nacional de Prestaciones (national nomenclature of medical fees for services). This list has become the main instrument regulating the service model, because the prices set favoured curative, highly specialized and technology-intensive care. Fees were established on the basis of an accounting unit, the galeno, which was used to adjust payments to inflation. It was also used to modify the relative values of various interventions, with a view to encouraging some and discouraging others.

The predominant method of reimbursing providers was the fee for service. One of the assumptions underlying the model was that professional associations would monitor the quality and volume of services supplied by each physician and, if necessary, apply appropriate discipline. This did not happen, however, nor was any form of control exerted on the part of the financing institutions. Volume was determined mainly between patients and doctors, under circumstances that provided neither with any financial incentive to economize. At the individual level, doctors competed for volume and income.

There was similarly relatively little control over expenditure on pharmaceuticals. The wholesale price of drugs was set unilaterally by the pharmaceutical companies, and prescriptions were decided by each doctor in the absence of incentives to be economical.

Compensation for professional services rendered in private hospitals was based on a rate per day per bed, as set by the national schedule. Added to this was payment for different procedures involving the use of technology, on a fee-for-service basis. Here also, there were no effective controls on volume.

Under these circumstances, the only possible option for cost-containment was cost-sharing by the patients. This led to an increase in the use of and consequent increase in the volume of private services, which was one of the main determinants of the financial crisis in the obras sociales. Third-party financing and fee-for-service payments led to strategies of over-treating and over-charging on the part of individual providers.

The relationship between insurers and providers was ruled by similar conditions in the private insurance sector. A small number of obras sociales developed their own health care services, whereby the transfer of funds was accomplished through budgets and professionals were paid a salary. In the public subsystem, financing was also done through global budgets and salaried doctors. The difference in the amount of payments when compared with the private sector was considerable. On the other hand, failure to keep up with the latest technology, along with a general decrease in available resources, weakened the public subsystem’s ability to attract medical students for postgraduate training.

Supervision at the central level was limited to bookkeeping, with no recourse to performance controls that might have rewarded efficiency and productivity. Budgets for services were renewed annually and remained a more or less constant percentage of fiscal resources. Each provider’s allocation was made without reference to parameters that take into consideration the expected demand or a predefined development program.

Relationship between patients and providers

Under the compulsory, contractual obras sociales system, patients were covered for services that were predominantly curative, whether provided in an ambulatory or inpatient facility. Some preventive activities, such as prenatal and child care, were compulsory for all obras sociales. Nevertheless, they followed the directives according to their own interpretation of priorities or availability of resources. Vaccination was generally supplied outside the system by institutions in the public subsystem.

Patients enjoyed freedom of choice of physician. They could, without being referred, choose to see a general practitioner, an independent specialist, or a specialist working out of a private hospital. Ambulatory-care practices were well equipped and had ample access to the most advanced diagnostic and therapeutic services.

Differences in the availability of resources and inefficiency in their management affected access to health care by beneficiaries of some obras sociales. This situation became apparent in the different utilization rates between ambulatory and inpatient care services, differences that could not be explained by either the epidemiological profile or the consulting habits of the population.

The public subsystem catered to the needs of the poor or "medically indigent" population. The concept of "medically indigent" is relatively ambiguous. A population is considered indigent if it is not part of the formal labour market and therefore not covered by an obra social, either directly or through a family member. Second, individuals are considered medically indigent if they have insufficient medical coverage for certain complex procedures and must therefore have recourse to the public sector, or if they are unable to meet the out-of-pocket expenses required at the time of receiving a service.

In theory, the activity of the public subsystem was regulated by means of plans and programs; in practice, however, it was governed by spontaneous demand. Since the only information collected by these facilities was related to production indicators, it was impossible to develop plans or programs based on population criteria, detect unmet needs, measure accessibility, or evaluate the system’s performance.

Relationship between population and third-party payers

As has already been pointed out, at the height of their expansion, the obras sociales covered close to 75% of the population, comprising the entire wage-earning population and their dependants. Affiliation with an obra social was determined by a member’s occupation. This made for a fragmented system, which weakened the possibility of forming an adequate risk pool. Nevertheless, it had the advantage of eliminating risk selection (discrimination on the basis of risk) by guaranteeing coverage to all beneficiaries under equal conditions, and without regard to their respective contributions.

Obras sociales were required by law to offer a set of general and specialized services. Nevertheless, in this aspect (as in others), the system was incapable of enforcing the rules, and the obras sociales were free to define the services to be covered and the co-payments to be demanded of beneficiaries at the time of receiving care. Their financing source consisted of income-related contributions from employees and employers. The proportion contributed by each changed over the years, from 1% and 2% of salary by the employee and employer, respectively, to 3% and 6%, as established under Law 22.660.

The combination of grouping beneficiaries by occupation and setting contributions proportional to wages made the financial capability of the obras sociales heavily dependent on existing employment and wage levels in each occupation. Insufficient coverage, poor service or excessive bureaucracy induced a small percentage of beneficiaries to procure supplementary coverage through private insurers. The range of premiums was very broad, as was the quality and scope of the services provided.

In the case of the public subsystem, it is not possible to speak of a relationship between the population and the institutions in charge of assigning resources and supplying services. The promotion of forms of "popular participation" underwent periods of ebb and flow, but never constituted a real possibility for intervention by the population in decision-making.

The emerging model

The current subsystems in the health services system (HSS) operate along the same general lines as those already analyzed for the period between 1960 and 1980. One notable difference, however, is the significant growth of the voluntary contract model, in the form of private insurance schemes, particularly those oriented toward the higher-income population. The other changes that support the hypothesis that a new model is now in place will be examined in greater detail with respect to the three subsystems. The two models are depicted schematically in Figures 

1 and 

2. As can be seen, the general structure of the two models is similar, but the relationships between payers and providers have undergone important modifications, as have the distribution of financial and material resources between subsystems, with the intermediary organizations growing in importance.

Relationship between third-party payers and providers

The most important changes in the obras sociales

system have occurred in the relationship between third-party payers and providers, in particular in the use of incentives aimed at ensuring financial equilibrium. This section will begin by relating the changes that have occurred in the various instances involved and in the contractual agreements between payers and providers. Then, it will synthesize the modifications that have occurred in the form of payment for services under the new contractual regime.

Contracts between obras sociales and providers have ceased to be centred in the organizations representing the latter. Deregulation has affected the entire supply system by stimulating suppliers to abandon the protective umbrella formerly afforded by the corporations of providers. The financial crisis of the obras sociales prompted those providers able to secure a better position in a somewhat more open market to abandon corporate contracts. The new groups formed were Uniones Transitorias de Empresas (UTEs, temporary associations of enterprises) or providers’ networks. These were associations of private hospitals, independent professionals, and, in some cases, public hospitals that agreed to contracting conditions with certain obras sociales. These contracts abandoned the traditional form of remuneration, the fee-for-service payment. Instead, they adopted per-capita remuneration and a form little used as yet, of lump-sum payments to diagnostic-related groups or "modules." In this way, the UTEs or provider networks periodically receive a lump sum that they have to manage and transform into fees for services provided to their beneficiaries.

This change in the method of payment has had considerable consequences for both payers and providers. The introduction of per-capita payment - a fixed sum per beneficiary covered by the financing entity - transferred the economic risk from the obras sociales to the provider networks. In this way, the obras sociales gained predictability in managing their budgets. Provider networks were obliged to control their members’ production by developing mechanisms for limiting costs and services so as to assure the viability of the financial scheme for which they were now responsible. These new contracting methods also favoured the appearance in the market of contract management businesses: the Administradoras de Prestaciones (APs, services managers), equivalent to the managed care organizations in the United States. These possessed no facilities of their own, but rather acted as intermediaries between the obras sociales and the providers’ networks, taking responsibility for managing resources put on the market by the obras sociales under the per-capita system. To this end, the APs contracted with one or more provider network and took charge of managing the services thus provided.

The institutions responsible for managing contracts had to discourage their members from over-provision of services or charging for practices not performed. It must also be noted that introduction of the per-capita method came about in a market with an oversupply of providers in relation to the capacity to pay. This required that either all providers in the system reduce their remuneration or that resources become concentrated in those services with the greater marketing or lobbying capability, forcing out part of the existing supply.

The new system, although still somewhat unstable, has so far produced better financial equilibrium. The instability is due to management organizations’ difficulties in controlling their members in the presence of strong incentives to beat the system, especially on the part of those providers with better chances of accruing clientele.

The new method of operation is becoming the norm among obras sociales under the national jurisdiction and has also been adopted by the provincial obras sociales with numerous beneficiaries. The smaller ones, generally found in the poorer provinces with fewer resources at their disposal, have not introduced forms of payment permitting them to transfer the risk to the providers. They continue to record a considerable level of overcharging and over-provision; in some cases have excessive management costs; and control expenditure through the use of co-payments and barriers to access.

Also noteworthy is the private sector’s strategy of investing in improved technology, which was expressed in an acceleration of the rate of capital formation from 1991 onward. The stability in prices achieved through the Convertibility Plan and the stimulation of competition through deregulation suggest an explanation for this tendency, which nevertheless seems contradictory in view of the oversupply of health services and the reduction in health spending. Some analysts think that opening up the economy allowed the country to bring its technological capacity close to that of more developed countries, and that investment in complex technology was a defensive strategy adopted by providers in the face of market saturation. The strategy of product differentiation took the form of acquiring of new equipment (Tafani, 1996).

Voluntary insurance schemes providing services under contract continued to pay for services provided by provider networks or their own institutions on a fee-for-service basis. Their viability was assured in part by the fact that they controlled greater resources per beneficiary than did the obras sociales.

In the integrated public subsystem, the main differences in the relationship between financing and provision of services came with decentralization, when the hospitals were allowed to function independently, as self-managed hospitals. This encouraged them to generate resources of their own, which they could use to improve their facilities or increase the remuneration to their personnel. In some jurisdictions, an attempt has been made to introduce prospective budgets based on expected demand.

Relationships between patients and providers

As noted earlier, the number of beneficiaries in the of compulsory contractual system (obras sociales) declined as a result of changes in the labour market, particularly, the reduction of salaried workers and the decline in the numbers of people employed in, for example, the metalworking, textiles, and railway sectors. Moreover, access to health care by the subsystem’s beneficiaries was also affected during the years of financial crisis by frequent withdrawal of services by providers in response to delays in payment or failure to comply with debt cancellation agreements.

This situation has gradually been rectified since the contracting system was modified as described in the previous section. At present, except for partial and localized conflicts, only Programa de Atención Médica Integral (PAMI, comprehensive health care program) is still subject to reduction or cessation of services to beneficiaries. This obra social, dedicated to pensioners and retirees, is of great significance within the system because of the number of beneficiaries in its charge, the magnitude of resources per beneficiary and, consequently, the total amount of resources it pours into the system. However, for various reasons, it has not managed to put its affairs in order and is currently ungovernable and in need of refinancing.

An additional consequence of the new contracting method is that beneficiaries of other obras sociales have suffered a reduction in the broad choice of both independent professionals and hospitals that they enjoyed under the previous model. Because of the new relationships between payers and providers, the supply of professionals and services has been greatly reduced for each obra social, and beneficiaries can opt only for services from the provider network with which the financing entity has signed a contract. There has been no modification, however, in the right to enter the system at any level and choose freely between general practitioners or specialists, whether in independent practice or integrated into more complex institutions. Nor has there been any regulation of, or limits set to, prescribing by professionals. Expenditure control on pharmaceuticals and procedures is accomplished through cost sharing, as well as audits, in the case of the latter. The introduction of gatekeepers, with a view to rationalizing consumption and containing costs, has been minimal in the system as a whole.

It is very likely that the changes mentioned in contractual relationships between those who finance and those who provide services will have, as a secondary impact, the further stratification of the beneficiary population. This is because contract management has had to become more careful regarding expenditure, and incentives have ceased to encourage over-provision of services or over-charging. Instead they have begun to reward systems that can control consumption. Also, the abrupt fall in inflation now prevents liquidating debts between financing entities and providers through the simple expedient of delaying payment.

The provincial obras sociales have, for the most part, continued with the system of free choice and fee for service, despite evidence that this encourages over-provision. Policies for curbing expenditure are directed toward co-payments, which vary between 20% and 30% of the value of each practice, and applying bureaucratic hindrances to discourage consumption. The population covered by medicina pre-paga (private insurance systems) has access to a relatively sophisticated set of services that over the last few years have incorporated the latest technical advances in matters of diagnosis and treatment at levels that are probably far above the needs of the insured population.

One feature characterizing the evolution of supply in recent years has been the emergence of new forms of health care service, that is some services that were formerly dispensed through hospitals are now being supplied through other facilities. These include emergency services, patient transport, day surgery, ambulatory services, vaccination, and home care. These new organizational forms, the result of the incorporation of new technology in ambulatory care, are concentrated in the metropolitan area and in the larger cities. The greater stratification in the beneficiary population and the greater obstacles encountered by its weaker sectors in getting the health care that they demand, are also reflected in the growing number of obras sociales beneficiaries requiring care from the public subsystem.

The public subsystem has therefore seen an increase in the population it serves, as expressed in the number of consultations and discharges. Other changes to the public subsystem concern to the greater importance assigned to primary (first-level) care, ambulatory service and focused programs aimed at covering high-risk groups. In the case of primary care, the change is apparent in the increase in outpatient services already mentioned. Focused programs form a part of projects financed by the World Bank - the most important at the national level being the Programa Materno Infantil (PROMIN, maternal and child health program) - or originate in local or national initiatives managed at the local level. These would include AIDS programs or food aid for poor families.

Relationships between population and third-party payers

This relationship is being deeply modified by government decision and strongly resisted by the trade unions, the net beneficiaries of the existing system. If the government succeeds in imposing its authority, employees will no longer be forced to join the obra social representing their occupation and will instead be able to channel their contributions into the institution of their choice. This strategy, called deregulating the obras sociales, is strongly backed by the World Bank and currently being put into effect after a 2?year delay in being sanctioned by decree. In the first year, the beneficiary will be able to choose from between all the obras sociales dependent upon the Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration). Support by the World Bank has been expressed in the form of a credit designed to regularize the financial situation of organizations wishing to be included in the program; to finance layoffs of redundant managerial staff; to obtain technical advice on updating information services; and to establish cost-control mechanisms.

The deregulating strategy is intended to promote competition in order to encourage efficiency in the management of resources by every obra social. Second, it is intended to stimulate mergers between obras sociales with few beneficiaries in order to reduce the number of institutions and increase the number of beneficiaries per institution, thereby obtaining an adequate risk pool. The main obstacle to rationalizing the existing system comes from the enormous disparities between obras sociales in terms of the amount of contributions per beneficiary. If the low-income population should move en mass to the obras sociales with higher per-capita resources, it is likely that this would lead to the collapse of the few institutions with balanced finances.

To address this problem, it has been resolved to limit the coverage that each obra social is obliged to provide to a “package” of services determined by the Programa Médico Obligatorio (PMO, compulsory medical package). The cost of the package is estimated at US $40 per month for each entitled beneficiary and attached family group, and ANSSAL guarantees that minimum contribution to all entitled beneficiaries in the system. Those wishing to attain a higher level of coverage, or to have smaller co-payments when they need health care, will make supplementary contributions. That is to say that, above a basic minimum of services established by the PMO, there will be different coverage plans based on a person’s ability or inclination to pay. In this way, the model incorporates the individual’s own assessment of risk, which it is supposed will facilitate more rational management of available resources.

The policy of rationalizing the financing of health coverage and eliminating the subsidization of one subsystem by another also applies to beneficiaries of obras sociales who seek care from public services. The establishment of self?managed hospitals that are empowered by decentralization to manage resources has, as one of its aims, to identify the insured population availing itself of public services, in order to recover the cost from the appropriate obra social or private insurance company.

The need to cut expenditure has led a majority of public institutions to solicit contributions (bonos voluntarios) from the uninsured population requesting care. On the heels of this practice has come a revival of the cooperadoras or asociaciones de beneficencia - updated names for charitable foundations - to take charge of managing such resources. For example, a hospital purchases and installs, on its own or with the help of private resources, an expensive piece of equipment such as computerized axial tomography. This equipment is then made available to other public institutions at a lower price than that current in the private sector. The foundation undertakes the management of the resources thus collected and directs the investment policies of the hospital applying the innovation. The future ability of private insurance companies to attract beneficiaries under schemes of compulsory social security contributions has put the need to regulate such foundations, which up to now have governed themselves through free enterprise, on the political agenda. Legislation is being discussed at the parliamentary level.

Health service system regulation

The structure of health services in Argentina has been characterized by a very weak presence of the state in the form of regulatory activity. According to the National Constitution of 1853, jurisdiction over health care activities belonged to provincial governments. However, as institutions representing the medical profession built in strength during the 1920s, the provinces gradually delegated various regulatory functions, such as the granting of licenses, the certification of specialists, the installation of private facilities, and, later, the supervision of private insurance organizations, to professional corporations. Medical schools flourished under the control of the academic professional sector, partly by virtue of university autonomy sanctioned by the reform process of 1918. Something similar happened in public health institutions under national, provincial, or municipal jurisdiction. Although regulation was in the hands of state officials or “technocrats,” doctors predominated in decision-making, and in their role as state officials. They defended their supposedly superior knowledge as professionals in regulating aspects concerning setting standards, defining priorities, organizing services, and controlling their practices.

Relatively early, therefore, the medical profession achieved autonomy from the state with respect to regulating the training, licensing, specialization, and practice of its members, following the model prevailing in Anglo-Saxon countries. With the development of health and social security, the medical profession lost part of that autonomy, particularly in matters relating to working conditions and remuneration, because the financing institutions were under the control of the trade unions, with or without participation by state officials. At the same time, independent professionals and enterprises owning private hospitals set up their own associations. In the 1950s and 1960s, these professional associations, or corporations, developed a considerable ability to defend their professional interests. They controlled the contracting for the provision of services to beneficiaries of obras sociales, to the point where they formed an oligopoly.

In 1970, the state attempted to assume control of health and social security by extending coverage under the obras sociales to the entire population of employees. The professional associations were forced to accept arbitration from the Instituto Nacional de Obras sociales (INOS, national institute of obras sociales), in which the presence of the Confederación General del Trabajo (CGT, general labour confederation) carried decisive weight. Even then, the state presence continued to be weak, and negotiations between professional associations and trade unions centred chiefly on the regulation of professional fees and charges.

The professional associations applied all the negotiating skills that they had developed under the previous circumstances (contracting freedom) to the new institutionalized relationship with the obras sociales. Contract specification, terms of payment for services, and the procedures specified in the Nomenclador Nacional de Prestaciones (national nomenclature of medical fees for services), as well as their relative prices, were all established by professionals in their role as advisors to the professional associations. The profession also managed to play a fundamental social role by imposing principles such as freedom of patients to choose their doctors; the freedom of doctors in prescribing, the fee-for-service basis of payment, and the exclusive right of professional organizations to control the ethical, technical, and scientific aspects of their members’ practices.

Thus, the regulatory model in effect between the 1960s and the 1980s featured the predominance of the medical profession at practically all levels of activity: in the development of standards for meeting the health needs of the population; in the organization of services of all kinds; in the training of medical and paramedical personnel; and in the definition of contracting methods, working conditions, and remuneration.

On the other hand, no direct regulation or control was applied to the specific work environment (consulting room, operating room, or hospital ward), in which the professional established a relationship with the patient in privacy. Decisions concerning the diagnosis of needs and the resources necessary to resolve them, the content of prescriptions, and follow up were likewise unregulated. Standards founded on particular scientific knowledge were assumed to have been incorporated by the professional during training and therefore excluded from supervision - not as an intrinsic professional right, but because it was believed to be the only guarantee of the efficacy of the therapeutic bond. Hence, it was not a question of the professional associations regulating and supervising their members’ practices, but of each of those members applying particular judgments to complex situations in a personal and private relationship with the patient. It was supposed that the efficacy of such a relationship would be compromised by the intervention of a third party not authorized by the professional.

Another area likely to be subject to regulation and control in the future is that of the management of contracts at the macro level according to a standard-of-performance indicator that would provide information on the balance between needs, demand, and the production of services. This function has not been carried out at any of the levels where it might have been, mainly: the corporations representing supply in the planning of contracts; the obras sociales responsible for managing the resources in their charge; or even the state itself, as being responsible for the functioning of the health services system overall.

Thus, regulation of medical practice gradually weakened because of growing specialization and the rise of existing or potential situations of conflict in specific areas of activity. The literature usually differentiates between distinct and potentially conflicting fields of professional interest as follows: academics, services management, and professional practice. Divergent roles, occasionally fulfilled by the same professional, led progressively to the shaping of specific interests in, or approaches to, professional conditions and methods of application.

In the case of Argentina, that differentiation evolved gradually and in a relatively peaceful way as the services system grew and diversified. On the other hand, the struggle for control of social security contracting brought out potentially conflicting interests in the form of two powerful rival associations representing independent professionals and private hospitals, respectively. The rivalry between them had been relatively restrained during the years of financial stability, but became a struggle as resources dwindled. The struggle was not expressed as a conflict between associations, however, but became the daily preoccupation of individual practitioners as they attempted to avoid losing ground.

The scenario changed with the deregulation of supply. Our working hypothesis is precisely that the change in relationships within the health care system led to a change in the instances and methods of regulation. Centralized regulation disappeared with the reduction of the Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration) in terms of function and political weight, and the elimination of the oligopoly over supply in the hands of the associations. The freedom in pricing and form of payment that characterized the new contracts deprived the Nomenclador Nacional de Prestaciones (national nomenclature of medical fees for services) of regulatory value, such that its list prices were no more than suggestions.

Because of contracting freedom, the most common means of regulating the system is generated by the play of the market, which existed but had little weight up until now. Payers and service providers freely negotiate capitation values and devise lists of professionals, services, and procedures covered by the contract. Admittedly, the result scarcely constitutes an open market because of the continued oligopsony (a market situation in which a few buyers control the demand from a large number of sellers) and of the limited number of providers’ networks or Uniones Transitorias de Empresas (UTEs, temporary associations of enterprises) representing the supply in each locality. Nevertheless, there is complete freedom to sign or rescind such contracts. There is no existing entity superior to the contractors themselves to assume control of the signed agreements. In the face of failure or voluntary retreat on the part of the state, there has been no rise in the system of consumers associations or obras sociales beneficiaries capable of defending the public interest.

There has also been a weakening of professional regulation of the organization and management of services. Under the previous model, the professionals had to come to an agreement with the managers, but directors of institutions were sovereign in their own sphere of action to made decisions exclusively to generate benefits for the whole. This situation has now been transformed through risk contracts paid on the basis of capitation. Capitation means that a pre-established sum per beneficiary, per month, is paid to the provider organization. Payment is dispensed for actual services rendered according to pre-established rates on a fee-for-service or other basis. Thus the interests of each individual provider in maximizing production conflicts with the profitability of the organization as a whole, and managers must be vigilant to ensure that the services produced do not exceed the amount available for payment.

Transferring economic risk from financing institutions to service providers through per-capita payments leads to a new regulatory challenge that rests with the directors of the provider network or in the service management organizations. New managers arise who may or may not be health professionals and whose function is to defend the interests of the provider networks, partly to the detriment of its individual members. The new financing mechanism discourages over-provision or overcharging. Supply-side management becomes an indispensable instrument for guaranteeing the profitability of the whole, but clashes with the traditionally accepted autonomy of the professional in decisions related to the doctor-patient relationship.

Attempts to control the system ex-ante, through previous authorization of practices, have proved ineffective. Attempts to control it ex-post, through statistical techniques, do not always make it possible to identify individuals physicians responsible for deviating from the norm. Thus, renegade conduct endangers the permanence of the new model.

Discussion

To finalize this presentation, it is necessary to identify clearly the subsystem where the most important changes in the health service system have occurred, bringing about modifications in financing, regulation, organization, and provision of health care. It is equally important to distinguish these from those subsystems in which the changes have been quantitative (in terms of population covered), but insufficient to alter the institutional design. The public subsystem and the private voluntary insurance subsystem, which provide coverage to about 50% of the population, have not had any essential aspects of their function changed by the reform projects.

In the case of the private insurance system, this may be because its organizational methods are governed by the logic of deregulation and the freedom to contract that guided the reform policy. Nevertheless, the possibility that at some time in the future these institutions might draw beneficiaries away from the social security subsystem necessitated the approval of a regulatory framework aimed at preventing discriminatory practices, such as refusing coverage to people with pre-existing conditions or in specific risk groups. This regulating legislation has not yet been passed.

As to the public subsystem, the main reform measure applied was decentralization, from the national government to the provincial or municipal governments. There has also been some progress toward the implementation of self-managed hospitals, in particular in the matter of obtaining additional financing by billing the obras sociales for care provided to their beneficiaries.

The most ambitious proposals, however, have yet to be implemented: those aimed at separating financing and provision by establishing demand-subsidizing methods. In some jurisdictions, concern with costs is slow to sink in; the licensing and accreditation process has made no headway; and no instances are known of setting budgets on the basis of production, efficiency, or the epidemiological profiles of the covered population.

The subsystem that has undergone the most sweeping changes has been the social security or obras sociales subsystem. Even in this case, one must to differentiate between the changes that have occurred in the financing institutions and the changes affecting provision, especially those that have occurred in the relationship between them.

It may be useful to begin by considering the reforms that were proposed but not fully implemented, mainly, the decree concerning the deregulation of the obras sociales, which was blocked by opposition on the part of the Confederación General del Trabajo (CGT, general labour confederation). If that deregulation had been adequately implemented and generally supported, the form of risk-sharing would have changed. It would have been possible to concentrate contributions in the obras sociales with the most efficient performance and the formation of risk pools of adequate size. This was the main objective of the proposal, but it has so far only been partially implemented.

The reforms that have truly been accomplished are those related to contracting freedom between payers and providers. Their effect on the services system has been manifold, affecting money flows, methods of payment, the weight of management in the system, forms of access to health care, and the organization of the services network.

The changes introduced have brought about modifications in the relative weight of each of the recognized methods of regulation:

• Central regulation residing in the Administración Nacional del Seguro de Salud (ANSSAL, national health insurance administration) has disappeared because it functioned fundamentally as a negotiating forum between payers and provider corporations.
• State regulation has been weakened further because the state has not assumed the function of controlling the system nor of generating information regarding its operation, standards, or quality.
• The most important nucleus of regulation is located at the intermediate level, and is expressed through the guidelines regulating contracts between payers, intermediaries, and direct providers.
• Professional self-regulation is still in effect, with as much weight as before in shaping human resources policy, controlling licensing and specialization, and defining standards of practice. Nevertheless, the power of the profession has been weakened in its ability to organize and manage services, and the financial balance of the system has limited the profession’s role as agent.

The analysis of the process of change does not make it possible to recognize a new organizational model functioning in a clearly defined way. On the contrary, we are faced with a very changeable scenario in which old actors and new try to consolidate their presence in the system by redefining the rules that govern their interactions. This results in a highly stratified scenario, both with regard to the population and its demand for services, and with regard to the appropriation of material and technical resources on the part of the providers. The present study does not make it possible to define excluded sectors, that is, those sectors with unsatisfied demands for care. On the contrary, the Argentine system continues to be characterized by the availability of relatively complex services to all population groups. The specific form in which each demand is resolved, however, may lead to exclusion from access to technical resources, which are unevenly distributed within the services system.

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