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Health services for whom?

On a recent trip to Barranquilla, Colombia, I met a young woman who had been diagnosed with a brain tumor. At the time, she lived with her mother in a poor neighborhood. They both worked, and the young woman was also studying in the evening.

If she had received her diagnosis a decade ago, this young woman would have had serious cause for alarm. At that time, there was little chance that a person of her means could have received timely and effective treatment from a public hospital—although a wealthy person could have readily obtained care at a private facility.

But the young woman’s story ended happily. Under Colombia’s new health system, she had enrolled in an insurance plan with a local Health Promotion Enterprise, which gave her access to the surgery she needed. Her insurance was part of a broader set of reforms designed to reorganize the country’s health care system to make it more directly accountable to the public, including the poor.

Colombia is not alone. Countries throughout Latin America are reforming their health systems to increase fairness, widen access, and improve quality. Examples of such reforms were the subject of a recent conference called “The Challenge of Health Reform: Reaching the Poor,” cosponsored by the IDB, the World Bank and Costa Rica’s social security agency. Participants from Guatemala recounted how the country adopted a new policy for purchasing basic services through nongovernmental organizations that has enabled 3.5 million rural people to receive modern health care for the first time. Other participants, such as the director of a program in Massachusetts, United States, described efforts to reach segments of the population that still lack private health insurance.

These initiatives reflect a profound shift in thinking about health care. After years in which political debates raged over the issues of “privatization” and “efficiency versus equity,” there is a growing consensus that real changes come only when new ways are found to hold public providers accountable for the health care of every citizen. Thus, both the government of Costa Rica and the Municipality of Bogotá are experimenting with “performance agreements” for their public hospitals. In return for greater financial discretion and autonomy, the hospitals agree to submit to annual budget reviews where they must demonstrate that their funds were effectively used in providing actual services. In other cases, countries are working to make health services accountable by giving the poor the same options that are available to the rich, such as buying health insurance or purchasing health services from the physician, clinic, or hospital that they believe will serve them best. This is the approach adopted by Colombia’s health reform, which subsidizes health insurance for the poor. In that country, the number of people covered by health insurance in the poorest 40 percent of the population increased from 8 percent to 53 percent in the span of five years. About eight million Colombians who formerly had little or no access to health insurance, such as the woman I met in Barranquilla, are now covered.

In addition to supporting the Guatemalan and Colombian programs described here, the IDB is helping to finance health reform initiatives in countries including Argentina, Bolivia and Brazil. In each case, the focus is on promoting institutional changes that will improve equity by giving people choices and making providers accountable for the quality of their services.

* The writer is a senior economist in the IDB’s Social Development Division.

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