Labour and social dimensions - Sectoral Activities

List of abbreviations

AARN

Alberta Association of Registered Nurses (Canada)

AFL

Alberta Federation of Labour (Canada)

AIDS

acquired immune deficiency syndrome

AMA

Alberta Medical Association (Canada)

FONASA

Fundo Nacional de Salud (National Health Fund -- Chile)

GDP

gross domestic product

HMO

health maintenance organization

ILO

International Labour Organization

ISAPRE

Instituto de Salud Previsional (pre-paid private health insurance plan -- Chile)

LA

Los Angeles (USA)

Medi-Cal

California health assistance programme for the poor, funded by the state and US federal government (USA)

OECD

Organisation for Economic Co-operation and Development

PAHO

Pan American Health Organization

RHA

Regional Health Authority (Alberta, Canada)

SEIU

Service Employees International Union (USA and Canada)

SERMENA

Servicio Médico Nacional (National Medical Service for Employees -- Chile)

SNS

Servicio Nacional de Salud (National Health Service -- Chile)

SNSS

Sistema Nacional de Servicios de Salud (National System of Health Services -- Chile)

UNA

United Nurses of Alberta (Canada)

WHO

World Health Organization

Executive summary

Advances in science and technology and ageing populations have made health care increasingly expensive at a time of slow growth in developed economies and constrained government budgets in developing economies. As a result, there has been widespread restructuring of health systems to achieve greater efficiency, reduce costs and extend coverage. Many public health systems are experimenting with privatization of parts of their health sector, among other reforms.

As governments and societies consider how best to structure health care systems for maximum efficiency and equity, several key issues have emerged. These include the proper roles of government and of private markets; the mechanism used to allocate available health resources among competing demands; and the utilization of human resources in this labour-intensive sector.

The International Labour Organization recognizes that health care personnel are central to the performance of health systems and that, in turn, the efficiency and equity of the systems determines the health protection of all workers. Several ILO Conventions and Recommendations are concerned specifically with conditions of personnel in the health and public sectors. Therefore, the organization attaches great importance to the reforms which are underway in this sector. The ILO Salaried Employees' and Professional Workers' Branch has commissioned the present paper pursuant to requests by health and public sectoral meetings of the organization to study the impact of structural adjustment and privatization of health systems on the employment of health workers and on health service delivery.

Health systems are complex structures whose major components interact to establish incentives and constraints which significantly determine system performance. Therefore it is essential to approach any analysis of such systems by studying the major structures involved. The current paper presents the analytic and economic concepts necessary to evaluate health systems, with a brief description of the functional components of any system: finance, delivery and the allocation mechanism. Because this study is concerned with privatization, particular emphasis is placed on factors which make it more likely that either governments or markets will perform a given function better. The conclusion here (and a growing consensus among health policy experts) is that governments are better positioned to organize the financing of health care, because of the advantages of establishing the largest possible risk pool and the greater ability to control costs when there is a single payer with monopsony purchasing power. With respect to delivery systems, both public and private arrangements have distinct strengths and weaknesses. There is not a consensus that one is superior, and the three case-studies indicate that the allocation mechanism may be an important determinant of the efficiency of either public or private delivery systems. The fee-for-service allocation mechanism is prone to cost escalation. Capitation systems can produce better cost containment (although they do not necessarily do so) but there is the danger that appropriate health care will be denied. In private delivery systems, either allocation mechanism requires government regulation to correct for market imperfections.

Health care is a labour intensive sector, with salaries and related expenses typically accounting for 50-75% of total sectoral costs. Health labour markets exhibit certain characteristics which must be kept in mind when evaluating health systems overall and employment effects specifically. Health professions require years of specialized training and so there is a long delay between labour market signals of over- or under-supply and a response in the number of entrants to the profession. Without overall human resource planning and market guidance (which usually requires a government role) there is likely to be overshooting, with surpluses or shortages of particular skills. Scope of practice regulations, designed to protect the public from unqualified health personnel, can also introduce rigidities which make the health sector inefficient and may be used by professional associations to seek rents.

Chile

Chile undertook the first privatization of a public health system in 1981 under the military government. It is studied here both because Chile has been looked to as a model of social sector privatization by some other governments and because the system's 16 years' experience presents an extensive record from which lessons may be drawn.

The Chilean reform allowed workers to assign their mandatory payroll contribution for health care to private insurance plans called ISAPREs. This had the effect of diverting resources from the public system. The government also made deep cuts in the fiscal contribution to the public health system. As a result, the public system deteriorated sharply, health employment fell and real wages in the sector declined. There was virtually no input on the restructuring by consumers or health care workers, although a few of the largest employers were consulted.

The private ISAPREs grew slowly but now cover about 25% of the population. They are very profitable, primarily because they have been successful in seeking out the healthiest and higher-income segments of the population. The public system covers the less healthy, lower-income 75% of the population, although it receives only a little more than half of all health financial resources to provide for this higher risk group. The result has been long waiting lists for care in the public system.

Since the restoration of democracy in Chile, the government has steadily increased the resources devoted to the public health system, but 15 years of low investment left an infrastructure and human resource deficit which has not yet been overcome. Most modern equipment is concentrated in the ISAPREs. Public health sector employment and compensation levels are still low compared to the early 1970s. There is now a dual labour market in the health sector, with higher wages and better working conditions in the private plans. The government has gradually begun to increase public sector wages and strengthen labour laws governing health workers.

Opinion polls show that the health system is a major concern to the Chilean public, and the government has attempted some structural reforms in addition to pumping more money into the public system. The ISAPREs have become a powerful political actor, however, and have been successful in blocking any serious reform.

Alberta, Canada

In 1993, a newly-elected provincial government in Alberta began a major restructuring of the publicly funded, privately delivered health system there. The provincial system is part of Medicare, the national single payer health system in Canada which is funded jointly by the federal and provincial governments and, in Alberta, also through premium contributions by households. Health spending had grown to 30% of the provincial government's budget; the reform sought to cut the contribution by 20%. A major emphasis was placed on institutional changes which were intended both to control costs and shift more of the burden for health care to the private sector. Health care premiums charged to households were increased and retired citizens were required to pay premiums for the first time.

The Alberta government allowed clinics to charge additional fees, beyond the Medicare payment, directly to consumers, which is not permitted under the Canadian single payer system. The federal government, which provides about 24% of the finance for the provincially-run system, withheld funds to Alberta until the province backed down and eliminated the fee co-payments. The single payer arrangement is seen by the federal government as key to the control of health care costs and to the ability of the government to manage the allocation of health resources. Private insurance is not allowed for any service covered by the public health programme, because of concern about the migration of financial resources from higher income groups to the private sector, as happened in Chile.

Another major objective of the Alberta reform was to shift the delivery of health care out of hospitals to less expensive settings. When the budget cuts were made, employment in the health sector was cut by almost 20%. Most of the lay-offs were among hospital staff. Some funds were transferred to pay for an expansion of care in lower cost facilities, such as nursing homes and home care, but there has been at least a temporary gap in the continuum of care. Waiting lists developed for hospital-based procedures. As a result of public and health care union pressure, some funding has been restored to the system, including provision to restore about 11% of the positions which were eliminated.

There is an ongoing effort to change the skill mix of health care workers to make the use of human resources more efficient and cost effective. Most unions are participating in the effort, although critical of the restructuring process. Major changes in scope of practice regulations are being proposed.

Los Angeles County, USA

The county government in Los Angeles provides a safety net of health services to the poor and uninsured in the county and the main emergency and trauma services for the public as a whole. This system is funded by federal, state and local governments. The burden on the county system has grown in recent years, due to a growing tendency by private employers not to provide insurance to workers (employment-based insurance has been the main source of health finance in the USA), economic recession and increased immigration.

Federal funding to the county system was limited in recent years by caps imposed by the US federal government to rein in its health care expenditure. In 1995, California moved from a fee-for-service allocation system to a capitated (managed care) system for state welfare recipients. This meant that the county public health system stood to lose at least part of its revenue to private managed care firms. Recently, the State of California cut off state funding for all but emergency and obstetric services to undocumented immigrants.

The combination of these changes in the funding stream and the structural problems identified above led to a severe budget crisis for the county, which responded by deciding to close the largest of the six public hospitals. Reaction by affected unions, public health advocates and the surrounding community was intense. Through a process of confrontation and cooperation, the county and these stakeholders evolved an alternative plan to seek federal funds to keep the hospital open while the county restructured toward more outpatient-based and preventive care and prepared to compete with private-managed care plans for state funds. The federal government agreed to provide additional funding based on a five year plan to eliminate hospital beds and expand primary care through clinics.

Two years into the plan, the county has eliminated about 20% of its hospital beds and is proceeding with plans to privatize the two smallest public hospitals. Primary care has been expanded mainly through contracts with private clinics. The unions have cooperated with the restructuring and have participated in designing a programme to retrain and reallocate the workforce toward primary care. About 10% of the county health workforce has been laid off. The unions won an agreement that these workers would have first right to positions created in the private clinics.

The short-term survival of the county health safety net has been assured and restructuring has produced efficiencies which should lower costs in the longer term. However the structural imbalance between increasing demand, from the growing proportion of the population which is uninsured, and constricting supply, due to severe revenue limits from public sources and competition by private-managed care plans for the insured poor means that the system is not in equilibrium. Recent federal decisions to limit the duration of welfare benefits means that many of the insured poor will join the uninsured in the future, producing even greater strain. The microeconomic efficiency gained through the Los Angeles restructuring will not be enough to offset these macroeconomic forces.

Conclusions

The paper concludes with a comparison of the lessons which can be drawn from the three cases studied for other governments and social partners considering health care reform. The discussion of which functional roles are best suited to either government or private markets is revisited in light of the empirical results of the three cases. The choice of mechanism used to allocate available health resources is discussed with material drawn from the cases. Finally, issues in the utilization of human resources, employment outcomes and health labour market policy are addressed. In each discussion, emphasis is placed upon long term implications of health system reform.

Selected cases in the Americas
by Sandra Polaski*

* At the time of the study's preparation, consultant on labour issues in health services and, at the time of this publication, Director of Labor Law and Economics Research at the NAFTA labour-related secretariat. Ms Polaski can be reached at the Secretariat, Commission for Labor Cooperation, 350 N. St. Paul, Suite 2424, Dallas, Texas 75201, USA. E-mail : polaski@naalc.org.

1. Introduction

Health care is a fundamental human need, essential for the full realization of the potential of individuals and societies. Scientific and technological advances in health care have prolonged human life and improved its quality, and have raised the productive capacity of individuals, expanding the wealth of global society.

But these advances have also made the delivery of modern health care to entire populations an expensive endeavour. As societies grow wealthy, the demand for health care increases and its provision grows to be an important sector of the economy. In the G-7 countries, health care accounted for an average of 9.3% of GDP in 1994.⁽¹⁾ In advanced, diversified economies it may be the single largest sector, as in the United States, where it accounts for over 14% of GDP. For developing countries, the imperative to improve the health of their populations is both an ethical and economic necessity, but it is constrained by the scarcity of resources and the need to prioritize their use to achieve optimal results. The average expenditure on health for all developing and transitional economies is about 4.5% of GDP, with wide variations between countries and regions.⁽²⁾

The importance of health care to human and economic development, coupled with its high cost, make it critical that this sector be organized in the most efficient and equitable manner possible. Over the last two decades, developed countries have experienced increasing strains on their economies from the share of GDP consumed by this sector; developing countries have faced reductions in already scarce available resources due to structural adjustment programmes. These stresses have led to widespread restructuring and experimentation with new organizational models for the health sector. The fact that the problems are widely prevalent has served as an impetus for comparative study of health systems to glean the lessons of experience.

The International Labour Organization is among the international organizations which have undertaken comparative studies of the sector. The ILO recognizes that health care personnel are central to the performance of health systems and that the efficiency and equity of the systems determines the health protection of workers. The ILO Salaried Employees' and Professional Workers' Branch has commissioned the present paper pursuant to requests by health and public sectoral meetings of the organization to study the impact of structural adjustment and privatization of health systems on health service delivery and the employment of health workers.

This study presents three cases in which governments have undertaken major reorganizations of health systems, including the privatization of some functions. The cases studied are the reorganizations of the national health care system in Chile, the provincial system in Alberta, Canada, and the local public health system in Los Angeles County in the USA. The three examples are important in themselves and because they are looked to as possible models by other countries and governmental jurisdictions grappling with similar problems. They were selected because they illuminate the pivotal issues of current restructuring efforts and debate. There are three key issues involved. The first concerns the proper role of the State and the role of the market in financing and delivering health care. The second key issue is how to allocate available health resources among multiple competing demands. The question here is how to organize institutions and incentives in the health sector to optimize allocation in terms of both efficiency and equity. The third key issue concerns health care labour markets and labour utilization. Health care is a labour intensive industry; the organization of human resources is an important determinant of the efficiency of the sector.

Each of the reorganizations is evaluated for its macroeconomic results in terms of efficiency, including its effect on government spending, and for its impact on equity and access to health services. The paper then examines the interaction between the reorganization and sectoral employment, wages, working conditions and labour-management relations. There is also a review of the degree and nature of participation by workers, unions and consumers in the process of reorganization.

Health systems are complex structures whose major components interact to establish incentives and constraints which significantly determine the performance of the systems. In order to understand the impact of a change in structure (such as privatization) on employment, efficiency and equity it is essential to analyze the core components of health systems, including finance, service delivery and the allocation mechanism used. Analytic and economic concepts necessary for doing so are presented in Section 2. The focus is on characteristics which distinguish health care from other sectors with respect to the functioning of governments and markets. The aspects of health economics addressed are those which are specifically relevant to the public-private mix and the question of privatization. The basic allocation mechanisms are also covered in this section. An overview of employment issues in the health sector is presented in Section 3. The interests and mandate of the International Labour Organization in this area are identified in this section as well.

The case-studies are presented in Sections 4 through 6. In each, a brief description will be given of the existing health system before restructuring was undertaken. The nature of the reform will then be described, as well as the objectives and motivations for the changes. Empirical results of the changes will be presented for the major categories of evaluation: efficiency, equity, employment and participation. The Chilean restructuring, which took place in 1981, is considered first. It was the earliest and most radical privatization of a public health care system and thus provides the most extensive experience on which to draw in assessing results. The next case considered is the province of Alberta, Canada, which undertook a major restructuring of a publicly financed, privately delivered health system beginning in 1994. Finally, the case of Los Angeles County in the USA is examined. In this example, a public system covering the poor and uninsured has undertaken restructuring and privatization of delivery of some services, beginning in 1995.

Section 7 of the paper compares experiences in the three cases. The lessons that can be taken from the experiences regarding efficiency, equity, employment and participation are drawn out for other governments considering reforms.

2. Analytic and economic concepts

Overview

To analyze and compare health care systems it is necessary to disaggregate their overall structures into three main functional components which make up any health system. These are the organization of finance (sources of funding), the organization of health service delivery (health care providers and facilities) and the mechanisms used to allocate available resources to health applications (linking finance to delivery).

The organization of finance and delivery may be either public or private; existing health systems exhibit an array of combinations of roles for government and the private sector in each of these functions. There are theoretical economic arguments which suggest that either public or private actors may be better suited to certain functions, because of tendencies of either to certain kinds of failure which should be anticipated in the design of reforms. These theoretical predictions are outlined in the discussion of each function below. For some functions, most notably finance, there are fairly extensive empirical results which confirm the predictions of theory and these will be noted as areas where optimal policy is fairly clear.

The third category for analysis, the mechanism used for resource allocation, is the link between finance and health services. This aspect of health systems determines how available funds actually are spent by the myriad decision-makers in health systems. Different allocational mechanisms create different incentives for providers. As a result, they produce quite varied outcomes, even where the available level of per capita finance is similar. The main existing allocation arrangements are discussed in the section on allocation of resources below. Some of these mechanisms can function in either public or private systems.

Finance

The major sources of funding for health systems are national taxes, local taxes, social insurance (mandatory contributions by workers, employers or households), private insurance and direct payments by users. Public finance systems typically combine tax revenue (public) and mandatory social insurance (quasi-public) sources of funds, and may also raise revenue through user fees. Private finance systems are based on direct user payment for services or prepayment through private insurance; insurance plans may also require co-payments at the point of service.

Both social and private insurance systems pool funds from a group (the risk pool) and use the funds to pay costs for those individuals in the group who actually utilize health services. This spreads the risk over the entire group and lowers the average cost of health care for each individual. If the population is divided into numerous risk pools, then risk may not be distributed evenly. In such a segmented insurance situation, risk pools with higher proportions of healthy individuals will require fewer health services. The insuring entity will thus be left with surplus (or profits) from the funds collected to cover that group. If the insurance market is competitive and premiums can vary, the segmentation of risk pools may lead to lower insurance costs for healthy individuals, in effect splitting the surplus between the insurer and the insured. Private insurers will have the incentive to engage in what is called risk skimming, the selection of those likely to incur the lowest health costs, in order to realize profits. Individuals with high risk (those in greatest need of health care) may be unable to obtain insurance. Where a public system coexists with a private system, risk skimming may shift those in greatest need of health care to the public system, making the average cost of care higher in that system, while diverting resources (insurance premium payments) into the private system. This tendency by private insurance markets to avoid risk means that efficient financing (in terms of matching all available resources for health with the full health risk exposure) requires creation of the largest possible risk pool. In practice, only public finance systems have achieved optimal risk pools. Even countries with sophisticated regulatory capability have not been able to prevent risk skimming in private insurance markets or mixed public/private insurance systems.

There is also an important consequence for equity of segmented risk pools. The scope for redistribution is narrowed or eliminated as the risk pool is fragmented. The ability to use funding from affluent and healthy individuals and groups to finance health care for low income groups, those at high health risk or for underserved geographical regions is curtailed if mandatory premiums or tax payments can be funnelled into a private insurance plan which pays for services incurred only by participants of that plan.

Another aspect of the organization of finance which has efficiency consequences for health systems concerns the relationship between the funder of health care (the payer) and the providers. If there is a single payer, that entity enjoys monopsony bargaining power over providers and is thereby better able to control costs. The only single payer systems are public finance systems providing universal coverage. In a system where there are multiple payers, a similar result could theoretically be achieved through effective coordination among them. This has been difficult to achieve in practice, however, even where sophisticated machinery exists, as in Germany. In multiple payer systems, cost shifting between payers has dominated. The greater the number of payers, the greater is the dominance of cost shifting over cost containment.

Finance of health systems is one area of policy where both theoretical and empirical approaches point in the same direction as to the best route to achieve optimal efficiency results. In both OECD and middle-income developing countries, those that have contained costs best while achieving health outcomes comparable to higher spending countries "have greater government control of health spending and a larger public sector share of total health expenditures."⁽³⁾

As it turns out, the finance model which produces the greatest efficiency is also the model with the greatest potential for equity. A large government share of expenditures allows for greater risk pooling and greater redistribution within the risk pool across income groups, age groups, vulnerable groups and individuals and regions.

Delivery

Health service delivery systems may be either public or private, including in systems where finance is public. Public and private systems each exhibit some specific strengths and some serious weaknesses which must be actively managed. Unlike the case of health finance, there is neither a theoretical consensus nor empirical evidence that either public or private models of health care delivery consistently produce superior results compared to the other model. This is true for efficiency as well as for equity results. In many cases, the allocation mechanism appears to be more important than whether a delivery system is public or private as such.

The strengths of public systems will generally include economies of scale, because of their large size relative to segmented private systems. They allow for systematic planning of infrastructure and human resource needs for the entire population. Because public health functions such as immunization, sanitation and communicable disease control are typically provided by the public system, an integrated public delivery system can combine prevention, primary and curative care as a continuum, which from the point of view of medical science will produce the best results.⁽⁴⁾ In terms of weaknesses of public health systems, the need for rules and predictability in large public systems introduces rigidity which may inhibit response to changing demand at the consumer level. The rigidity may also delay response to knowledge-based changes in technique or organization. Where public and private systems coexist, the rigidity may impede strategic changes by the public sector in response to organizational change in the private health sector. In a mixed public-private environment, such delays can lead to increased risk shifting or cost shifting from the private to the public sector.

Private health delivery systems may be more responsive to changing demand. They may be more flexible in their use of resources and inputs and more readily able to adopt new technologies and organizational structures. However, the main strengths of private markets in other sectors the use of prices as allocation mechanisms and competition as a means to efficiency work less well in the health sector. For markets to produce efficient results, there must be competition between providers and symmetrical information between providers and consumers. Competition works to eliminate excess profits and inefficient use of resources. Reliable and equivalent information shared by consumers and providers will allow consumers to choose the most effective and efficient providers, thus moving the overall system toward greater efficacy and efficiency. Private health delivery systems are widely recognized to be imperfect markets, because the numerous submarkets which comprise them tend not to be perfectly competitive (as discussed below) and because there is very significant asymmetry of information between consumers and health care providers. The nature of health care itself, as a determinant of well-being or even survival of the individual consumer, results in a weakening of the price mechanism as an efficient means for optimizing the use of resources. The consumer's elasticity of demand is lower for essential health care than for most other consumption. If a third party, whether the government or a private insurer, is paying the fee, the consumer's sensitivity to cost will be lower still. Thus, the essential conditions for markets to succeed are either absent or inadequate in health care markets.

The major submarkets which make up private health care physicians' services, hospitals, managed care organizations and pharmaceuticals each exhibit some degree of market failure. With respect to physicians, markets have typically been organized as private or small group practices. The resulting market structure has tended toward monopolistic competition, in which providers can charge more than their opportunity costs because of perceived quality differentiation and a high degree of asymmetry of information between providers and consumers. These markets are further distorted where physician organizations restrict the supply of physicians through their role in accreditation of individuals and training institutions. Hospital and pharmaceutical markets tend to be oligopolies or monopolies because of economies of scale, high capital requirements, sunk costs, operating licenses, patents and other barriers to entry. They also exhibit product or service differentiation and high information asymmetry. In the case of integrated private delivery systems (managed care), such as health maintenance organizations (HMOs), the market structure tends toward oligopoly. Managed care businesses typically have very high capital requirements for entry because they combine both insurance and health care delivery functions and thus must finance reserve requirements as well as infrastructure; they require sizable risk pools; there are important economies of scale in both provision of services and purchasing power; and there may be sunk costs and licensing barriers to entry as well. Because these major submarkets within private health delivery systems are imperfectly competitive, market power leads to rents and prices (relative to opportunity costs) above those in the surrounding economy.

Another efficiency loss that occurs with private systems is that they do not contribute to public health functions such as immunization and other disease prevention activities, public health education and environmental health measures such as sanitation, as noted above.

Allocation of resources

Allocation mechanisms can be grouped into three broad models: integrated public systems, fee-for-service systems and capitation systems. In integrated public systems, both finance and delivery are organized by the government. Allocation is primarily a matter of centralized planning and budgeting. Such systems may exist at the national, provincial (state) or local level. The focus in this model is on the supply of health care inputs, including physical facilities, health care personnel and equipment.

In contrast to integrated public health systems, fee-for-service and capitation models are utilized in systems in which finance and delivery are distinct, whether public, private or mixed. Fee-for-service systems allocate finance to health care providers on the basis of services actually rendered. The decision about what services should be supplied, and how much care should be consumed, are made jointly by the individual provider and the consumer. The incentive for the provider is to increase the amount of health services utilized to increase revenue. Because of the high degree of asymmetry of information, the influence of the provider is very great in the consumption decision. As discussed in the previous section, the consumer's elasticity of demand for health care may be very low. Payment by a third party will further reduce the consumer's usual price sensitivity. As a result, fee-for-service allocation mechanisms tend to produce overconsumption of health care and higher total health expenditure, all else being equal.

Capitation systems allocate resources by paying a fixed amount per capita to a provider or group of providers in advance of service utilization. The providers agree to provide all necessary health care to the covered beneficiaries for the fixed capitation payment. The incentive for the providers is to limit the amount of health services utilized, either by keeping beneficiaries healthy, or simply by restricting access to services. Thus, capitation reverses the incentives present in fee-for-service allocation, from the point of view of the provider. Instead of overprovision of services, the incentive here is for underprovision of health care. As with fee-for-service, the capitation allocation mechanism can be used in either a public or private system.

The risk that covered individuals will require health services is borne by the payer (government or private insurers) in fee-for-service models. In capitation models, the risk is borne by the provider. In both fee-for-service and capitation models, the focus is on demand for health care, rather than on supply, as in the case of integrated public systems.

Each of these allocation models has strengths and weaknesses. The different incentives that they create for individual providers and consumers often lead to unintended distortions in the system as a whole. There is no mainstream consensus that any one of them is optimal, and this is currently an area of extensive experimentation. Various combinations of these models are utilized in the three case-studies, and will be examined in depth there.

3. Employment

Despite increasingly sophisticated technology and improvement in inputs such as equipment and pharmaceuticals, health care remains a labour intensive industry. Therefore the functioning of health labour markets is an important determinant of the efficiency of the sector. Further, the health sector is a significant source of employment in the society.

Health labour markets exhibit a number of specific characteristics which must be kept in mind in evaluating health systems. The major health professions, including physicians and nurses, require years of training. There is a long delay before labour market signals of over or under supply are translated into changes in supply of health professionals. In the case of nurses, for example, there have been sharp swings in compensation in recent years in OECD countries such as the USA and Canada. Low nursing salaries in the 1960s and 1970s led to low numbers of entrants into the profession. As demand grew in response to demographic and funding changes, nurse shortages arose, which pushed up salaries, especially during the late 1980s. Enrollment in nursing schools grew in response and there is now downward pressure on wages.⁽⁵⁾ Such swings in availability and cost of specific grades of labour in the health sector complicate planning and lead to inefficiency.

Other distortions may be created in health care labour markets by scope of practice regulation, through which public or professional bodies establish binding restrictions as to which professionals may perform various functions. The basic thrust of such regulation is sound, since it is designed to prevent insufficiently trained health practitioners from working beyond their levels of knowledge. However such regulations can be rigid, artificially restricting the assignment of tasks which can change based on constantly evolving levels of training as well as changing technology and clinical practice. Further, lobbying by practitioners' associations, particularly those of physicians and other very highly skilled professions, can easily combine rent seeking with legitimate concerns about patient safety and the desire for appropriate returns to education. Because there are large disparities in salary levels among health professions, the allocative inefficiencies of such restrictions can be substantial.

Gender concentration in certain professions probably accounts for some of the high disparity in salaries. In all of the cases studied here, physicians are predominantly male while nurses are predominantly female. This means that scope of practice restrictions may have adverse equity consequences, in addition to any efficiency problems they create.

The size and labour intensity of the health sector has made it an important sectoral interest for the International Labour Organization. Employment levels, wages, conditions of work and gender disparities are the subject of numerous ILO Conventions and Recommendations. The Nursing Personnel Convention, 1977 (No. 149), deals specifically with terms and conditions of employment for nurses and their participation in determining these conditions.⁽⁶⁾ These issues will be addressed in the case-studies.

4. Privatization of health care in Chile

Overview

The military government which took power in Chile in 1973 under General Augusto Pinochet made major policy changes in the health sector there. The partial privatization of the public health care system in 1981 was the most radical. It was the first of a now-growing number of restructurings in various countries aimed at transferring portions or functions of public health systems to the private sector. After fifteen years' experience, the Chilean case presents the most extended record on which to draw in evaluating the impact of such policy changes on government, consumers, employers and the health sector workforce, as well as the consequences for cost efficiency, equity and quality.

Currently, some governments and policy advisers look to the Chilean privatization as a positive model. As such, it carries a significance even beyond its importance within the Chilean national context. However, the now lengthy Chilean experience gives reason for serious concern as to whether this approach will achieve either efficiency or equity goals. Since the restoration of democracy in 1990, elected governments have reversed many of the health policies of the military regime. The privatized portion of the health system, however, has resisted change, with negative consequences for the overall performance of the health sector.

Background

The health system which existed before the military coup in the early 1970s had been built over five decades, beginning in the 1920s, by successive Chilean governments, unions and employers. In 1952, the various elements of the system were consolidated and centralized in the National Health Service (SNS, Servicio Nacional de Salud). The public health sector continued to develop as part of one of the most extensive social welfare systems in Latin America. By the early 1970s, about 90% of the population were covered by three public health systems. The largest was the SNS, which provided free care in public facilities to about 65% of the population, roughly those in the bottom three quintiles of household income. This plan encompassed most blue-collar workers and their dependents (roughly half of the population), as well as the uninsured poor (about 17% of the population). Finance for the plan was provided by workers' payroll contributions through a social insurance scheme and for the poor, from general government revenue. The SNS also provided preventive public health services for the entire population, financed by general revenue. A second service, the National Medical Service for Employees (SERMENA, Servicio Médico Nacional), was introduced in 1968. This was a separate payroll-based insurance system which paid part of the costs of health care for white collar employees and their dependants. SERMENA benefits were paid through a voucher system, with individual beneficiaries deciding whether to obtain health services through the public system or private providers. SERMENA covered about 20% of the population, roughly the fourth highest quintile of income. About 5% of the population was covered by publicly funded health services for the armed forces and police. The remaining 10% of the population were primarily upper-income households which financed their own health care and utilized private providers.

Mandatory payroll contributions by all employees were set at 4% of payroll, allocated to either SNS or SERMENA. Public spending on health, including budget contributions by government and the mandatory social insurance contributions, was approximately 2.9% of GDP as of 1970.⁽⁷⁾

The public health sector was centralized in its administration. SNS operated all public health services. It built and maintained hospital and clinic infrastructure and trained and employed most health sector professionals and other workers. Planning of both human resource and physical infrastructure needs was conducted centrally. Geographical coverage was quite extensive, relative to Latin American health systems of the period. In addition to the health services already described, Chile also had an extensive and interconnected system of maternal and child nutrition support programs. Public health clinics identified pregnant women and children suffering from or at risk of malnutrition, and provided them with food supplements and additional health monitoring.

A private health sector also existed, composed primarily of individual and group professional practices. While most physicians and other professionals worked for the SNS, many maintained private practices on the side, delivering services to affluent private payers and affiliates of the SERMENA system. In addition, a few industries such as banking, construction and copper operated prepaid medical plans (cajas) for their white collar employees, funded by both employer and employee contributions. Such plans covered about 2% of the population. Private expenditure for health care grew as a proportion of total health expenditure up to 1969, but fell somewhat in the early 1970s as a result of higher state spending on health under the Salvador Allende government. Estimates of the proportion of private spending in the health sector during this period vary, with figures for the late 1960s ranging from 53% to 60%.⁽⁸⁾

Despite the notable successes of the pre-1973 health system, there were significant shortcomings in equity and adequacy of supply of health services. A 1968 government survey found that 60% of total health expenditure was consumed by the wealthiest 30% of the population. At most income levels, health services were deemed to satisfy only about half of the demand for them.⁽⁹⁾ Whether and to what extent the system was redistributive, and if such redistribution was progressive, is a matter of strong disagreement among analysts.⁽¹⁰⁾ In spite of these limitations, the Chilean health system and its planning apparatus were widely considered a model in Latin America, for their scope, efficiency and lack of corruption.⁽¹¹⁾

Privatization and restructuring

The military government reorganized the health sector through a series of funding, policy and institutional changes in the 1970s and early 1980s. The first changes after the 1973 coup consisted of a series of sharp funding cuts to the public health system. Health spending by the State was reduced approximately 15% in 1974 and an additional 22% in 1975. These early cuts were partly a response to macroeconomic instability, notably annual inflation of over 600% and a large fiscal deficit. However, they also reflected the strongly neoliberal orientation of the economic advisors to the military government, who favored a much smaller public sector and a "subsidiary role of the State".⁽¹²⁾ The contraction of public spending had the intended effect of increasing the private share of health expenditure, which grew by 22% from 1974 to 1976.⁽¹³⁾

While overall public health spending and services were reduced, the regime followed a policy of targeting resources to the poorest segments of the population. For example, the pre-existing maternal and infant health and feeding programmes were maintained but more narrowly targeted. This had the effect of converting what had been a preventive programme into a curative programme for those already suffering from malnutrition.⁽¹⁴⁾

In 1979, the military regime introduced the first institutional restructuring of the health system. The major elements of this initiative were the reorganization of funding and service delivery and the exclusion of the Chilean medical society (Colegio Médico) from its long-standing official role in policy formulation, wage-setting and professional regulation. In the reorganization, the functions of policy formulation, service delivery and finance were separated into three distinct institutions. The role of the Ministry of Health was narrowed, with an emphasis on policy formulation and regulation. The SNS, renamed the National System of Health Services (SNSS, Sistema Nacional de Servicios de Salud) was decentralized into 26 regional health service delivery areas with devolved responsibility for operating hospitals and outpatient clinics in each region. Primary health clinics were subsequently spun off to municipal administration. A separate agency, the National Health Fund (FONASA, Fundo Nacional de Salud), was established as the funding mechanism for the public health system. FONASA was responsible for collecting and distributing health finance. The main sources of finance continued to consist of workers' mandatory payroll contributions, federal budget contributions and co-payments (user fees) from middle- and higher-income users of the public system. Any participants in the public system could also opt to use private providers, by purchasing vouchers from FONASA. The level of co-payments required for use of private providers was higher than in the public system.

Another aspect of the reorganization was a significant shift in the approach to allocation of resources. In contrast to the earlier allocation of finance, under which funds were distributed to support the centrally planned supply of services (the number of hospital beds, medical personnel and other inputs), the new approach put emphasis on the demand side. Reimbursement was made on a fee-for-service basis for services actually delivered. There were two important exceptions to the fee-for-service allocation mechanism. Salaries and other personnel expenses continued as a direct budget allocation. Employees of the SNSS facilities continued to be public employees, directly employed by the Ministry of Health. The other exception to the fee-for-service approach covered investment in infrastructure and fixed costs.

The second major institutional change made in 1979 was designed to break the political and policy power of the Colegio Médico.⁽¹⁵⁾ The physician's group had been a major opponent of the defunding of public health services by the military regime and its plans for institutional restructuring. Historically the group had been an important actor in health policy, with legal input into medical policy, fee schedules and the salaries of physicians and other health sector workers. The organization also had legal standing as a professional regulatory body. Membership was mandatory. As part of the 1979 reorganization, the government eliminated the formal role of the Colegio Médico in health policy formulation and wage setting, and made membership voluntary. It also forbade gatherings of doctors for non-clinical purposes, thereby eliminating the possibility of their unionization in response to the downgrading of their role.

Another round of institutional restructuring, which proved to be the most significant of the many profound changes in the health system, was undertaken in 1981. The government authorized the creation of private, for-profit health insurance plans (ISAPREs, Institutos de Salud Previsional). The ISAPREs were allowed to compete with FONASA for workers' mandatory payroll contributions. Employees could now enroll themselves and their dependents in the ISAPREs, which in turn would provide health care services through private providers with whom they contracted or in their own facilities. This meant that a portion of the mandatory quasi-public contribution to the public health system could now be redirected to the private sector, thereby diverting an important source of finance from the public system. The insurance risk pool was also segmented as a result, into a public and numerous private risk pools. The new plans were loosely modeled on the cajas which existed in a few industries for higher salaried workers. Several of the initial ISAPREs were modifications and expansions of existing cajas. The structure of the plans is similar to that of some types of health maintenance organizations (HMOs) in the USA and elsewhere, although co-payments for services are higher and more extensive in the ISAPREs.

The government's motivation in creating the ISAPREs was both to continue to downsize the public health system and to expand the private sector by attracting private investment and thus building up a competing infrastructure and delivery system.⁽¹⁶⁾ From the beginning, the ISAPREs sought to attract the highest paid and healthiest segments of the population. They accomplished this through their fee structure, which exceeded the mandatory 4% payroll contribution and therefore required an often substantial additional voluntary contribution; they also required co-payments for many services. In many plans, risk skimming to select the healthiest possible risk pool was also accomplished through explicit exclusion of women of child-bearing age, individuals with existing medical conditions and other high-risk individuals, such as the elderly. There were no legal restrictions on the ability of the ISAPREs to siphon off the healthiest segments of the population (those least expensive to care for) from the public system. This was in keeping with the Pinochet government's general philosophy of deregulation in the newly privatized sectors.

Initially the ISAPREs grew much more slowly than anticipated, in part because their inception coincided with the severe recession of 1982-83. Falling real wages and unemployment of 30% of the workforce caused a sharp contraction of private demand, including in the health sector.⁽¹⁷⁾ Some of the weaker ISAPREs went bankrupt, and were taken over by the government. The recession in Chile was a product of the world recession and the related debt crisis, aggravated by aggressive private sector borrowing and weakness in the country's recently privatized and largely unregulated banking sector. The government took over large parts of the failing financial system and underwrote private debtors with exchange rate preferences. The government had achieved a fiscal surplus by the late 1970s as a result of spending cuts, including those for health.⁽¹⁸⁾ But now the deficit ballooned again. The new fiscal deficit was created by the public expenditures on behalf of high-income sectors, by the recession itself and by government spending necessitated by the privatization of the social security pension plan in 1981.⁽¹⁹⁾ The government addressed the new deficit through further cutbacks in health and other social spending and even more aggressive efforts to shift health finance and delivery to the private sector. The mandatory payroll contribution rate was increased to 5% in 1983, to 6% in 1984 and to 7% in 1986. In 1983, the co-payments required in the public FONASA system were increased sharply. In aggregate, the consumer price index measured a 134.8% increase in health care co-payments by the end of that year.⁽²⁰⁾ Government spending in the health sector was curtailed by an additional 20%. Thus, a further major shift of expenditure to the private sector was accomplished.

The higher mandatory payroll contribution rate and higher co-payments in the FONASA system made the ISAPREs relatively more attractive to a somewhat wider pool of workers. The government took further steps to increase their utilization, including a tax break for employers who contributed up to an additional 2% of payroll (above the mandatory 7% contribution by employees) to fund the higher ISAPRE premiums. As the economy recovered in the mid-1980s, the ISAPREs began to grow. The failed ISAPREs which had been taken over by the State were reprivatized. By 1988, about 12% of the population was covered by the private plans; the number rose to about 15% by 1990, and to about 20% by 1992. The figure is currently about 25%. As of 1995, the rate of growth appeared to be slowing.

As the ISAPREs grew, there was an increasing public perception that the unregulated status of the plans had given rise to abuses, including the discriminatory exclusion of women and elderly already noted and what was seen as price gouging.⁽²¹⁾ In 1989, the military government, which had begun regulating some other privatized sectors where problems had arisen (such as banking and finance), drew up plans for a Superintendency of ISAPREs to regulate the organizations. A new law required the plans to provide lifetime contracts, which only the affiliated individuals could cancel by withdrawal; previously the ISAPREs issued only annual contracts, giving them the ability to cancel coverage for subscribers who developed health problems. The law also forbade discrimination against women, the chronically ill and the elderly, which had formerly prevailed.

The military government lost a popular plebiscite in 1988 through which it sought a mandate to continue in power. As a result, presidential elections were held in 1989 and a civilian, Patricio Aylwin, was elected and took office in 1990. The new government debated whether to implement the Superintendency and other measures adopted by the military regime or to pursue a more thoroughgoing reform of the controversial and unpopular ISAPREs.⁽²²⁾ The final decision was to implement the limited oversight and regulation enacted by the Pinochet government.

The level of government spending on the public system has been significantly increased by the civilian governments since 1990, in response to widespread discontent with waiting times, deteriorating facilities and other quality problems in the public system. Opinion polls show the health system to be one of the top issues of concern among the public, reflecting both the inadequacy of the public system and criticism of the ISAPREs. For example, the ISAPREs were ranked lowest among insurance and financial institutions in a widely cited recent public poll.⁽²³⁾ The two democratically elected governments since 1990 have attempted to achieve better quality in the public system and greater equity overall. But the allocation of a disproportionate share of finance to the private plans has circumscribed the possibility of redistribution and quality improvement, even with substantially greater fiscal effort.

The regulations governing the ISAPREs were revised in 1992 and again in 1995; among other provisions, these changes placed restrictions on the frequency with which the ISAPREs can increase their rates. There is ongoing consideration of measures to increase transparency, including establishment of basic benefit packages to make the private plans more easily comparable by consumers.⁽²⁴⁾ However, the fundamental structure of the health sector remains a source of public dissatisfaction and a topic of debate. No political consensus has emerged on whether or how to reform the system.

Evaluation of the effects of privatization

Categories for analysis

The effects of the privatization and related restructuring of the health care system in Chile are divided into the following categories for analysis: the political process involved; the impact on the economic efficiency of the health sector; the budgetary repercussions for the government; the results in terms of equity and quality for consumers of health care; and the effects on employment, wages and working conditions in the sector.

The political process of restructuring

Before turning to the outcomes of the Chilean reforms, it is important to bear in mind the process under which the reforms were undertaken. The Chilean restructuring was marked by a virtual absence of participation or political input by employees in the sector, including medical professionals, health care consumers or the public in general. All of the major decisions on funding levels, privatization and the specific institutional transformations were taken by the military government and its economic advisors during a period when the national congress was dissolved and political parties were forbidden to undertake political activity, thus eliminating any checks or balances.⁽²⁵⁾ Without elections and with no legislative apparatus, there was no formal mechanism for public or sectoral input to these decisions. The labour movement was a specific target of repression after the 1973 coup.⁽²⁶⁾ Repression and unemployment (especially in the downsized public sector) reduced union membership to one-third of its previous level. Collective bargaining was banned from 1973 to 1979; when re-allowed, it was under a new and restrictive labour law, which limited bargaining to the firm level, and curtailed the right to strike. The Colegio Médico, as discussed above, was excluded from policy-making and stripped of its previous status and role in the health system. The government did consult informally with the largest employers, who generally welcomed the increases in employee contributions as a way to cut down their own direct and indirect contributions to health care.⁽²⁷⁾ The ability of the government to reduce the size of the public health sector, shift costs to individuals and reduce wages and employment for health sector workers and professionals was a result of the authoritarian nature of the regime.⁽²⁸⁾

Economic efficiency

The partial privatization of the finance of health care is the most significant of the reforms in terms of the impact on economic efficiency. The introduction of the ISAPREs led to a diversion of increasing portions of the mandatory payroll contributions away from the public health system. The private plans also segregated portions of the overall risk pool of the population into separate, smaller risk pools. As discussed above, the private plans aggressively sought (and still seek, under somewhat restricted terms) the healthiest and wealthiest segments of the population. As a result, they receive the maximum quasi-public revenue (7-9% of the highest salaries) while incurring lower costs than the public system because of the superior health status of the population they cover. The adverse impact of this segmentation on the public system has been quantified in a World Bank study:

The ISAPREs, by targeting the richest segments of Chilean society, impoverished the rest of the social insurance system. Each salaried beneficiary who chose to shift to an ISAPRE cost the public system 2.5 times the contribution of an average salaried worker. Because the ISAPREs are permitted to rate individual health risks, they have "skimmed" the population for good risks, leaving the public sector to care for the sick and the elderly.⁽²⁹⁾

As of 1990, for example, ISAPREs received 45.5% of all expenditures on health care, through payroll contributions, additional premiums and co-payments. The public system received 54.5% of expenditures, through payroll contributions, co-payments and federal and municipal fiscal contributions.⁽³⁰⁾ However, while receiving nearly half of all health spending, the ISAPREs provided care to only about 15% of the population. The public system was responsible for about 70% of the population, which was covered by the FONASA system. It also served as provider of last resort to the 12% of the population not covered by either insurance system, a group which turns to public hospitals when in need of care.⁽³¹⁾ Thus the share of resources flowing to the public system has been cut dramatically, without a commensurate reduction in the burden of providing care. The consequences for equity of this division of resources will be discussed below.

In terms of economic efficiency, the separation of risk pools has meant that a small, relatively young and relatively healthy segment of the population receives a disproportionate share of health resources, while the much larger, older and less healthy segment is undersupplied. This is not an efficient allocation in terms of the overall health of the population. Expressed in the paradigm of investment in human capital, higher marginal returns to investment in health would be achieved by allocating a greater proportion of resources to the underserved population in the public system. These theoretical concepts are supported empirically through the experience of societies with single risk pool, single payer financing schemes compared with those employing multiple source financing and segmented risk pools. For example, the United States, which has a multiple payer health financing system, has consistently experienced costs which are about 40% higher than those of Canada (14% of GDP compared to 10%). The Canadian system has single payer public financing with a single risk pool in each province. The two countries have comparable private health delivery systems, similar income levels and similar health outcomes.⁽³²⁾ Both relied until very recently on fee-for-service allocation mechanisms. Thus most of the vast difference in costs between the two health systems must be attributed to the different modes of finance.

There are many channels through which multiple payer finance leads to higher overall costs. Multiple payers have incentives to shift costs to other payers, while single payers have incentives to control costs. Cost shifting is evident in the risk skimming behaviour of the ISAPREs discussed above. In addition to having the incentive to control costs, single payers have the power to do so through their monopsony bargaining power over providers of health care. In multiple payer systems, by contrast, the payers lose some bargaining power, which providers gain, over prices. Providers and private payers both have some ability to shift costs to other payers through manipulation of billing.

Another source of higher costs arises if private plans have market pricing power due to market concentration. In Chile, the six largest ISAPREs enrolled 85% of all ISAPRE participants as of 1990; there was a positive relationship between the size of the ISAPRE and the level of profit.⁽³³⁾ The top six plans still controlled almost 81% of the market as of 1995.⁽³⁴⁾ The tendency toward oligopolistic market structures is characteristic of HMO plans like the ISAPREs, as noted in Section 2. Another related channel through which multiple payer systems generate higher costs is administrative costs, including advertising, recruitment, premium and co-payment collection and fee negotiation and payment. Of the 45.5% share of total health expenditure that the ISAPREs received in 1990, they retained 23% of that amount as either profits or administrative costs.⁽³⁵⁾ The average return on capital and reserves among ISAPREs was 40.5% in 1990; the average return for the period 1986-90 was 34.8%.⁽³⁶⁾

In fragmenting the risk pool and reallocating resources between the public and private systems, the partial privatization was not cost efficient and it also was not pareto efficient.⁽³⁷⁾ It may have produced better health care for a small segment of the population, but at the expense of the large majority, which suffered a deterioration as a result.

Effect on government

The effects of privatization and restructuring on the fiscal burden of the Chilean government can be divided into three distinct time periods or phases. The first was the period of cutbacks of government contributions to the health system, which prevailed during most of the military regime. The second is the subsequent period in which the cutbacks have been reversed, mainly since the return to democratic government. The third period is the projected impact of privatization on the state in the future, resulting from the segmentation of the risk pool, possible shifting of retirees from private plans to the public plan and demographic changes. These phases are discussed in detail below.

Table 1 presents public spending on health in per capita terms and as a share of GDP from 1974 to 1993. Figures for 1970 are included for comparison.

Table 1. Public spending on health, 1970, 1974-93⁽³⁸⁾

Year

Per capita, 1992 pesos

Percentage of GDP

Year

Per capita, 1992 pesos

Percentage of GDP

Year

Per capita, 1992 pesos

Percentage of GDP

1970

21 601

2.9

1980

17 789

2.1

1987

18 213

2.3

1974

18 712

2.7

1981

16 152

1.9

1988

20 849

2.4

1975

14 498

2.6

1982

16 941

2.3

1989

20 614

2.2

1976

13 543

2.2

1983

13 479

1.9

1990

19 361

2.1

1977

14 650

2.2

1984

14 241

2.0

1991

22 440

2.4

1978

16 202

2.0

1985

13 745

1.9

1992

26 535

2.6

1979

15 952

1.8

1986

13 428

1.8

1993

29 149

2.7

The figures include both contributions from central government revenue (from taxes and other sources) and mandatory payroll contributions to health insurance, that is, both public and quasi-public sources. This is the standard definition of public expenditure used by the World Bank, OECD and others. Figures from FONASA indicate that the share of total public health spending that came from the central government budget was about 49% from 1974 to 1984, dropped to 39% from 1985 to 1990 and then rose to 46% from 1991 through 1994.⁽³⁹⁾ Applying these percentage shares to the data in Table 1, central government contributions amounted to only about 1% of GDP from the late 1970s to the mid-1980s, then dropped to as low as 0.7% of GDP in 1986 before starting to recover slowly. It is only since the re-democratization that the central government contribution as a share of GDP has once again exceeded 1% and continues to grow.

Despite the limitations of the data, and while spending varied from year to year, the trend was clearly for much lower public spending from 1974 until the late 1980s. Government health spending cuts during the period after 1974 reduced the fiscal burden and initiated what has been termed passive privatization, or cost shifting to the private sector, mainly individual consumers.⁽⁴⁰⁾

Reduced spending within the public health delivery system was primarily manifested in lower employment levels and lower salaries for physicians and health care workers (discussed in the final subsection of Section 4 below) and in reduced investment. Capital investment fell from about 9-10% of total public health expenditure in the early 1970s to 2-4% during the period 1974-88.⁽⁴¹⁾ The combination of lower investment and lower employment over a period of fifteen years produced a marked deterioration of infrastructure and long waiting lists for services in the public sector. These results were not unintended by the military government, which, as noted, sought to reduce the role of the State in the health sector. However, the depth of the spending cutbacks while the public system still provided care to the overwhelming majority of the population led to what was widely described as a crisis in the health system by the mid-1980s. Professional medical associations and others began to strongly criticize shortages of personnel, medicine and supplies, as well as the deterioration of medical technology and infrastructure.⁽⁴²⁾ The regime began to increase health expenditure beginning in 1987 in response to the widespread crisis of confidence in the health system. Since 1990, with the return to civilian government and the restoration of normal democratic channels for the expression of public sentiment on social policy, public spending on health has been increased significantly. Table 1 shows that public health expenditure per capita surpassed 1970 levels for the first time in 1991. The share of this increasing budget devoted to investment has been tripled compared to the late 1980s.⁽⁴³⁾ In light of the public discontent and responsive decisions taken by the two democratic administrations since 1990, the fiscal cutbacks under the military regime can be interpreted as having created a deficit of infrastructure and personnel which is now being addressed through much higher levels of spending. In this sense, the burden of public health was not shifted from the State to the private sector to the degree it appeared at the time. Rather, the earlier spending cuts can be seen as a shift of government spending to the future, with the accumulated deficit now being paid out of current revenues. In one study, the amount that was cut from public health spending from 1983 to 1991 was calculated as the equivalent of US$1.85 billion. This amount is quite comparable to the estimate made by the new democratic government in 1990, which assessed that the need for infrastructure repair and technological upgrading in the public health system would cost US$1.5 billion.⁽⁴⁴⁾

The "passive" privatization of the health sector pursued by the military regime had among its objectives to call forth greater effort from the private sector, which in practice meant mainly from private households. This was accomplished by several mechanisms: the increase in the mandatory payroll contributions from 4% to 7%; in the private sphere, the premiums (above the mandatory 7%) and co-payments required in the ISAPREs; and in the public sphere, the mandatory co-payments for middle and higher income users. Whether the aggressive restructuring accomplished this goal is ambiguous at best. A recent study by the World Bank, which attempted to overcome shortcomings and omissions in health expenditure data by various methods, found that, as of 1990, 53% of health expenditure occurred in the private sector.⁽⁴⁵⁾ While there is no directly comparable study for earlier periods, various analysts have estimated the private share of expenditure in the late 1960s at 53% to 60% of total health spending, as noted in the background subsection above. Further, the sharp increases in health spending by the federal government in the six years since the 1990 World Bank study suggest that the current ratio of private spending is probably 50% or less, a proportion which is typical of Latin America as a whole.⁽⁴⁶⁾

The preceding discussion took into account only the "passive" privatization of health care. A second major impact on the government stems from the partial privatization of the finance and risk pools. This "active" privatization produced results which are more longlasting and difficult to either manage or to reverse than the effects of the cuts in central government funding. The result of the active privatization has been an increase, rather than a decrease, in the public burden in the health sector, since a significant share of private contributions to health expenditure, the mandatory payroll deductions, have been diverted from the public system to the ISAPREs, while the responsibility for providing care to 75% of the population continues to rest with the government. The figures given in the previous subsection on the allocation of resources to the private health sector relative to the size of the population served give a broad indication of the public burden which has been created by the partial privatization. In the absence of fundamental restructuring, this burden will continue to require sharp increases in government spending in the future, the third time-period for which effects must be considered. As noted above, the share of spending in the public system provided by the federal government has already risen from 39% in the 1985-90 period to 46% in 1991-94, without yet achieving a satisfactory equilibrium between supply and demand.

A further potential problem for the future period looms in the prospect that increasing numbers of the elderly will switch from the ISAPREs to the public system as premium and co-payment costs in the private plans continue to rise while their incomes decline in retirement. Although the first reforms to the ISAPRE system in the late 1980s legally limited the ability of those plans to terminate coverage because of age, the cost of the plans to the beneficiaries often produces the same result. If retirees who have contributed to the ISAPREs during their working lives migrate to the public system at the point when their medical costs are rising because of ageing, this will create what has been described as an impossible financial burden on the public system.⁽⁴⁷⁾ The segmented risk pools prevent health care expenditure smoothing over the life-cycle, since surpluses accumulated during younger, healthier periods have been retained by the ISAPREs as profits. Despite the earlier regulatory reforms banning discrimination, as of 1992 more than 70% of ISAPRE affiliates were under age 40 while only 2% were 65 or older.⁽⁴⁸⁾ The coverage of the elderly population is one of the current issues in the debate over reform of the system. The private plans have opposed government proposals to set aside a small portion of the 7% payroll contribution to prefund retirement health coverage.⁽⁴⁹⁾

Effect on equity and quality for consumers of health care

The public and private health systems provide distinctly different levels of spending for participants, with consequences for equity and quality of care. Within the public system there are also differences in contribution levels, which will be discussed as well.

A broad measure of the differences between the public and private systems is the amount of spending per individual beneficiary. One report for 1990 put per capita outlays by the public system at only 22% of those by the ISAPREs.⁽⁵⁰⁾ In 1994, according to FONASA, the average private sector per capita outlay was US$280, while in the public sector it was US$170, or 60% of the private level.⁽⁵¹⁾ While the two sets of data are not directly comparable, it is likely that the increase in government spending since 1991 has narrowed the gap between the systems to some degree. Nonetheless, there continue to be long waiting lists in the public system. Facilities are still in need of expansion and repair, even after five years of sharply increased public investment. Most modern technological equipment and supplies continue to be concentrated in ISAPRE facilities.⁽⁵²⁾

The redistributive potential of the health system is curtailed by the high proportion of resources going into the ISAPREs. Contributions to the private plans, which come from the most affluent segment of the population, are not available to subsidize the public health system, which is utilized by lower income segments, nor for use in such related applications as preventive public health measures, public health education and public health research.

Within the public system itself there is significant progressive redistribution. Statistics for the public plan for 1990 show a net subsidy of US$65.2 million (about 22% of all beneficiary contributions to the system) from the highest quintile of contributors to the lowest three quintiles. The fourth quintile, consisting of middle income contributors, was essentially self-financing.⁽⁵³⁾ The progressivity within the public system is a product of the payroll contribution formula (a percentage of salary with no upper contribution cap) and of the co-payments introduced during the restructuring. Those beneficiaries whose are in the bottom 50% of income are not required to make co-payments for use of public health services. Beneficiaries in the next 25% income bracket make co-payments equa to 25% of costs; and those in the upper 25% income bracket pay 50% of costs.

The importance of the constraints on redistribution which were introduced by the privatization must be understood in the context of the overall inequitable distribution of income and the high concentration of wealth in Chile. In 1992, the top 20% of the population received 60.4% of all income, while the bottom quintile received only 3.3%.⁽⁵⁴⁾ The inequality grew dramatically under the economic policies of the military government, with the bottom three quintiles losing income share (the lowest quintile of household lost more than half of its share of national income), the fourth quintile remaining steady and the top quintile increasing its share of national income by about 35%.⁽⁵⁵⁾ Public health insurance systems are sometimes criticized for favoring upper and middle income sectors over the poor, particularly where the poor are relegated to a separate system because they are not in the formal workforce and therefore not covered by social insurance. These criticisms do not apply to the public system in Chile, because the poor are largely included in the public system and the contribution and co-payment mechanisms produce progressive internal redistribution within the system.

Effect on employment, wages and working conditions in the health sector

The employment trend in the Chilean health sector for most of the period from 1974 to 1990 was a decline in employment and real wages. The cuts in public health spending were concentrated in reduced personnel costs (both employment levels and wages) and investment. Total employment in the public health system and in certain occupations for selected years is presented in table 2.

Table 2. Employment by SNS and SNSS
for selected years, 1975-92

Year

Total

Doctors

Dentists

Nurses

Midwives

Auxiliary
Nurses

Transport
and aides

1975

76 000

5 248*

n/a

2 550*

n/a

21 389*

n/a

1980

67 000

4 128

1 752

2 509

1 839

n/a

n/a

1985

62 000

6 063

1 886

2 737

1 990

23 557

14 108

1990

59 800

6 085

1 112

2 416

1 662

20 670

13 110

* = 1978.
(Sources: Compendio Estadistico 1992; Scarpaci (1988)

The reduction in real wages resulted from a series of policies by the military government. From 1973 to 1979 collective bargaining was banned; although bargaining resumed thereafter it was under an amended labour law which weakened the power of unions. In 1982 the government eliminated wage indexation, which meant that inflation subsequently eroded wages. During 1982 the real minimum wage, the wage floor for collective bargaining and public sector wages specifically were each reduced. From 1982, public sector wages no longer set the level for economy- wide wages but began to lag the private sector.⁽⁵⁶⁾ Within the public health sector, salaries represented 40% of total public expenditure in 1984, 35% in 1988 and 34% in 1992.⁽⁵⁷⁾

The erosion of both salaries and employment in the health sector resulted in 1985 in only 79% of Chilean doctors practicing in their profession, according to an estimate by the Colegio Médico.⁽⁵⁸⁾ This unemployment of doctors existed alongside a shortage of medical personnel in the public system which produced long waiting lines and declining numbers of medical consultations in the late 1980s.⁽⁵⁹⁾

The fragmentation of the system undermined the human resource planning capability which previously existed. This has resulted in labour shortages for some skills, particularly nurses and overspecialization (75% of physicians are specialists).⁽⁶⁰⁾

Since the re-democratization, there have been some improvements in both levels of employment and wages. Total employment in the public system had risen to about 66,000 by 1994, comparable to levels just before privatization, although still well below employment levels in the early 1970s. Employment in the ISAPREs was low, in keeping with the small share of the population affiliated with them, until they began to grow in the late 1980s. By 1992, the private plans employed 38% of practicing physicians, more than half of employed nurses, and about 30% of other nursing personnel. These relative proportions suggest that the ISAPREs have adopted a medical model which utilizes nurses more and physicians less than the traditional physician-intensive Chilean model. Such a shift may produce an efficiency gain. As the ISAPREs have grown in recent years, a dual labour market has developed, with higher wages and better working conditions in the private plans. This has led to the migration of some of the most skilled and experienced workers from the public to the private system.⁽⁶¹⁾ One result has been unfilled vacancies in some professions in the public system, including nurses and midwives. On the other hand, increased spending levels by the government, a revision and strengthening of the labour law in 1990 and the competition for medical personnel have contributed to some recovery of wages in the public system. In 1994, legislation was adopted which set a minimum wage and standardized conditions for personnel in the public facilities which had been decentralized to municipalities, where some of the poorest working conditions and wages existed.⁽⁶²⁾

5. Restructuring of health care in the Province of Alberta, Canada

Overview

The Canadian system of health care provides universal coverage through a combination of public finance and mainly private delivery of services. The plan is financed by the federal and provincial governments from tax revenue, supplemented in some provinces by mandatory premium contributions by households or by employers. The system is organized at the provincial level within certain required federal guidelines. Most health care providers are private non-profit institutions (including hospitals, nursing homes and clinics) and for-profit self-employed practitioners (such as physicians and dentists).

Like most industrial countries, Canada has faced a growth in health costs which outstripped growth of GDP in recent years, as the overall rate of growth of the economy began to slow in the 1980s. The economy went into a prolonged recession in the early 1990s, and in response to reduced revenues, federal contributions to the health system were frozen for five years. Thus, more of the burden of financing health has been shifted to the provinces, which face their own fiscal pressures from slow growth and recession. The result has been a period of deficits, cutbacks and restructuring by the provinces as they struggle to cope with the combination of expanding demand and constrained budgets. The province of Alberta has undertaken the most radical restructuring over the last several years, under a conservative provincial government elected in 1993. Other Canadian provinces have watched the changes there with a range of reactions which mirror the political coloration of their governing parties and electorates. Recently the newly elected conservative government of the largest province, Ontario, has indicated it would like to emulate many of the policies implemented in Alberta. The impact of restructuring in Alberta may thus begin to be amplified throughout the Canadian system.

Background

The Canadian health system is structured as a publicly financed, single payer plan at the provincial level. The entire population of each province constitutes a single risk pool under this structure. Financing, as mentioned, comes from the federal and provincial governments and from premium contributions. All funding sources are channelled into a single payer entity at the provincial level. The federal share of total national spending on health care has been roughly 24% in recent years; the provincial share is approximately 48%; and the balance comes from private sources. These private contributions consist of premiums paid by households or employer payroll taxes (differing arrangements are used in different provinces) and out-of-pocket payments by consumers for health costs which are not covered by the public system, such as pharmaceuticals and non-essential care.

The plan is administered by the provinces with a fairly high degree of autonomy, as long as federal standards are met. The key federal standards are (1) the requirement that provinces provide universal health insurance coverage in a single risk pool, (2) access to and coverage of all medically necessary services and (3) the exclusion of user fees or direct billing of consumers by health care providers, above the payments made by the provincial plans, which must be the single payer. The federal government does not make the practice of user fees and extra-billing by the provinces unlawful, but it penalizes them for such actions through dollar-for-dollar deductions from the federal contribution to costs. This provision, a part of federal health legislation since 1984, has effectively maintained the single payer nature of the Canadian health system by eliminating any incentive for the creation of a separate, privately financed sector in the core health services covered by the public system.⁽⁶³⁾ It has also meant that the bargaining power of provincial authorities with health providers has remained intact, since they are in a monopsonist position in the hospital, physician, health labour and other service delivery markets.⁽⁶⁴⁾

Provinces are required to administer their insurance plans on a universal, non-profit basis, as noted. This has provided key cost advantages for the government and the society as a whole, compared to the Chilean and US examples discussed in this study. Because coverage must be universal, the risk pool has been kept intact. Adverse selection in the form of risk skimming has been avoided and thus the public insurer has not been left with a disproportionate share of the less-healthy or those at greater health risk because of factors like poverty. Secondly, the monopsonist position of the single payer has provided a key mechanism for restraining costs in the delivery system. Finally, there is no possibility of price discrimination by providers, which typically occurs in multiple payer systems and which has the effect of appropriating consumer or public surplus to the provider.

The growth in health costs in Canada has been primarily a product of three factors: demographic changes, technological innovation in health care, and problems which arise from the fee-for-service allocation mechanism of the system. With respect to demography, longer life spans, lower birth rates, less immigration and the ageing of the post-war baby boom have all led to a much higher proportion of older segments of the population, who use more health services. The demographic bulge of the baby boom means that this tendency will increase for the next several decades. Technological innovation has been similar to that in other industrialized countries, with more expensive equipment, procedures, supplies and medicines all contributing to better health outcomes, but at much higher costs. The fee-for-service payment mechanism, through which physicians and other providers decide what services to provide and are payed according to a pre-negotiated schedule for such services, has been shown to produce higher overall costs. This results from overutilization of health services (particularly expensive diagnostic and surgical procedures), a problem which follows from the financial incentives for the provider to overprescribe. The shortcomings of the fee-for-service system have probably been exacerbated by an oversupply of physicians in Canada, which developed during the 1980s.

The growth in costs resulting from these factors, combined with the slowdown of overall economic growth over the last 15 years, have produced the so-called "denominator effect", in which health spending increases as a percentage of GDP. While federal and provincial governments faced reductions in revenue (or slower revenue growth) because of a slowing economy and then several years of recession, health costs continued to climb, becoming an increasing share of both federal and provincial budgets. Total health expenditures as a percentage of GDP, were essentially stable through the 1970s and early 1980s at about 7.1% of GDP; the percentage grew after the 1982 recession and experienced a particularly rapid increase during the long recession of the early 1990s. Spending peaked at about 10.1% of GDP in 1992 and 1993; it has since moderated to about 9.7% and has held steady at that level.⁽⁶⁵⁾

An early result of the denominator effect, beginning in the late 1980s, was a reduction in the contribution by the federal government to health costs, including a five year freeze on federal contributions beginning in 1990. The shifting of the burden to provinces contributed to growing deficits at that level of government.

Alberta is a province in western Canada whose economy has traditionally been based on extractive industries, including oil, agriculture and cattle. This economic base has produced frequent boom and bust cycles as a result of the tendency for volatility in commodity prices. There is a relatively low population density except for the metropolitan areas of Calgary and Edmonton. Alberta has typically spent the lowest proportion of provincial GDP on health care of any of the Canadian provinces. In 1994 for example, Alberta spent 7.9% of GDP on health, compared with the Canadian average of 9.7%.⁽⁶⁶⁾ Nonetheless, because of growing health costs, which rose by 215% (unadjusted for population growth and inflation) from 1980 to 1992 and the freeze in federal contributions beginning in 1990, health spending as a portion of the total provincial government budget grew from 20% in fiscal year 1980/81 to 30% by 1992/93.

Restructuring in Alberta

A conservative government was elected in 1993 on a platform of rapidly balancing the provincial budget. The new administration set out to cut health costs dramatically, along with all other social spending by the provincial government. The approach taken included setting a global goal of reducing government health spending by 20%, along with a number of steps to restructure the health system which were intended to force cost containment, institutionalize the cost containment gains which resulted and shift some costs to the private sector. The proposed spending cuts were quite drastic compared with other provinces, which, facing many of the same fiscal constraints, cut health expenditure by about 1.2% overall during the same period.⁽⁶⁷⁾

The major elements of the restructuring, which began in 1994, are summarized here, with a fuller discussion of each in the following sections. First, the overall structure of health administration was reorganized, with authority transferred downward from the provincial level, and upward from the hospital level, to 17 regional health authorities (RHAs). Second, treatment was shifted out of hospitals to less-expensive delivery sites through shrinkage of hospital budgets and closure of hospital beds. Third, the scope of practice of individual health professions was shifted to allow utilization of less highly compensated workers in place of more highly compensated ones. Fourth, the government increased premium payments by the public. Revenue from this source rose from 11% of provincial health spending in 1993 to 16.2% in the last fiscal year. Fifth, the government attempted to expand the role of the private sector through a controversial foray into allowing extra-billing. The federal government responded by cutting $3.2 million dollars from the province's transfer payment. The provincial government has backed away from the private billing experiment, but continues to advocate for changes in the federal law to allow for such partial privatization of finance of the health system and continues to pursue other forms of privatization at the margin.

Reorganization

A key component of cost containment in the Alberta restructuring is the creation of the regional health authorities as the main institutions for administration. As indicated above, the RHAs represent both a decentralization of responsibility for administration from the provincial to the regional level, but also a recentralization of the previous system of individual hospital governance through boards at each of the 200 provincial hospitals. The decentralization of provincial-level functions to the RHAs was intended to allow streamlining of costs at the provincial level. The recentralization resulted in the elimination of a number of management positions on the former hospital boards. The result of these changes was that administrative staff levels and costs were reduced by 20% during the first year of RHA operation.

The recentralization through the elimination of hospital boards also provided a more favorable structural setting in which to accelerate the shift of treatment out of hospitals to less-costly delivery sites, such as clinics, outpatient surgery centres, long-term care facilities and home care. The trend out of hospitals had already begun in Alberta, as discussed in the next subsection. However the provincial government sought a much more rapid downsizing, including closure of some hospitals and the conversion of others to less-intensive care. With the elimination of the hospital boards and the shift of authority to the RHAs, a potential locus of opposition to such an accelerated shift was eliminated.

The RHAs were responsible for implementing the major reorganizational steps discussed below. There was latitude for each region to emphasize a different mix of cost cutting, but all regions were constrained by the severely reduced overall budgets they were given.

The establishment of RHA jurisdictions along geographic and political demarcations has raised problems in that the populace routinely crosses these boundaries for the actual provision of services, because tertiary care and specialists are not evenly distributed. Under the very constrained budgets assigned to RHAs when they began operating in 1995, regions had the incentive to shift treatment and thus cost to other regions where possible. Numerous changes in reimbursement arrangements and a major shift in the funding formula have already been required after two years of RHA operation.

A political debate arose early in the reorganization concerning the role and responsiveness of the RHAs, given their extensive power to allocate resources. The RHA members were appointed by the provincial government, and perceived to be beholden to it. Individuals employed or funded by the provincial health system were categorically excluded from sitting on the RHAs, and so the views of physicians, nurses and other workers in the system were not included in decisions. In response to political pressure, the government announced in the spring of 1996 that in the future, one-third of the authority members will be appointed by the provincial government and two-thirds will be elected in municipal elections to be held in 1998. Thus, the local democratic control will not become operative until the major elements of restructuring have been completed.

Shift out of hospitals

A shift in the locus of delivery of health care from hospitals to less expensive sites began in earnest in Canada in the early 1990s. As in other OECD countries, this shift was a correction in course from an overexpansion by hospitals (relative to population growth) during the previous decade and also a response to technological advances (such as laparoscopic surgery) which allowed an increasing number of procedures to be performed safely outside of hospitals, or with shorter hospital stays. These microeconomic forces of supply and demand, as measured by hospital bed vacancy rates, had begun to produce a contraction in the number of hospital beds; but vacancy rates still stood at about 30% in 1993. The increased macroeconomic pressure to contain health spending naturally focused on hospitals, which accounted for 58% of total provincial health spending. The new Alberta government sought to accelerate the contraction significantly to reduce the fiscal burden. Hospital beds were reduced by 25% during the first full year of the restructuring plan, compared to reductions of 11% and 6% in the previous two years. The government sought to reduce the number of hospital beds from 3.8 per thousand population to 2.4; that target was exceeded by late 1995, with hospital beds falling to 1.47 beds per thousand, a number lower than in any other developed market economy.⁽⁶⁸⁾ This overshooting of the target was probably a result of the severe contraction of RHA budgets compared to previous funding levels.

Further downward pressure was also put on numbers of admissions and average length of hospital stays. The government's three year plan for restructuring calls for a reduction of patient-days per thousand population from 1,083 to 745, which would make it the lowest ratio in Canada.

Changes in the skill mix of health care workers

The health care sector is highly labour intensive worldwide, with the majority of health expenditures going to professional fees and wages in most health systems. For Canada as a whole, the proportion of the wage bill has been estimated as high as 75% of total health expenditure.⁽⁶⁹⁾ The reorganization in Alberta targeted the skill mix of health care workers as another major area in which to achieve cost reductions. One target was the number of physicians, which had grown much more rapidly than the population during the 1980s. The outcome of negotiations between the government and the well-organized physicians appears to have been to maintain a steady state for the near future and to reduce medical school graduates over the longer term.

Initial efforts to shift work to lower skilled and lower paid workers were constrained, because regulations govern the scope of practice of each professional discipline. Among the professions governed by scope of practice regulations, the following changes have been made: nurses were allowed to provide extended health services normally performed by physicians in areas of sparse population, which were deemed underserved; a midwifery programme was begun; and optometrists' scope of practice was extended. In institutional settings such as hospitals and nursing homes, the assignment of tasks is typically determined by management, with scope of practice constraints operating only as outer limits to potential task assignments. As a result, the effort to lower the wage bill was particularly concentrated in such facilities. Nursing tasks which did not require nurses with degrees or diplomas (based on existing scope of practice laws) were increasingly assigned to licensed practical nurses and nurse aides. The number of registered nurses working in Alberta, most of whom work in hospitals, dropped by 43% between 1992 and 1995.⁽⁷⁰⁾ The government also undertook a longer term effort to modify scope of practice regulations to enable future skill mix changes. A Workforce Adjustment Program was created as a joint initiative of employers, unions and government, which included a Health Workforce Rebalancing Committee and funds for assistance to displaced work

AARN	Alberta Association of Registered Nurses (Canada)
AFL	Alberta Federation of Labour (Canada)
AIDS	acquired immune deficiency syndrome
AMA	Alberta Medical Association (Canada)
FONASA	Fundo Nacional de Salud (National Health Fund -- Chile)
GDP	gross domestic product
HMO	health maintenance organization
ILO	International Labour Organization
ISAPRE	Instituto de Salud Previsional (pre-paid private health insurance plan -- Chile)
LA	Los Angeles (USA)
Medi-Cal	California health assistance programme for the poor, funded by the state and US federal government (USA)
OECD	Organisation for Economic Co-operation and Development
PAHO	Pan American Health Organization
RHA	Regional Health Authority (Alberta, Canada)
SEIU	Service Employees International Union (USA and Canada)
SERMENA	Servicio Médico Nacional (National Medical Service for Employees -- Chile)
SNS	Servicio Nacional de Salud (National Health Service -- Chile)
SNSS	Sistema Nacional de Servicios de Salud (National System of Health Services -- Chile)
UNA	United Nurses of Alberta (Canada)
WHO	World Health Organization


Year	Per capita, 1992 pesos	Percentage of GDP	Year	Per capita, 1992 pesos	Percentage of GDP	Year	Per capita, 1992 pesos	Percentage of GDP

1970	21 601	2.9	1980	17 789	2.1	1987	18 213	2.3
1974	18 712	2.7	1981	16 152	1.9	1988	20 849	2.4
1975	14 498	2.6	1982	16 941	2.3	1989	20 614	2.2
1976	13 543	2.2	1983	13 479	1.9	1990	19 361	2.1
1977	14 650	2.2	1984	14 241	2.0	1991	22 440	2.4
1978	16 202	2.0	1985	13 745	1.9	1992	26 535	2.6
1979	15 952	1.8	1986	13 428	1.8	1993	29 149	2.7


Year	Total	Doctors	Dentists	Nurses	Midwives	Auxiliary Nurses	Transport and aides

1975	76 000	5 248*	n/a	2 550*	n/a	21 389*	n/a
1980	67 000	4 128	1 752	2 509	1 839	n/a	n/a
1985	62 000	6 063	1 886	2 737	1 990	23 557	14 108
1990	59 800	6 085	1 112	2 416	1 662	20 670	13 110
* = 1978. (Sources: Compendio Estadistico 1992; Scarpaci (1988)

Labour and social dimensions of privatization and restructuring : Health care services

Restructuring and privatization of health care services: Selected cases in the Americas by Sandra Polasky

Labour and social dimensions of privatization and restructuring :
Health care services

Restructuring and privatization of health care services: Selected cases in the Americas
by Sandra Polasky