For a long time people covered the treatment of their illnesses with own resources, attending the different alternatives that could be found. Historical events were profoundly changing the structure of the society, their customs, their culture and among them the concept of health; Hence, forge health professions and appearing various healthcare devices. Public authorities became aware of the necessity of establishing certain guarantees in favour of the population, which mainly concerned the development of hygienic measures, preventive medicine and environmental sanitation.
This situation resulted in different political and ideological visions with respect to health care in different countries, Depending on the conformation of the social characteristics, policies, Economic and historical of each one of them. Such characteristics gave rise to models like the Liberal, the Socialist and the mixed.
It is common in the literature that uses the concept of model and systems as a synonym. For this reason it is important to stress the difference between the two to not confuse them:
The Model It makes the scope of the policy and it can be defined as "the set of criteria or doctrinal and ideological foundations in which health care systems are built up", the aspects are determined as: receiving population, who finances the system, benefits that are going to give, performances and competencies of health public-health authority.
While the System It makes to the operability and execution of the Model, but at the time of defining it appear different ways of conceptualizing it own characteristics and complexities that saves.
The World Health Organization relates them with the concept of health in its broadest aspect "as a set of interrelated elements that contribute to health in homes, workplaces, public places and communities, as well as in the physical environment and psychosocial, and in the health sector and other related sectors".
Also, WHO displayed the different actors that compose it by explaining that "system is the set of all activities, officers or not, related to the provision of health services to a particular population, You must have appropriate access to the use of such services. Composed of all available health staff, the formation of this type of personnel procedures, sanitary facilities, professional associations, the economic resources that for any reason or source put at the service of health and existing official and unofficial device".
And it adds that "this whole must be harmonized in a homogeneous system that allows use of resources enabled for the achievement of the maximum satisfaction of the preset objectives: ensure the right to health not only as a universal right, but as a resource for social development, Economic and individual of a person".
Although all system is included in a larger one, the suprasistema, they are those who believe that health systems are a variant of social systems, and as such, they appear as one of the institutions and most consistent social functions and greater complexity in society.
From the sociology defined to the health care system as "the set of social mechanisms whose function is the transformation of resources widespread in specialized products in the form of health services in society".
A) Health care models
1. Liberal: Health in this model is considered as a consumer good, It does not necessarily have to be protected by the public authorities in their entirety. The responsibility of the State is summarized to serve groups most disadvantaged and vulnerable to the contingencies of illness, with minimal financial contribution to the system by the State.
The other population groups (medium and high) stick to private insurance companies or directly engaged in providing medical provider, without intermediaries. The use of the services is based on the law of supply and demand.
This model is present in the private system of United States, being the reference among other countries. Relevant aspects of the model:
- Service providers develop their devices according to the approaches of economic profitability. High competitiveness existing among different providers to capture customers makes the technology, and cientifico-medica research move forward significantly and to attract the best professionals.
- Some features of this system are being implemented in other health systems, as the analysis of costs per process (excessive use of complementary tests in Diagnostics and drugs excess) to make them more efficient.
- Its financing rests on companies that co-finance a health insurance contract with private agencies, This situation generates disadvantages and inequalities for the different segments of the population. Two-thirds of employees receive this coverage. Self-employed workers, those in part-time or those who have small businesses must employ much more expensive individual policies, so it often reject them. Outside the company there are no rights. More retirees from 65 years are entitled to a minimum coverage,for those who do not fall into these categories: nothing.
- A variant of the Liberal model is the Singapore model, that it has introduced the concept of individual capitalization in health systems. Funding is generated in a Central Provisora of funds (20% salary of the worker + 20 % entrepreneurs). Between the 6-8% going to an account. Each individual can withdraw money from that account to cover health expenses.
2. Socialist or statesman: its most significant feature is that benefits are given in conditions of equity, gratuity and universality for all segments of the population. It is funded entirely by General State budgets. The private sector is non-existent. From this model they derive two types:
a) Semashko model. It began in the former USSR and the countries of the Soviet bloc after World War II. From 1990 Russia and all the Communist countries of Europe have abandoned centralized system, fully controlled and operated by the State.
b) Unified model for public. Applied in Cuba and North Korea, in this system the State takes an important role in ensuring access to health funding and supplying health services directly through a single, integrated system vertically. The coverage is granted with criteria of fairness, gratuity and universality to the entire population. Prioritization of public health is through preventive medicine and health education to increase the levels of health at the expense of the creation of expensive medications and health care services, as well as investment in public services has been one of the features most relevant and imitated by other countries. This system is not very effective with regard to the individual, It excludes the options of benefits under the control of consumer and limits the effective representation of users in the Organization of the service.
3. Mixed. It is common in many European and Latin American countries. It is defined by the contribution that has public and private sector in the management of the system. Depending on the country, It differs from the participation of both sectors giving it its own characteristics in the financing, in the modes of provision and functionality, as well as different levels of assistance.
Two European models gave origin: Model security Social-Bismarck. It is the oldest and most advanced in the world, inspired by the social legislation of Germany in 1883.
- The State guarantees benefits through mandatory fees.
- The model ensures the assistance only to workers who paid the obligatory insurance, Bearing that constitute parallel networks of charities for workers who are not "traded".
- Professionals are paid through medical Act and the hospital institutions receive a global budget.
- The network of public health is in the hands of the State, It is also in health authority.
- All the citizens of these countries currently enjoy a universal health, free and equitable.
Secondly the Model tax-Beveridge, inspired by the Beveridge report of 1942, that formalized the Organization adopted by Sweden in the Decade of 1930, and it gave rise to the national health system in different countries.
- The funding is public through taxes and State budgets.
- The provision is given in terms of universality, equity, free and freedom of access of the entire population.
- Planning and public health are in the hands of the State and taught in autonomous communities and municipalities that decide and measurable health plans developed and enforceable.
- Comprehensive parliamentary control over the system.
- The means of production are State although there is a part of the private sector, patients participating in the payment.
It has a global budget limited to hospitals.
In third place, is worth mentioning that in Latin America there were other similar models but with historical and social characteristics of the region.
1- Segmented model: It is the model most frequently used in Latin America. Coexist three sectors in the system:
–Public sector: represented by the State, who deals with providing assistance to those excluded individuals on the market, i.e. those who belong to social groups more needy and vulnerable and without social security coverage. It is financed by fiscal resources which may come of General Finance or tax with affectation specific to this purpose. At the same time the State is service provider through its health network.
–Social security sector: its organization is decentralized into non-governmental intermediary entities, but with high regulation by the State. The funding is effected through contribution of workers and employers contributions, resources that has the character of mandatory. By definition, It only covers to the contributors to the system and their family group.
–Private sector: the provision of health services is carried out through private market providers. Performs financing the complaining user through the system called prepaid. In general insurance are contracted individually, Although they can be hired collectively. In Argentina what you must provide each user is calculated based on the risk of getting sick and ill (that is to say, through the rates of incidence and prevalence of different diseases) and the type of service.
These three sectors funded system, but two of them are also service providers: the public and private. The latter provides service to private insurance to social insurance.
The problems that presents this conformation imprint area of health a peculiar logic since it implies the coexistence of disjointed from each of these subsystems, I differ with respect to their target population, the services provided, the origin of the resources and decision at the system level. To this we must add the existence of serious fragmentation levels in each sector.
The economic interdependence of the three sectors, the duplicity of functions, inefficiency in resource management and provision of services important differences between various segments of population in relation to their coverage resulting lack of equity and discrimination in the provision of the system, i.e. marked inefficiencies.
2- Public contract (Brazil accounted for example of this mode)
• Public funding is combined with a growing private participation in the provision of health services, through the contracting of services.
• The population has expanded options and providers are more opportunities for autonomy and competition.
• The overall public budget is assigned to a plural set of suppliers according to criteria of productivity and quality.
• This model leads to the fragmentation of provision and complicates the quality control and costs.
3- Structured pluralism (It is a new modality that are transiting Colombia, Mexico, Argentina and Brazil)
It represents an intermediate point between the two poles (public and private) in which health systems have worked, What prevents the ends of the monopoly in the public sector and the atomization of the private sector. This new alternative search to the system is no longer organized by social sectors but by functions. They play here a role health ministries in each country assuming roles of stewardship and regulation of the system and ensuring the strategic driving, instead of being one provider of health services.
• Social security becomes the principal responsible for the financing and expands gradually to achieve a universal protection, guided by principles of public finance.
• The direct provision of services would remain open to all a pluralistic scheme of institutions, both public and private.
• In urban areas would foster competition among suppliers, and in rural areas other innovations to foster pluralism would be organized cooperatives and solidarity health companies. In any case, the challenge is to increase the options for consumers and providers, with clear rules that minimize potential conflicts between equity and efficiency.
In conclusion, It could be argued that all the models described synthetically have been varying in time and generating changes in search of new alternatives to be more efficient and save greater equity in the provision.
The following table shows the transition that at our discretion have been taking and where they are going:
The widespread perception is that no unique and pure concrete model allowing to solve all the problems of population health in our environment there is. The ideal health care model does not exist, any model you choose has supporters and detractors by its own characteristics and complexities. Health in its conception has an ethical dimension that relies on social values, political and religious crisscross with different ideological views and interests of all kinds that do not always have common assessments.
Health, objective of entire system, It is essential to life, for a country's economy and welfare. WHO argues that the Mission of all system is to increase levels of health in all aspects and the isolated individual situations and/or society, so is your operating condition to establish indicators of measurement of welfare and level of development of a society.
Health and health services are one public responsibility and a social right. The State must ensure their protection, promotion and access to an appropriate and timely way independent of their social class health services, income level, labour insertion, genre, ethnicity or age.
It is common to most of the described models define the policies of health beyond health ministries, since they consider them intersectoral encompassing all those actions aimed at improving the health.
(B)) Characteristics of health systems common to all models
• Health systems are operational instruments designed by the political authority of the various countries to comply with their health theoretical models.
• The most specific trait of all health systems is its professional character. The doctor is the hub of the system, the key decision maker (on behalf of the patient) with great autonomy in their decision-making.
• Medical health systems decisions determine the quality and efficiency of these.
• Health systems must be permanently aligned medical practice (with their incentives and interests) with the mission and values of the health system, articulating the administrative management with the collegiate clinical management based on the professional authority.
• The most important determinants of individual and collective health does not depend on the health sector. This has a limited ability to produce health, approximately a 11%, faced with the 89% (It comprises the genetic load, lifestyles and the environment).
• The health sector is increasingly important in a country's macroeconomic indicators, This amount of resources generates powerful interests in economic actors with great influence on health decisions. Example of this: Pharmaceutical industry, medical equipment, Professional, social security, etc.
• The health with respect to other types of employment employment growth, give the sector a great capacity for social and labour pressure, whose management is especially problematic. By ej.: nurses, assisted residences, socio-sanitary services, care of chronically ill, professionals concentrated in a same employer (hospitals), a mix of different occupational groups with different interests, among others.
Health systems in addition to being complex as described are characterized by being partially implicit by the large number of components and relationships between the parties are to compare, with the black box of a complex machine with unknown function.
Health systems, they are also open systems and therefore interact with other systems: the politician, the Prosecutor, educational and economic saving with these relations of interdependence, that is the health sector depends on the actions of these, any variation in any of them has strong impact on your exercise, such is the case of the tax system (fundraiser) the provider of financial resources or the lack of definition and support the political system leaves the health system without rectory on the whole health. The educational, cornerstone at the moment of join in educating the population prevention through its systematic and parasistematicos methods; and finally, Perhaps the most relevant economic system that produces strong impacts in different sectors when it has relevant imbalances as it is the case of the variations in employment (unemployment).
Maintain a balance in the interactions of these systems leads to the maintenance of the system and to improve the standard of health producing the expected results in the population that is covered in a country.
At the same time, social and environmental systems (suprasistemas) they contain to the health system and interact permanently conditioning in its operation in terms of the impact that generate, as well as its capacity to respond to the constant demands that presents the medium, by measuring their ability to feedback in terms of effectiveness and efficiency, that is to say, produce the best results (prolong the life, minimizing diseases, disabilities, promote well-being- internal satisfaction, etc.), ultimately the satisfaction of users. See graph (PowerPoint presentation that accompanies this work)
(C)) Functions and components of health systems
The components might be defined as internal parts of the system, that in his actions he determine the operating balance of the system. The components are:
The parties are related through functions: financing, Regulation (legislation), provision and management (planning and control system).
(D)) Health care organizational structure of health systems
The Organization of medical care is the result of the socio-political and economic structure of society in which it operates. (Modelo-Sistema).
In European countries the health care is in the form of assistive device, submitted directly to the power of the State and managed by authorities and bodies representing saying power, It is what has been called national health service. In this system the services are structured within the scheme of assistance integrated with an overall state planning, both in terms of the geographical distribution of the assistive device and in the definition of benefits and in the modalities of action of health personnel, that it be regulated by detailed regulations. Government action involves the definition of the jobs needed in the health field and the creation of health centres and their trim levels, and it is aimed at the extension of benefits to the whole population.
The socialist countries adopted this scheme in General for its health devices, but also some other countries like Latin Americans they have structured schemes somewhat similar shared with the private sector.
Such is the case that because of economic rationalization and the increasing evolution of the assistance measures have allowed that in recent years, in many European countries offered medical care-oriented part of the population by private health centres, generating an important development of private medical insurance and giving rise to the change of vision sustained for many years of the national health system.
Obviously in almost all countries is progressing towards mixed models described previously by varying some of them in the form of management, This is, different participation of public and private financing and provision of services.
We can say that there is a great diversity in relation to the organizational structure of the health, which are the result of combining the two basic elements that constitute all health systems:
1. Sources of funding: economic resources
2. Providers: medical, hospitals, pharmacies, etc.
The health care structure common to most systems is:
Despite the therapeutic advances, the steady increase in the cost of health, the massive demand for assistance, repeated reforms and inequalities in health care are still the order of the day, both between countries and inside them. Many factors influence this: environment, power and work, Customs, among others. But health systems and modes of financing also generate consequences that unlike the previous can be improved by intervening in its defects, such as bureaucratization, the absence of regulation, the lack of equity - accessibility, efficiency both micro and macroeconomic; in final "health systems that ensure the satisfaction of the population with regard to the promotion, Prevention, protection and restoration of the health of individuals and communities in a country" (WHO).
In conclusion this document has attempted to make a conceptual and general description of the different models and systems in force in most of the countries; describe common characteristics and complexities of the system considered the most complex of all social systems.
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