An analysis of health system reforms in recent decades shows an apparent pendulum phenomenon. In times of macroeconomic adjustments, the pendulum swings to contain expenditures, suppress rights, and open the market, under the argument that competition improves quality. In this context, primary health care (PHC) is seen as a selective policy for excluded populations. Meanwhile, in favorable political and economic conjunctures, the pendulum swings in the opposite direction, and health is considered a condition for development and social cohesion, with an emphasis on building networks coordinated by PHC in order to guarantee the systems’ sustainability.

The article by Lígia Giovanella & Klaus Stegmüller (p. 2263-81) updates this discussion. In addition to describing recent containment measures, the study consistently analyzes their effects. There are many similarities with the post-welfare agenda measures applied from 1980 to the mid-1990s: budget cuts with restrictions on services, increases in copayments, cost transfers to users, diminishing state responsibility, and increases in various forms of privatization.

This discourse had a harmful influence on reforms in Latin America, where (unlike the central countries) there was a strong cutback in public spending. The drop in these expenditures during economic crises and fiscal adjustments has been well-documented in Latin America (Sojo A. Ciênc Saúde Coletiva 2011; 16:2673-85). Public financing was particularly vulnerable in 1994-1998 and 2001-2003, with a negative annual variation greater than the drop in the region’s GDP. Although public spending in health remains low, it has shown an upward trend, although associated with high out-of-pocket spending by families.

The current European context has still not witnessed any decrease in public spending, but the study suggested that such cuts may be expected in England and Spain due to legal restrictions. Since enactment of Royal Decree Law no. 16/2012, access to the Sistema Nacional de Salud (SNS) in Spain requires coverage by the social security system, and is no longer a universal citizen’s right. There has also been growing pressure to include forms of privatization in national systems that are considered macro-efficient, as in the case of Spain.

To what extent can a recessive context and increased regulation in these countries lead to market expansion in Latin America? The dynamic of accumulation in the health sector is intense, with complementary gains among the medical-industrial and medical-financial segments and major hypertrophy of services (consultancies, information technologies, exportation of hospitals, and medical tourism). Estimates for the coming years by private consultancy firms such as IMS Health and Deloitte have identified Asia, Africa, and Latin America as the most promising health care growth markets.

A cutback in resources affects quality and threatens the social legitimacy of national systems oriented by PHC, such as the Spanish SNS and the UK National Health Service (NHS). The same trend has occurred in the Portuguese national health system. This risk involves the loss not only of sources of evidence, but also important references for solidarity, public administration, and health practices. This scenario, combined with the current discourse proposing “universal health coverage” in medium and low-income countries, should be analyzed with care. Without a broad discussion on models for health care practices in the health systems, the proposal may represent more of a business opportunity than timely access to health care.

Eleonor Minho Conill
Universidade Federal de Santa Catarina, Florianópolis, Brasil.
eleonorconill@gmail.com

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