Sonia Fleury, Susana Belmartino, and Enis Baris, eds. Ottawa: International Development Research Centre; 2000. 292 pp.
ISBN 0-88936-923-2



In the past two decades Latin American countries have experienced major sociopolitical changes and economic crises. These changes, as well as ones in the epidemiology of major causes of morbidity and mortality, have been associated with changes in health care systems.

This book is an assessment of the health care reforms that have taken place in recent decades in three countries: Argentina, Brazil, and Mexico. The intent of the authors is to describe the political and economic context of the reform period, compare the transformations in the methods of financing and delivering health care, and assess outcomes for people in different socioeconomic groups in the three countries. This study includes descriptive, qualitative data on the health care systems, as well as a more-quantitative analysis of household surveys of health service utilization.

The first section of the book describes the historical context of health care provision and other types of social protection in Latin America. In the second section one chapter for each country is devoted to a political and economic analysis of the social transformations in each country over the past 20 years. A second chapter for each country describes in detail the legislative and administrative tools used to effect health care reform. For the more-quantitative analysis of health service utilization, other contributors to the text carried out a population-based survey of health care utilization in one major metropolitan area of each country. The survey examined three high-priority conditions: hypertension, diarrhea in children, and prenatal care and delivery in women.

The different social, political, and economic trends in the three countries have led to very different structures in their health care and social protection systems. In the 1970s, Argentina's system covered almost all of the population but was highly stratified with regard to access to the health care system. The working class was very organized and homogeneous, and much of the social security system was controlled by trade unions. Brazil and Mexico both had systems in which social security covered a small part of the working class, and large numbers of people were effectively excluded from most health services.

In the past two decades all three countries have suffered economic crises and introduced various structural adjustment policies to move toward economic recovery. Argentina's economy has become somewhat more stable, but with growing unemployment and underemployment. Brazil has experienced hyperinflation, which has been controlled only in recent years. Mexico has not suffered extreme inflation, but levels of poverty increased in the 1990s.

The three countries have different epidemiologic profiles as well. In Argentina the major causes of death are cardiovascular diseases and malignant tumors. In Brazil the causes include cardiovascular disease, but also symptoms and diseases of uncertain definition, indicating some characteristics of a developed country but also poor health care coverage. Mexico has a mixed profile, with major causes of death being cardiovascular disease, accidents, and respiratory diseases.

All three countries attempted health reforms in the 1980s and 1990s. In all three the reforms have taken place in the context of crises of authority and profound economic change. The three countries have all tried to decentralize their health care systems, and all have shifted more of the health care delivery to the private sector. In Brazil the new visions for reshaping the relationship between the State and different population groups came primarily from organized civil society groups, within the context of a transition from a military government to a more democratic, civilian one. In Argentina and Mexico the impetus came more from Government authorities.

Brazil has integrated the social security health care network with the public system, but in the other two countries the systems remain separate. Argentina has a contracted-insurance model, with trade unions still managing a large portion of the financial resources but with increased competition between health service providers seeking that business. In Mexico the social security system has its own health services network.

The qualitative chapters in the middle section of the book provide detailed descriptions of these arrangements and the changes that have occurred in them. The quantitative chapter presenting the results of the utilization survey describes a very complex model to attempt to explain factors that might be responsible for variations in use of services. The survey results support the conclusion that none of the three countries has a very equitable system: one of the major factors associated with utilizing services is the ability to make out-of-pocket payments.

The work of these authors is an important attempt to analyze changes in health care systems and their effect on the population of three large Latin American countries. The writers acknowledge several important limitations, including problems comparing the systems of three countries with different languages, cultures, and social organization. It is difficult to establish causal links between different political and economic orientations and institutional arrangements of health care systems. In addition, there was a lack of baseline data to use in comparing the health utilization findings.

The book is not easy to read. In some chapters the descriptive language could be clearer. Some of the graphs and tables intended to clarify narrative descriptions are themselves very complicated. Readers who are already familiar with the health care institutions of the three countries, or persons with direct experience in policy-making at the national level, may find the discussion easier to follow. It is likely to be more difficult for health professionals and others who might be interested in this work as a way of gaining a better understanding of the international debate on the organization of health care systems.

Despite these limitations, this book is an important contribution to the debate. The authors conclude that none of the countries has achieved a system that is equitable. All the countries still have health policies that contribute to the segmentation of the population and that pit the middle class against the poor. These countries have a long tradition of strong government control over the lives of citizens, but without a tradition of social solidarity. If these countries are unable to promote such solidarity with subsequent reforms, the nations may succeed in modernizing their health care systems at the cost of moving even further from the ideal of fairness. This book should inspire politicians to reassess the goals and direction of the reform process.


Linnea Capps
Harlem Hospital
and Columbia University
New York, New York

Organización Panamericana de la Salud Washington - Washington - United States