SciELO - Scientific Electronic Library Online

 
vol.44 issue2Dental health policies in Brazil and their impact on health inequalitiesAnaphylaxis associated with the vaccine against measles, mumps and rubella author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Revista de Saúde Pública

Print version ISSN 0034-8910

Rev. Saúde Pública vol.44 no.2 São Paulo Apr. 2010

http://dx.doi.org/10.1590/S0034-89102010000200019 

COMMENTS

 

Hospital management autonomy in Chile: the challenges for human resources in health

 

Autonomia na gestão hospitalar no Chile: desafios para o recurso humano em saúde

 

 

Claudio A Méndez; M Cristina Torres A

Instituto de Salud Pública. Facultad de Medicina. Universidad Austral de Chile. Valdivia, Región de Los Ríos, Chile

Correspondence

 

 


ABSTRACT

In Latin America, some health sector reforms have included steps to the implementation of autonomous hospitals. In Chile, the health system is implementing a reform that introduces a network of self-managed institutions. These organizations will be high complexity centers that involve greater technical diversity, cost centers and mechanisms to evaluate users' satisfaction. For human resources in health, the implementation of these centers creates challenges in the planning of service provision and a change from the traditional management style of the teams to one based on networks. These challenges include the estimation of gaps in medical specialists and in other professions in the health sector. In order to be successful with self-management, Chile needs to establish universal and local policies that address training and the organization of health service provisioning in these institutions.

Descriptors: Hospital Administration. Health Care Reform. Personnel Administration, Hospital. Health Management. Chile.


RESUMO

Destacam-se algumas experiências de reforma sanitária na América Latina que têm dado lugar à implementação de hospitais autônomos. No Chile, o sistema de saúde implementou uma reforma que introduziu os Estabelecimentos de Autogestão em Rede. Estes serão centros de alta complexidade que abarcarão uma maior complexidade técnica, centros de custos e mecanismos de avaliação da satisfação dos usuários. Para o recurso humano em saúde, a implementação destes centros estabelece desafios no planejamento para a provisão de serviços, assim como na transição da gestão clássica das equipes a uma baseada em redes. Estes desafios envolvem a estimativa de vazios de especialidades médicas, assim como de outras profissões do setor. Para o sucesso da autogestão no Chile, conclui-se que se deve avançar em estabelecer políticas globais e locais que abordem temas de formação e organização da provisão de serviços de saúde nestas instituições.

Descritores: Administração Hospitalar. Reforma dos Serviços de Saúde. Administração de Recursos Humanos em Hospitais. Gestão em Saúde. Chile.


 

 

INTRODUCTION

The health systems reform implemented over recent decades in Latin America included changes to separate the functions of financers and providers, granting of rights to health care services, implementation of health insurance, increasing coverage, changes to human resources policies and implementation of new management models.16 Moreover, the performance of management duties20 and the decentralization of services29 were strengthened. The implementation of the administrative changes was done at a mid- and low-level of the systems.12 These modifications were translated into restructuring processes and not into greater autonomization in the management of hospital services and institutions.12

In regards to human resources in health, the reforms on the continent introduced changes that favored greater productivity, performance evaluations, implementation of incentive systems and new types of contracting.6 Nonetheless, the inequity in its distribution, the concentration of specialties, the increase of professional migration and the flexibility of employment contracts, continue to constitute areas in need of more regulation.25

In Chile the administration of the health sector in the 1990s showed weak institutional integration, a lack of coordination between levels of care and under-utilized human resources.ª In this regard, the modernization of the public administration during this same decade recognized performance and training as important elements in the career development of human resources for health.8 However, aspects related to the training and planning of human resources for health continued unresolved.

Currently in Chile health reform is being implemented to optimize the organization of the system, the prioritization of health interventions and the implementation of hospitals with self-management rules. The implementation of the network of self-managed institutions (Establecimientos de Autogestión en Red) involves human resource policies utilizing new tools for management and quality in health provisioning.

This article had the objective of introducing some of the policy challenges around human resources for health in regards to the network of self-managed institutions. Conceptual aspects and experiences with hospital autonomy in Latin America are initially addressed, in order to later describe the challenges in managing human resources for health in the administration of these establishments.

 

HUMAN RESOURCES POLICY AND REFORMS

Human resources for health constitute the central component and largest allocation of resources in health systems3 and are a crucial support for the successful implementation of health reforms.15 Nonetheless, the management of human resources for health and its importance to the success or failure of reforms has been a neglected topic.7 Another typical concern in this respect has been the inability of ministries of health to establish planning processes that satisfy the requirements of the managers, of the population and of the health system as a whole.24

In general the effects of health system reforms upon human resources for health have translated into changes in contract types and labor conditions, a duality in relation to public/private employment, new recruitment and retention mechanisms and changes to the skills needed for the reform processes, among others.26 Due to these issues, some authors21 recognize the need to discuss aspects such as increasing efficiency, improving performance, greater equity in the distribution of human resources in services, the development of policy and planning capabilities and the development of a new perspective about human resources through identifying priorities in the process of health systems reform.

Aligning health care reforms and human resources for health requires human resource policies that aim to formulate tools which facilitate planning processes, provide support for decision-making and promote guidelines for evaluation of performance.10 At the same time, considering the efficient use of human resources within the context of institutional capacity should be an essential part of the reform process; this includes the reorientation of education, the training and practice of professionals and the study of ways to retain and strengthen the capacity of human resources for health.1

 

HOSPITAL AUTONOMY

Hospital autonomy involves public hospitals that pass from being part of the public health sector to being institutions that rely on greater freedom in their governance and management.9 Autonomy seeks to improve efficiency, the acknowledgment of physician responsibilities, accountability and recipient decision-making in the provisioning of services.22 Likewise, it seeks to improve the quality of care, to reduce costs and to increase institutional surpluses.28

In Africa, many experiences of hospital autonomy were implemented through decentralization processes.5,13 In Latin America, there have been other experiences. The implementation of autonomous state entities (Entidades Autónomas del Estado) in Columbia and of the self-managed hospitals (Hospitales Autogestionados) in Argentina are examples of autonomy that pose policy challenges for human resources for health.

In Columbia when Law 100 entered into force, the public hospitals were transformed into autonomous state entities with the power to establish contracts with the health promotion companies (Empresas Promotoras de Salud, EPS).14 The EPS carried out the functions of health insurance providers and of service providers for insured patients,14 and they provided services to the institutional health service providers (Instituciones Prestadoras de Salud, IPS). The IPS were the public or private health service providers responsible for delivering services.11 This way, the public hospitals could acquire autonomy to establish contracts with the EPS and provide health services.

The establishment of the EPS and the IPS began an uncertain scenario for human resources for health, where fears of hospital privatization, employment instability and the desire for information and guidance to face the changes were the main aspects described in their implementation.23 Moreover, the contracting of third parties by the IPS generated greater employment flexibility and a reduction in salaries.8

The Argentinean reform of the 1990s decentralized the health care system, in regards to insurance providers as well as in the provisioning of services. In the provisioning of services, allowing the self-management of public hospitals stood out.18 These establishments could negotiate contracts with private insurance and with service providers, sell services, charge co-payments and devote part of their income to incentive structures for human resources.4 Nonetheless, these changes provoked differences in the budget destined for the management of human resources18 and the existence of a fearful climate and lack of confidence among health teams.19

 

HEALTH CARE REFORM AND AUTONOMY OF HOSPITAL ADMINISTRATION IN CHILE

The changes to the health system during the military dictatorship of the 1970s and 1980s caused a severe under-financing of hospital services, which impacted on the quality of the service and on the financing of human resources.17 Therefore, when democracy was reestablished, the health sector sought to recover the investments in health, the infrastructure and the accessibility of the services.2

Since the year 2002, the country implemented health reform aiming to define explicit health guaranties available on demand to citizens and to improve the care and management models of the system.27 Thus, the reform was begun with the promulgation and approval of Law 19,988 which established the necessary financing to meet the priority social objectives of the government.b Later, the government promulgated Law 19,937 for the health authority and management,c Law 19,966 for a general plan of guaranties in health (GES)d and the modification of the ISAPRES law Number 18.433 through Law Number 20,015.e The later law was concerned with the obligations and rights of users and continues through the legislative process of the National Congress.

The most important contributions of the approved bodies of law are described in the Table.

The Network of Self-management Institutions

The Law 19,937 on health authority defines the network of self-managed institutions as those hospitals dependent on the health system, which have greater technical complexity, development of specialties, administrative organization and number of services provided. Organizationally, they should comply with procedures for cost measurement, quality of care, user satisfaction and should grant the highest level funding in their budget to personnel.

The directors of the establishments can direct the execution of programs, design future plans and organize the institution internally. Likewise, they will include a consultative council of users, consisting of five representatives from the local community and two representatives of workers from the establishment, which will have a consultative role in the setting of policies and the evaluation of institutional plans.

Initially, the year 2009 was envisioned for the implementation of these institutions in all the country, however this date was postponed in order to optimize aspects of their implementation.

 

THE CHALLENGES OF SELF-MANAGEMENT

At first, reform proposed the development and the strengthening of human resources through the redefinition of the medical professions, continuing education, accreditation and the study of career mechanisms and incentives.27 However, these proposals were not included, when implementing the organizational and structural changes to the system. Therefore, among the network of self-managed institutions, the challenges for human resource policies are rooted in working in a network model and in the provisioning of services for the GES pathologies.

The business model centered on the production process begins to not work when used in a network. The innkeepers style, "each one tightens their screw" without being involved in the final result, should be changed to a strategic focus centered on meeting user demand for health services through the supply of institutional services adjusted to the actual and the projected demand. Also, it is necessary to change from making decisions grounded on the existing record to decision-making based on anticipation, changing from mass coverage of care for focusing on diverse priority groups. Even then the strategic focus requires an understanding of different settings to guarantee intra- and inter-institutional synergies.

Thus, meeting the demand for the GES in the network of self-managed institutions can allow for an understanding of human resource requirements and planning; with greater clarity in the identification of gaps in medical specialties and gaps in other health professionals, which are a bottleneck to resolving and managing demand. In turn, planning should identify the general competencies that are expected of human resources under self-management.

Finally, the perception of health teams in regards to changes and the decision-making that autonomy grants them should be considered in order to reduce uncertainty regarding issues such as labor flexibility and privatization of services, which were described in other processes of hospital autonomy on the continent.

 

FINAL COMMENTS

The implementation of the network of self-managed institutions constitutes an experience that is not exempt from the difficulties of other processes implemented on the continent. Because of this, success depends on the tasks carried out by the health institutions and on the regulatory frameworks and incentive structures of public policies for health in Chile.

 

REFERENCES

1. Alwan A, Hornby P. The implications of health sector reform for human resources development. Bull World Health Organ. 2002;80(1):56-60. DOI:10.1590/S0042-96862002000100010        [ Links ]

2. Artaza O, Montt J, Vásquez C. Estructura y recursos humanos en un hospital público chileno: una experiencia de cambio. Rev Panam Salud Publica. 1997;2(5):342-51. DOI:10.1590/S1020-49891997001100007        [ Links ]

3. Beaglehole R, Dal Poz MR. Public health workforce: challenges and policy issues. Hum Resour Health[internet].2003[citado 2009 feb 23];4(1). Disponible en: http://www.human-resources-health.com/content/1/1/4        [ Links ]

4. Belmartino S. Una década de reforma de la atención médica en Argentina. Salud Colect. 2005;1(2):155-71.         [ Links ]

5. Bossert T, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan. 2002;17(1):14-31. DOI:10.1093/heapol/17.1.14        [ Links ]

6. Brito P. Impacto de las reformas del sector de la salud sobre los recursos humanos y la gestión laboral. Rev Panam Salud Publica. 2000;8(1/2):43-54. DOI:10.1590/S1020-49892000000700008        [ Links ]

7. Buchan J. Health sector reform and human resources: lessons from the United Kingdom. Health Policy Plan. 2000;15(3):319-25. DOI:10.1093/heapol/15.3.319        [ Links ]

8. Carrioni CA, Hernández ML, Molina G. La autonomía de las instituciones prestadoras de servicios de salud (IPS): más un ideal que una vivencia institucional. Rev Fac Nac Salud Publica. 2007;25(2):75-84.         [ Links ]

9. Collins D, Njeru G, Meme J, Newbrander W. Hospital autonomy: the experience of kenyatta national hospital. Int J Health Plann Mgmt. 1999;14(2):129-53. DOI:10.1002/(SICI)1099-1751(199904/06)14:2<129:AID-HPM541>3.0.CO;2-R        [ Links ]

10. Dussault G, Dubois CA. Human resources for health policies: a critical component in health policies. Hum Resour Health[internet].2003[citado 2008 ago 21];1(1). Disponible en: http://www.human-resources-health.com/content/1/1/1 DOI:10.1186/1478-4491-1-1        [ Links ]

11. Echeverri O. Mercantilización de los servicios de salud para el desarrollo: el caso de Colombia. Rev Panam Salud Publica. 2008;24(3):210-6. DOI:10.1590/S1020-49892008000900008        [ Links ]

12. González García G. Las reformas sanitarias y los modelos de gestión. Rev Panam Salud Publica. 2001;9(6):406-12. DOI:10.1590/S1020-49892001000600013          [ Links ]

13. Hanson K, Atuyambe L, Kamwanga J, McPake B, Mungule O, Ssengooba F. Towards improving hospital performance in Uganda and Zambia: reflections and opportunities for autonomy. Health Policy. 2002;61(1):73-94. DOI:10.1016/S0168-8510(01)00212-3        [ Links ]

14. Hernández M. Reforma sanitaria, equidad y derecho a la salud en Colombia. Cad Saude Publica. 2002;18(4):991-1001. DOI:10.1590/S0102-311X2002000400007        [ Links ]

15. Hómedes N, Ugalde A. Human resources: the Cinderella of health sector reform in Latin America. Hum Resour Health[internet].2005[citado 2008 ago 21];3(1). Disponible en: http://www.human-resources-health.com/content/3/1/1 DOI:10.1186/1478-4491-3-1        [ Links ]

16. Infante A, de la Mata I, López-Acuña D. Reforma de los sistemas de salud en América Latina y el Caribe: situación y tendencias. Rev Panam Salud Publica. 2000;8(1/2):13-20. DOI:10.1590/S1020-49892000000700005        [ Links ]

17. Jimenez J, Bossert T. Chile's health sector reform: lessons from four reform periods. Health Policy. 1995;32(1-3):155-66. DOI:10.1016/0168-8510(95)00733-9        [ Links ]

18. Lloyd-Sherlock P. Health sector reform in Argentina: a cautionary tale. Soc Sci Med. 2005;60(8):1893-903. DOI:10.1016/j.socscimed.2004.08.032        [ Links ]

19. Machado AL, Giacone M, Alvarez C, Carri P. Health reform and its impact on healthcare workers: a case study of the National Clinical Hospital of Cordoba, Argentina. Soc Med. 2007;2(4):156-64.         [ Links ]

20. Marín JM. Fortalecimiento de la función rectora de las autoridades sanitarias en las reformas del sector de la salud. Rev Panam Salud Publica. 2000;8(1/2):21-32. DOI:10.1590/S1020-49892000000700006        [ Links ]

21. Martínez J, Martineau T. Rethinking human resources: an agenda for the millennium. Health Policy Plan. 1998;13(4):345-58. DOI:10.1093/heapol/13.4.345        [ Links ]

22. McPake BI. Public autonomous hospitals in sub-Saharan Africa: trends and issues. Health Policy. 1996;35(2):155-77. DOI:10.1016/0168-8510(95)00778-4        [ Links ]

23. McPake B, Yepes F, Lake S, Sanchez L. Is the Colombian health system reform improving the performance of public hospitals in Bogotá? Health Policy Plan. 2003;18(2):182-94. DOI:10.1093/heapol/czg023        [ Links ]

24. Narasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G, Elzinga J, et al. Responding to the global human resources crisis. Lancet. 2004;363(9419):1469-72. DOI:10.1016/S0140-6736(04)16108-4        [ Links ]

25. Organización Panamericana de la Salud. Desarrollo y fortalecimiento de la gestión de los recursos humanos en el sector salud. Washington; 2001.         [ Links ]

26. Rigoli F, Dussault G. The interface between health sector reform and human resources in health. Hum Resour Health[Internet].2003[citado 2009 feb 23];9(1). Disponible en: http://www.human-resources-health.com/content/1/1/9 DOI:10.1186/1478-4491-1-9        [ Links ]

27. Sandoval H. Mejor salud para los chilenos: fundamentos sanitarios, políticos y financieros de la necesidad y oportunidad de hacer una reforma al sistema de salud chileno. Cuad Med Soc (Santiago de Chile). 2004;43(1):5-20.         [ Links ]

28. Sharma S, Hotchkiss D. Developing financial autonomy in public hospitals in India: Rajasthan's model. Health Policy. 2001;55(1):1-18. DOI:10.1016/S0168-8510(00)00106-8        [ Links ]

29. Ugalde A, Hómedes N. Descentralización del sector salud en América Latina. Gac Sanit. 2002;16(1):18-29. DOI:10.1590/S0213-91112002000100004        [ Links ]

 

 

Correspondence:
Claudio A. Méndez
Instituto de Salud Pública
Facultad de Medicina
Universidad Austral de Chile
Av. Carlos Acharán Arce s/n
Campus Isla Teja
Casilla Postal 567, Valdivia, Chile
E-mail: claudiomendez@uach.cl

Received: 3/10/2009
Revised: 8/6/2009
Approved: 8/20/2009

 

 

a Sojo A. Reformas de gestión en la salud pública en Chile. Comisión Económica para América Latina y el Caribe: Santiago;1996. (Series Políticas Sociales, 13).
b Ministerio de Hacienda. Ley Nº 19.988, de 14 de julio de 2003. Establece financiamiento necesario para asegurar los objetivos sociales prioritarios del gobierno. Diario Oficial. 13 ago 2003[citado 02 feb 09].Disponible en: http://www.bcn.cl/leyes/pdf/actualizado/213493.pdf
c Ministerio de Salud de Chile. Ley Nº 19.937, de 30 de enero de 2004. Modifica el D.L. nº 2.763, de 1979, con la finalidad de establecer una nueva concepción de la autoridad sanitaria, distintas modalidades de gestión y fortalecer la participación ciudadana. Diario Oficial. 24 feb 2004[citado 06 ene 09].Disponible en: http://www.bcn.cl/leyes/pdf/actualizado/221629.pdf
d Ministerio de Salud de Chile. Ley Nº 19.966, de 25 de agosto de 2004. Establece un régimen de garantías en salud. Diario Oficial. 03 sep 2004[citado 06 ene 09]. Disponible en: http://www.bcn.cl/leyes/pdf/actualizado/229834.pdf
e Ministerio de Salud de Chile. Ley Nº 20.015, de 03 de mayo de 2005. Modifica la ley 18.433 , sobre instituciones de salud previsional. Diario Oficial. 17 mayo 2005[citado 06 ene 09]. Disponible en: http://www.bcn.cl/leyes/pdf/actualizado/238102.pdf

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License