Evidencias sobre gobernanza, equidad y financiamiento en salud en méxico: lecciones para paises latinoamericanos

Arredondo, Armando; Orozco, Emanuel; Aviles, Raúl

doi:10.1590/S0104-12902015S01014

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Articles • Saude soc. 24 (suppl 1) • Apr-Jun 2015 • https://doi.org/10.1590/S0104-12902015S01014 copiar

Evidencias sobre gobernanza, equidad y financiamiento en salud en méxico: lecciones para paises latinoamericanos

Autoría SCIMAGO INSTITUTIONS RANKINGS

Este articulo incluye evidencias sobre equidad, gobernanza y financiamiento como resultado de la reforma de la salud en México. Partió de una investigación evaluativa de diseño transversal con análisis cualitativo y cuantitativo en servicios de salud para población no asegurada desarrollada durante 2002-20010 Bajo criterios de factibilidad técnica, política y financiera, siete estados mexicanos fueron seleccionados. Los datos se recopilaron a través entrevistas a profundidad con actores clave (proveedores, usuarios, líderes comunitarios, legisladores y directivos), técnica de consenso y revisión documental y estadísticas oficiales. El procesamiento y análisis de la información se realizó con los paquetes ATLAS-TI Y POLICY MAKER. La reforma en salud ha podido modificar la dependencia del nivel central; existe nueva formula de equidad; los lideres comunitarios y usuarios plantean la necesidad de implementar sistemas de rendición de cuentas en salud a nivel municipal y estatal; las estrategias de reforma no cuentan con mecanismos adecuados para una participación de todos los actores del sistema de salud, aún cuando la democratización en salud se constituyó como eje conductor de la reforma; los niveles de inequidad en la asignación de recursos y los gastos catastróficos en salud afectan de manera desigual, teniendo impacto negativo en los estados con marginación social. Enfasis especial se hace en una lista de fortalezas y debilidades que a manera de lecciones aprendidas se sugieren para lograr una mayor equidad, mejores niveles de gobernanza y mayor protección financiera en los proyectos de reforma en salud a nivel mundial y particularmente en América Latina.

Gobernanza; Financiamiento en salud; Equidad; Lecciones.

Region	Population	Marginalization index (*)	Public insurance index(*)	Epidemiological lag (*)	Indigenous population (*)	Political party in power	Geographic position
A	710 982	High	Low	High	High	Left	North
B	741 037	Medium	Medium	Medium	Medium	Center	Northern
C	7 838 010	Low	High	Low	Low	Right	Central

Strengths		States
	Colima	BC Sur	Jalisco
Negotiation with federal sources	++	+	++
Negotiation with state sources	++	-	+++
Diversification of financing sources	++	+	+++
Municipalization of health services	-	-	++
Consolidated decentralization	+	+	++
Combination of financing funds	+	+	++
Favorable opinion on pre-payment	++	+	++
Growth based on goals of strategic programs	+	-	++
Implantation of new financing sources and schemes	++	+	+++
Autonomy in spending	++	++	++
Optimization in expenditures	+	+	++
Community negotiation of resources	+	+	++
Local capacity for negotiation/fundraising	+		++
Resource allocation as a function of needs	+	+	++
Perception that financing has broadened service production	+	+	++
Favorable opinions on recovery fees	++	++	+++

Weaknesses		States
	Colima	BC Sur	Jalisco
Dependence on federal level	++	+++	++
State administrative recentralization	++	+	++
Limited negotiation for financial resources	++	++	+
Lack of knowledge on financing sources and funds	++	++	+
Lack of strategic vision on new federal sources and schemes	+	++	-
Uncertain destination of recovery fees in view of SPS	++	++	+
An accounting system which makes follow-up of funds more difficult	++	++	+
Financial difficulties due to federal delegation of responsibilities	+	++	+
Normative rigidity that limits financial transfers	+	+	-
Limited state contributions	+	++	+
Unfavorable opinions on recovery fees	++	++	++

Strengths		States
	Colima	BC Sur	Jalisco
Existence of equity indicators	-	+	++
Establishment of strategies to achieve optimization of resources	+	+	++
Technical criteria in resource allocation oriented towards satisfaction of health needs	+	+	++
Resource allocation for the operation and growth of the state health system	++	-	++
Improvement in opportunities for healthcare	+	+	++
Improvement in access to health services	++	++	++
Implementation of plans and programs for greater equity (SPS)	+++	++	+++
Capacity to operate the SPS	++	+	+++
Implementation of plans and programs to improve financing (SPS)	++	++	+++
Existence of programs for health coverage and access for vulnerable populations (SPS)	+++	+	++
Favorable community impact of health services	++	++	++
Support for the municipalization of health services	-	-	++

Weaknesses		States
	Colima	BC Sur	Jalisco
Limited management of equity as financial allocation criterion	++	+++	+
Limitations in state administration of resources	++	++	+
Limited management of formulas for allocation and use of resources	++	+++	+
Out of phase with new healthcare schemes	-	+	-
Lack of capacity to operate the SPS	+	++	+
Dependence on citizen contributions	++	++	++
Dependence on governmental contributions	++	+++	+
References on out-ofpocket user expenditures	++	++	+++
Orientation of resources to cover operative needs (salary payments)	+++	+++	++
Traditional financing sources are affected	++	++	++
Operative personnel rejects the SPS	+	+	+
Operative expenditures that may be a financial burden to the system	++	++	+
Population without access to programs through prepayment	+	++	+

Strengths		States
	Colima	BC Sur	Jalisco
Identification of legal and normative frameworks	++	++	+++
Creation of mechanisms to improve financing	++	+	++
Mechanisms to monitor the use of resources	+	+	++
Margin for local decisionmaking	++	++	+++
Capacity to operate the health system	++	+	++
Orientation towards accountability	++	++	+++
Initiatives to promote greater participation	++	+	++
Coordination between government levels	++	+	+++
Increased negotiation for financial resources	++	+	+++
Social participation in fundraising	++	+	++
User empowerment	+	+	+
Participation in program design and in decisionmaking	-	-	+
Critical vision of political clientelism with programs and public resources	-	+	+
Community initiatives to improve well-being	+	+	+
Spaces for community participation (linked to governmental programs)	++	+	+
The population sees itself as being better informed in health matters	+	-	+
Support for community work to improve health units	++	+	+
Community involvement in decision-making	-	-	+
Mediation mechanisms to support vulnerable groups	++	+	++

Weaknesses		Region
	A	B	C
Limited knowledge of legal framework and its scopes	+	++	+
Rigidity of normative framework	+	+	-
Limited scopes of the reform		+	-
Federal centralism	+	++	+
Limited local capacity	-	++	-
Efficiency problems in the production of health services	++	++	+
Lack of mechanisms to monitor the use of resources	++	++	+
Lack of intersectorial coordination	+	++	+
Cronyism/influence peddling	++	++	+
Political electoral clientelism	++	+	+
Social participation in official programs (Health Committees)	+	+	+
Deficient planning	+	+	-
Lack of mechanisms for increased negotiations of financial resources	+	+	-
Limited social participation in financing	+	++	+
Lack of opportunities for social participation in program design and decision-making	++	++	+

Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br

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