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INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAState-Society correlation and social institutions whichoverlapped with them; from another perspective, theclass bias, which differentiated them, left its mark onsocial policies, especially those related to health.The discrimination between workers and employees,instituted with Social Security, gave rise to a historicstruggle, led, since the 30’s, by the socialist doctorSalvador Allende. He was minister in the social governmentera (1939-1941), notable parliamentarian,and President of the Republic (1970). Allende pursuedthe integration of the social previsional funds or theunification of all health services in one institution, andthe rectification of geographical and class disparity.Allende believed that health iwas a universal right andthat health status is determined primarily by factorssuch as proper wages, housing, nutrition, education, leisureand culture [Allende, 1939].The disputes aroundthese issues emerged strongly during the "Socialist Republic"halfway through 1932.This occurred when progressivecurrents strove for socio-economical transformationsalong with medical groups that, influencedby the soviet health system, defended the disseminationof "sanitary factories" ("usinas") throughout thecountry. The objective was to form a universal, integrated,efficient and humane organization, directed bya "technical commanding group", with centralized planningas its main instrument.In the health sphere, these events re-created thehistoric struggle between three ideological currentsthat divided professionals and whose vestiges still persist:the right or conservative wing, defender of statemedical assistance for the poor and the needy; thecenter wing, favorable to the maintenance of provisionof medical assistance separated from public health; andthe left wing, partisan of a unique system of health, integratedand universal, inspired by social medicineprinciples. In the interim, the legal reforms of the systemof social protection resulted in a hybrid of thesepositions, due to the State of compromise.The demands for more equitable social policieswere partially acknowledged when, after eleven yearsof legislative transaction, the unification of the pensionfunds brought about the modification of the regime ofbenefits of Social Security in 1952. As part of the samelaw, by means of parliamentary artifices, an article wasimplemented that merged all the medical and hospitalservices and the jurisdictions of public health of thecountry in one institution – the National Health Service("Servicio Nacional de Salud", SNS), inspired by theNational Health Service (NHS) created in 1948 in capitalistEngland, financed by the Treasure, and whosecoverage was universal. Nevertheless, this intention ofimitating the NHS was abridged as the SNS remained apart of the Social Security and, as such, was subjectedto the same financial limitations, with restrictive coveragefor the urban workers. Consequently, the relationshipof the conjuncture revealed the power of thelandowners (right-wing) system upon impeding the inclusionof peasants, and of the center wing on opposingthe leveling of workers and employees. Thus, the healthcoverage was preserved for the urban workers withtheir dependents and for indigents who could certifythis condition. In spite of this, it should be stated thatthe SNS was a pioneer in Latin America, a paradigm forits institutional engineering, its technical competenceand territorial organization in "health zones"; for theadoption of new planning and programming methodsand for the excellence of its leading members (all ofthem educated at the Sanitary School, created in 1943).In addition to these events, the foundation of theMedical School in 1948 had an effect (presided over byAllende). This institution gained monopolistic representationof the profession, the exclusive ethical piercontrol and the rest of prerogatives of public status,turning into a crucial national and sectorial actor. Attributableto this corporative power, doctors wereable to negotiate a privileged statute by which theywere converted into civil servants.24
Observatorio Latinoamericano de Salud.In 1960, the population reached 7.4 million, with72% of the work force earning less than minimum wage.As far as the SNS, it had 95.5% of the beds in thecountry and took care of 70% of the Chileans, whichillustrated that many people without legal rights usedthese services as recourse to the indigence file.The absence of a solution to the problem of universalaccess to the SNS and the chronic financial deficitprovoked several disputes until 1968, when thedemocratic Christian government, with the socialists’support, decided to create a Unified Health System.Nonetheless, the legal project was mutilated due to arange of pressures: the employees’ associations insistedon conserving the schemes of free election administeredby the National Medical Service for Employees("Servicio Médico Nacional de Empleados", SER-MENA), established in 1942; the doctors were lookingfor an increase of their wages by way of the expansionto private practice, in agreement with the continentalmovement in favor of a higher status for the profession;the opposition parties viewed in this conflict theopportunity to confront the government. As it wasnot possible to reach more generous political agreements,the outcome was a very peculiar law that insertedthe regime of the SERMENA (and its scanty resources)in the SNS only for employees,. These employeesthus had access to the public services throughthe professional’s free election and received co-paymentfor medical action, but in a different schedulefrom traditional beneficiaries. In sum, within the SNStwo forms of management were instituted, removingthe existent unity and reinforcing the discrimination ofclass, without solving the financial issue.In 1971, president Allende raised the issue of theUnified Health System ("Sistema Unificado de Salud",SUS), whose design comprised fiscal financing, universalcoverage, communitarian participation, equity inthe access to and quality of care, and a set of redistributivesocial policies. Even so, in the prevailing environmentof ideological polarization in 1973, the SUSwas blocked by the opposition, causing the MedicalSchool’s adherence to the President’s resignation.The brutal military coup of September 1973abruptly terminated the democratic path that hadbeen expanded throughout the country for 140 years.It aborted any progressive initiative, sank the nation interror, and annihilated civil, political, and social rights,arduously conquered, sowing insecurity among citizens.The reforms of authoritarian neoliberalismThe pioneer neoliberal experiment undertakenduring the dictatorship in Chile, under the dogma ofmarket primacy and the failure of the Keynesian orprotector State, was formulated and implemented in ashort time (1978 – 1981) by the hegemonic nucleuscomposed of Pinochet and economists that derivedfrom the Chicago School. In the social field, the propositionof "modernization" in prevention and healthrelied on the active participation of the MedicalSchool, at that time in the hands of an ultra right-winggroup that had taken it by assault.In the area of Prevention, the funds accumulatedby civil workers were transferred to lucrative mercantilesocieties – the Administrators of Pension Funds("Administradoras de Fondos de Pensión", AFP). Inspite of the serious restrictions imposed by the internationalcrisis of the time, the new system was feasiblethrough the massive transference of resources fromthe social sectors to the Administrators of PensionFunds and the decree of a mandatory 10% share of thetaxable rent, from which the employers and publictreasury were exempted. It is important to note thatvia democracy and not by force, several countries areadopting the Chilean model, despite its proven promotionof inequality.25
Page 2 and 3: PEOPLE’S HEALTH ASSEMBLY 2GLOBAL
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INFORME ALTERNATIVO SOBRE LA SALUD
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Life and Healthas Commodities
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