Desigualdad Social y Equidad en Salud: Perspectivas Internacionales

Moreover, Costa Rica, where the emphasis on privatization has been less, showsbetter tendencies in equity of access to services than Chile or Colombia (Guimarâes2001). Its CCSS has the same package of services available to people with differentcapacity of payment (Vargas, Vazquez et al. 2002). There, practically the entirepopulation has access to the health services of the CCSS. For example, 96% of allbirths in 1999 took place in CCSS hospitals (plus 2% in private clinics and 2% homedeliveries) (Rosero-Bixby 2004). In addition, the data show substantial improvementsin access (and equity) to outpatient care between 1994 and 2000, when the reformswere adopted. The share of the population whose access to outpatient healthcare was inequitable declined from 30% to 22% in pioneering areas where reformbegan in 1995-96. By contrast, in areas where reform had not occurred by 2001, theproportion underserved has slightly increased from 7% to 9%. Similar results comefrom a simpler index based on the distance to the nearest facility (Rosero-Bixby2004). Furthermore, the percentage of people without equitable access to primaryhealth services dropped by 15% between 1994 and 2000 in areas where health sectorreform was implemented in 1995-1996, whereas areas that had not yet initiatedhealth sector reform in 2000 experienced only a 3% reduction (Rosero-Bixby 2004).Thus, Equity in access to primary care has also improved considerably, perhaps becausethe first reforms were implemented in less developed areas of the country.Contrary to Costa Rica, the health reform of 1996 in Mexico could imply theincrement of a previous tendency of deterioration of equity in access to services. Infact, the creation of different service packages for the basic mandatory health insurance,a variety of additional health plans with different premiums and co-payments,and direct fee for service will lead to a vast stratification in access and quality ofservices. There, the negative tendency in equity is a continuation of past practices.For instance, the richest 10 percent of households spent 8.5 times more than thepoorest 10 percent in 1984, 16.4 times more in 1992, 18.3 times more in 1994, and16.5 times more in 1996. Data also indicates that many low-income families cannotafford to pay for medical care: 46 percent of the poorest 10 percent of householdswere found to have medical care expenditures, in comparison with 76 percent ofhigh-income families. There is also a differences in the kind of services purchased(Laurell 2001). These tendencies even before the reform of 1996, can be explainedby a reduction of the general budget of the IMSS and the failure of payments offunds for decentralized programs by the federal government.Similar to Mexico, the experience of Brazil also shows that people in lower incomegroups experience more difficulties in getting access to health services. Thesedifferences are not only in the number of services but also in the types of services.Health care in Brazil still encompasses dual subsystems, which present distinct formsof institutionalization: the private service provides coverage to Brazilians who areyounger, present lower risks, and who have higher purchasing power; the unifiedsystem of health provides direct services to those who have a lower or no purchasingRiutort, Cabarcas17