As part of a series begun in 1990 with the «Poverty Report» (the first on this subject since 1980), followed in 1991 by the «Report on Development Strategies» and in 1992 by the «Environment Report», by mid 1993 the World Development Report 1993: Investing in Health (WORLD BANK, 1993) was published. This was probably the most complete document on health in developing countries published until then. The Annual Report of 1994, dedicated to Infrastructure, completes an interesting phase of renewed concern for sectors «forgotten» for more than a decade.
The Report is very balanced and its preparation involved cooperation from WHO and UNICEF, amongst other organizations. The starting point is the advances achieved for the improvement of health during the last decades; it revolves around the concepts of avoidable mortality and disease burden; it gathers the strategy of Health for All and the suggestions of the World Summit in Favour of Infancy; it recognizes the problems generated by uncertainties and deficiencies of the health insurance market and, finally, suggests a «Plan of Action» based on three axes:
a) governments should promote an economic context that allows families to improve their health by adopting economic policies that benefit the destitute, investing more in education, and protecting the political and social rights of women;
b) public expenditure in health should be improved by: b.1) reducing expenditure at tertiary level; b.2) financing a series of public health measures, amongst which are the fight against infectious diseases, prevention of AIDS, environmental pollution, and behaviour patterns that put others at risk (e.g. drunk driving); b.3) financing and providing a range of essential clinical benefits, to be determined by the countries based on their epidemiological characteristics, national preferences, and level of income; b.4) improving management of services payed by public moneys by decentralizing and subcontracting services;
c) diversity and competition (including international competition) should be promoted, both in the insurance of health care not included in the basic package, as well as in providing services and in inputs supply. Distribution of information on the performance of health care providers, drugs and equipment, as well as on the cost and effectiveness of health interventions and of the accreditation level of health establishments.
The book (205 pages of text, 130 of statistical appendixes and a wide glossary of terms and abbreviations) has become an inevitable reference document without detriment to the greater or lesser degree of consensus its plan could evoke. Its impact on the health policies of Latin American governments has been enormous. However, there is as yet no evidence as to what extent its publication may involve a change in the loan policy of the Bank and institutions related. Unfortunately, a revision of the World Bank loan policy, carried out after the publication of the Report on Poverty, does not allow to be very optimistic (EMMERIJ, 1993).
A year later (July 1994), the XLVI Meeting of the Regional Committee of the Panamerican Health Conference discussed the Joint Report of ECLAC and PAHO/WHO on «Health, Equity and Productive Transformation in Latin America and the Caribbean».
It is, without reservations, a document that will become important in the region. From a multisectorial focus, it tries to harmonize equity with efficiency in the allocation of resources and effectiveness in health interventions. It emphasizes promotion, prevention and intersectorial action. It proposes an extended coverage by guaranteeing universal access to a basic benefits package, technically defined, financially and socially acceptable. It emphasizes the concentration of actions towards lower income and high risk groups. It incorporates the need to invest in infrastructure, institutional development and human resources. It points out the need to reform finance and management both in Health Systems (macroeconomic perspective) and the services provided (microeconomic perspective). It underlines the growing importance regulatory functions have for public authorities without opposing them to those of provision. Also, it ties decentralization to community participation and individual and collective responsibility of the population for its own health.
The document (115 pages) follows another one written jointly in 1992 by ECLAC and the UNESCO Regional Office for Latin America (CEPAL/OFICINA REGIONAL DE LA UNESCO PARA AMERICA LATINA Y EL CARIBE, 1992). It shows several similarities with the proposals of the World Bank Report though the emphasis is different. For example, it insists on institutional development and collective participation. To increase the income of ministries and insurance institutions it suggests, among other possibilities, a reduction in military expenses, closure or privatization of inefficient businesses and reduction of fiscal fraud or fraud in the payment of contributions (LEÓN, 1993, pp. 17-19), as reasonable mechanisms in times of global «détente» and economic growth. It stresses that the expansion of private sector participation should not be aimed at replacing the State, but should instead bring more rationalization to the public sector. Finally, it notes that the existence of two separate public subsystems in terms of financing and provision (one for the poor and another for the not-so-poor) is negative and should be corrected.
In my view, the document is more a proposal and less analytic than the World Bank Report, too optimistic as to the anticipated benefits of competition between public and private insurers, and not accurate enough on the contents and limits to decentralization of services (COLLINS and GREEN, 1994, pp. 459-475) (features that shares with the Bank Report). All in all, and probably because it refers only to Latin America and the Caribbean, I believe that is somewhat better adapted than the Bank report to the region realities and tendencies. However, its usefulness will have to be measured by its influence on the various national health policies.
Finally, it is important to analyze paragraph seventeen of the Action Programme of the Summit of the Americas (Miami, December 1994). It proclaims the desire to reduce, by the year 2000, infant mortality to one third, and that of mothers to half of that in 1990. It emphasizes care for the poor, the disabled and the natives. It urges the search for international financing to fight transmissible, endemic diseases (including AIDS). It encourages strengthening of public health infrastructures. It supports the establishment of a basic package, and even though it insists that every country should establish its own, it nevertheless defines the content of that package: health education (including AIDS prevention), family planning and mother-infant and child health. It agrees on a region meeting under the auspices of the IDB, the World Bank and the PAHO/WHO, on health systems reforms.
In short, it is a proposal for a basic package which, without being defined in «minimal» terms, is much more restrictive and focalized in areas such as mother-infant health, infectious diseases and «marginal» groups, than it would be desirable.
At the beginning of 1995, several countries (Guatemala, El Salvador, Ecuador, Uruguay and Argentina, amongst others) had begun, or had in mind to begin, processes of sectorial reform. In consequence, it would be desirable that the aforementioned meeting (held in the PAHO/WHO Headquarters September 29/30, 1995), for which preparation a working group was created by the IDB, the World Bank, OAS, ECLAC and WHO (VIERA, 1995), should contribute to exchange experiences as a step forward in the definition of a framework for reforms, and make progress in technical and financial cooperation in this field.