HEALTH FINANCING PROFILE - ARGENTINA 89374 Argentina has one of the highest levels of GDP per capita in Latin America and has historically spent a considerable portion of GDP on health. It has, however, lagged far behind other upper-middle income nations on several health measures such as life expectancy, infant mortality, maternal mortality and under-5 mortality (table 2).1 Approximately 40% of Argentina’s population remains uninsured and the government has a constitu- tional responsibility to finance and provide health services to this population. The poor northern prov- inces have a higher percentage of uninsured (approximately 60%) and public facilities in these regions are more poorly provisioned and staffed. This disparity in coverage and quality of care between poor provinces and rich ones is echoed in health outcomes between these same provinces. Outcomes in poor provinces are often several orders of magnitude worse than in rich ones.1 At the federal level, the government has initiated several programs with national coverage to address these provincial inequalities. Several results-based financing mechanisms have been implemented to offer incentives to provinces and health providers for improved health outcomes. Plan Nacer – now succeeded by Programa SUMAR – is the most ambitious of these programs and has reached over 90% coverage of the target population.2 Health Finance Snapshot Argentina has consistently spent a relatively high percentage of GDP (8 to 9%) on Total Health Expenditures (THE). General Government Expenditure on Health (GGHE) fluctuates, generally remaining close to 60% of THE while private insurance remains a smaller but important portion of health spending. Table 1. Health Finance Indicators: Argentina 1995 2000 2002 2003 2005 2007 2009 2012 Population (thousands) 34,855 36,931 37,657 38,001 38,681 39,368 40,062 40,765 Total health expenditure (THE, in million current US$) 21,450 26,196 8,484 10,648 15,260 21,553 29,047 40,889 THE as % of GDP 8 9 8 8 8 8 9 8 THE per capita at exchange rate 615 709 225 280 394 547 725 892 General government expenditure on health (GGHE) as % 59.8 53.9 53.6 51.7 53.5 58.2 66.0 69 of THE Out of pocket spending as % of THE 28.0 29.0 29.8 31.1 29.9 25.7 20.1 20 Private insurance as % of THE 11.0 14.0 13.0 14.0 13.0 13.0 11.0 8.0 Source: WHO, Global Health Expenditure Database; National Health Accounts, Argentina 4 Out of pocket spending (OOPS) in Argentina remains lower than in many other Latin American countries as a Figure 1. Total Expenditures on Health by type, Argentina portion of THE (Figure 1). 4 OOPS are, however, regressive in their incidence with households in the lowest income quintiles pay- ing a higher percentage of their income in OOPS than households in the highest quintiles (Figure 2). Total Expenditure on Health as a percentage of GDP Figure 2. OOPS as % of Income by Income Quintile, 2010 Source: Ministry of Health, Argentina. “Encuesta de Utilizacion y Gasto en Servi- Source: WHO, Global Health Expenditure Database; National Health Accounts, Argentina cios de Salud Argentina – Year 2010” (2012) Health Status and the Figure 3. Demographic Indicators, Argentina Demographic Transition Argentina has undergone the demographic and ep- idemiological transitions so that it finds itself with an aging population suffering increasingly from Crude birth rate chronic non-communicable disease and less from (per 1,000 communicable (infectious) disease. However, on population) several important measures such as maternal and infant mortality, outcomes are stratified. For ex- Infant mortality ample, the poor provinces of Formosa and Jujuy rate (per 1,000 had a maternal mortality rate over 100 (per 1,000 live births) live births) in 2008 while the city of Buenos Aires had a rate of just 9.3 Under-5 mortality rate Demographic Transition (per 1,000 births) 4 Birth and mortality rates are declining (figure 2). 4 The total fertility rate (TFR) has fallen from 3 in 1990 to 2.3 in 2012. Source: United Nations Statistics Division and the Instituto Nacional de Estadistica y Censos, Argentina. 4 The ‘bulge’ in the population pyramid is moving upward (figure 4). Table 2. International Comparisons: Health Indicators Epidemiological transition Upper Middle Argentina Income Country % Difference 4 Mortality from non-communicable (chronic) ill- Average nesses has far surpassed infectious disease mor- GNI per capita (year 2000 US$) 5,170.0 3,420.8 33.8 tality (Figures 5 and 6). Prenatal service coverage 99.2 93.8 5.4 Contraceptive coverage 78.3 80.5 -2.8 Figure 5. Mortality by Cause, 2008, Argentina Skilled birth coverage 94.9 98.0 -3.3 Sanitation 90 73 18.9 Respiratory Infections TB Success 48 86 -79.2 Maternal & Infant Mortality Rate 12.6 16.5 -31.0 Perinatal <5 Mortality Rate 14.1 19.6 -39.0 Communicable Maternal Mortality Rate 44 53.2 -20.9 Diseases Life expectancy 75.8 72.8 4.0 Non- THE % of GDP 8.0 6.1 23.8 Communicable Diseases GGHE as % of THE 60.6 54.3 10.4 Physician Density 3.2 1.7 46.9 Hospital Bed Density 4.5 3.7 17.8 Source: WHO, Global Burden of Disease Death Estimates (2011) Source: World Bank, DataBank. Health, Nutrition and Population Statistics. Figure 6. Non-Communicable Disease Mortality, 2008, Argentina Figure 4. Population Pyramids of Argentina 1950 1980 2010 90-94 75-79 Male 60-64 Female 45-49 30-34 15-19 0-4 1000 0 1000 2000 0 2000 2000 0 2000 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision. Source: WHO, Global Burden of Disease Death Estimates (2011) Health System Financing and Coverage Argentina’s health system has historically been split into three private systems, both at the national and provincial levels. The distinct regimes: the public system which is free for all, the Obras public system has been decentralized since 1993. These three re- Sociales (OS) which provide coverage in a mandatory contributo- gimes are fragmented but Argentines under each regime utilize a ry social health insurance scheme, and a supplementary private mix of public, private and OS facilities and services leading to a insurance system. Numerous providers exist in both the OS and complex web of OOPS and cross-subsidization between systems. Figure 7. Timeline of Argentina’s Health System Creation of the Superintendency of Health Services (SSS) in the MOH. Creation of the Direc- Comprehensive Medical Assistance Administrative, economic and financial, FESP (Essential Public torate of Public Health Program (PAMI) created to provide oversight body for all agents in Argenti- Health Functions and Pro- and Social Assistance. health benefits to retired workers. na’s National Health Insurance. grams Project) initiated. 1943 1949 1971 1993 1996 2005 2007 Directorate of Public Health and Decentralization of health Plan NACER introduced Social Assistance becomes the service provision from the (maternal & child Ministry of Health. federal to the provincial and health). Later expanded municipal levels. National to Plan SUMAR. MOH retains regulatory role. Argentina’s health system has several broad coverage regimes which are not only separate from one another, with fragmented risk and financial pools, but are also internally fragmented as well. 1. Public sector: Non-contributory. Covers the uninsured but Argentines with contributory insurance also utilize public facilities at times. Services are provided for free at public facilities which have fixed budgets (i.e. unrelated to outputs/results) and are run by decentralized provincial and municipal governments with financing mainly from the federal budget. Explicit enroll- ment is not necessary. A number of supplementary programs based on Results-Based Financing (RBF) principles exist (table 4). 2. Contributory Social Insurance (Obras Sociales), other than PAMI (see below): Run by trade unions and professional organi- zations. Over 250 in existence although a small percentage dominate the market share. Workers and their employers make mandatory payroll contributions. Beneficiaries primarily utilize private facilities. There exists a redistributory mechanism be- tween different OS to offset the cost of high-cost and low-prevalence illnesses for smaller OS with fewer financial resources. 3. Private Health Insurance (EMP): Voluntary prepaid contributory regime. Has close to 200 insurers nationwide, both non-profit and for-profit although market share is dominated by just a few for-profit insurers. Premiums are set by each insurer and vary across individuals. Insurers contract with private facilities as well as with independent health providers to pay for services for private beneficiaries. 4. Comprehensive Medical Assistance Program (PAMI): Later called National Institute for Retirees and Pensioners (INSSJyP). PAMI comprises contributory health coverage for retirees and pensioners and their families affiliated with the Obras Sociales. Services are provided free of charge at public facilities and some private facilities. Table 3. Types of Health Coverage — Argentina Beneficiaries Source of Financing Service Provision Benefits Indigent, informal workers, General taxation (mainly Regulated at the provincial and municipal levels which provide Public unemployed. federal budget). Public facilities. their own outline of mandatory services covered. -Mandatory employee (5% of -National OS subject to the MOH-supervised Mandatory Health Mandatory Contribu- Workers in the formal sector wages) and employer (3%) Program (PMO). Mandated coverage of 95% of the causes of and independent workers contributions. tory Social Security Mainly Private facilities and outpatient, surgical and hospital care, dental care, mental who pay contributions -Fixed voluntary monthly (Obras Sociales), through the AFIP (‘monotri- payment for independent Decentralized Public Hospitals. health, rehabilitation and palliative care. - Provincial OS are not required to adhere to PMO coverage rules other than PAMI butistas’). workers– varies based on but have their own lists – benefits vary. income. Those who are able to prepay Subject to the MOH-supervised Mandatory Health Program (PMO). Prepaid premiums of Prepay Private Insu- or whose employers provide Mandated coverage of 95% of the causes of outpatient, surgical beneficiaries and/or their Mainly Private facilities. rance (EMP) optional supplemental employers. and hospital care, dental care, mental health, rehabilitation coverage. and palliative care. Comprehensive Private facilities and Decentrali- Contributory Retirees and Employee and Employer Coverage mandated as with the other OS Medical Assistance Pensioners (and dependents). contributions. zed Public Hospitals. (see above). Program (PAMI) Source: Ministry of Health, SSS, Argentina. Table 4. Selected Supplementary Public Health Programs Based on Results-Based Financing (RBF) Principles Eligible/Target Goals Financing Benefits & Service Priorities Population Essential Public • Vaccine-preventable diseases; Health Actions • Tuberculosis; Varying target popu- Provinces and municipalities receive performan- - Improve the stewards- • HIV/AIDS; lations for the various ce payments based on number of Public Health hip role and appropriate • Vector-borne diseases; programs. Actions achieved (from an agreed list of Actions). regulatory environment of the • Non-communicable diseases; nation’s public health system. • Safe blood. Essential Public Health Functions and Programs - Capitation payments to provinces based on Project (FESP I and II) Women with seven or enrollment of qualified beneficiaries (the size of Range of preventative and curative servi- “Incluir Salud” Program more children, severe- the payment given per beneficiary depends in ces covering diseases like kidney failure; - Public health insurance ly disabled people and part on provincial achievement regarding a set hemophilia; Gaucher’s program for extremely vulne- population over 70 of performance indicators). disease; HIV, Fabry’s disease; multiple rable and uninsured people. receiving non-contri- - The financing received by the provinces is used sclerosis, amyotrophic lateral sclerosis, butory pensions. to make fee-for- service payments to public cystic fibrosis and hepatitis C. health facilities treating beneficiaries. - Decrease infant and mater- nal mortality rates. - Similar financing mechanism as in the case of Basic package of free services for: Women (aged 20-64) - Increase utilization and “Incluir Salud” (see above). • Maternal and child basic care; and children (< 20) quality of key health services - The provincial performance indicators here are • Preventive health care; Plan NACER/SUMAR for the target population. not enrolled in any measures of coverage/attainment among the • Certain types of complex care (conge- contributory health - Improve institutional mana- target population (e.g.: pre-natal care coverage, nital heart disease surgery, inpatient insurance scheme. gement by strengthening cancer screening, etc.). neonatal care, others). the incentives for results. Source: Ministry of Health, Argentina and The World Bank: Projects and Operations, Argentina. Access to and utilization Figure 8. Health Beneficiaries by Figure 9. Service Utilization of medical consultations Type of Coverage by Income Quintile, 2010. and medications in Ar- gentina is high, even among the lowest in- come groups4 (figure 9). In 2010, 34.7% of all medical consultations took place in public fa- cilities, 20.1% in OS fa- cilities and 45.2% in pri- vate facilities4. Source: Belló and Becerril-Montekio. “Sistema de salud de Argentina”, 2011. Source: Ministry of Health, Argentina. “Encuesta de Utilizacion y Challenges and Future Agenda Gasto en Servicios de Salud Argentina – Year 2010” (2012) 4 While the richest income quintiles mainly utilize private facilities, a full 17.4% of the richest quintile and 25.9% of the sec- ond-richest utilize public facilities (figure 10). This has led to cross-subsidization of the private sector by the public sector as public facilities are rarely reimbursed by private insurers or OS. 4 The fragmentation of the Argentine system is an ongoing issue. Risk and financial pools are fragmented between the public sector, the Obras Sociales and the private insurance regime. However, internal fragmentation within each regime has also been blamed for inefficiencies and also for heterogeneous quality of services among different regions, provinces and facilities.5 References Figure 10. Type of Facility Utilized by Income Quintile, 2010. 1 World Health Organization. Global Health Observatory, Interagency estimates. 2 Cortez, Rafael and Daniela Romero. “Argentina: Increasing Utilization of Health Care Services among the Uninsured Population: The Plan Nacer Program”, The World Bank UNICO Studies Series, No 12, 2013. 3 Belló, Mariana and Victor M. Becerril-Montekio. “Sistema de Salud de Argentina”, Salud Pública México, vol.53 suppl.2, 2011. 4 Ministry of Health, Argentina. “Encuesta de Utilizacion y Gasto en Servicios de Salud Argentina – Year 2010” (2012) 5 Cavagnero, Eleonora and Marcel Bilger. “Equity during an economic crisis: financ- ing of the Argentine health system”, World Health Organization, discussion paper, No. 3, 2009. This profile was prepared by Dr. Deena Class, A. Sunil Rajkumar and Eleonora Cavag- Source: Ministry of Health, Argentina. “Encuesta de Utilizacion y Gasto en Servicios nero with inputs from Michele Gragnolati. de Salud Argentina – Year 2010” (2012)