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Too
good to be true
It seems that
President Flores’ solution to the public health problem did not end with the
conflict at the Salvadoran Social Security Institute (ISSS, in Spanish). Now
the conflict has jumped from the ISSS to the union of doctors and to
different social organizations as well. The problem has taken a critical
turn: the national health system might go on strike. President Flores’
solution, instead of responding to the doubts and the demands of the doctors
and the unions, it only contributed to increase those doubts. His words have
no credibility. That is why they demand from him a legislative decree to
forbid the privatization of the public health system.
The creation of a new public health system has a weak spot: it lacks
consensus. It is an imposed solution that did not go through a negotiation
process, it was made public against the opinion of one of the most important
and affected sectors. No reform of this nature can be successful without the
approval of the sectors involved in this case. This principle is taught even
by the World’s Bank (El Banco Mundial), the leading promoter of the public
services’ privatization. The only sector that has enthusiastically saluted
the approach of the Executive power is the business elite, which in a
reunion gave its immediate support to the government. This unconditional
support can be important for the government, but it is not a very good sign
for the sectors connected with the public health, which are the leading
protagonists of the conflict. The members of the union reject the proposal
because they consider that President Flores is lying again.
The reform intends to keep the present level of medical attention without
increasing the sum of money that the contributors pay, but providing the
public with a better service. This is an attractive approach for a
population that has been mistreated, disrespected and inefficiently assisted
by the ISSS for decades. In theory, those insured will be able to choose to
remain in the ISSS program or to go to a private clinic. The reform is
ambitious. It duplicates the coverage for the children of the contributors,
and that is an important sector. In the near future, it promises to include
the independent workers, the rural workers, the domestic service, and the
immigrants. The answer of the contributors is predictable. Most people will
tend to find in the private health system what they cannot find in the ISSS:
they will not have to wait for months for an appointment or for an operation.
They will not have to wait for hours to receive medical attention, they will
receive their medications immediately, and their tests will be promptly
practiced, and the indirect costs will be lower. In a word, the proposal is
attractive. You could almost say that it is too good to be true. It looks as
an irresistible proposal since it is aimed to a vulnerable sector and it is
also aimed to allegedly improve one of the worst public services.
If most of those insured choose to leave the ISSS by the end of two or three
years, the ISSS will not be financially viable and it will become an
obsolete institution. Its destiny has already been decided. With this, the
government might achieve two objectives: to privatize the service and to
eliminate a source of conflicts that turned unmanageable along the last few
years. If, as it has been promised, in a few years the coverage becomes
universal, then the national system of health will also become obsolete. By
then, the ARENA administration will be able to get rid the Ministry of
Health. There are plenty of reasons to suspect.
If the arguments that the defenders of this reform use is that the ISSS is
being inadequately administrated, and that plenty of corruption cases have
taken place inside it
–and those are facts that cannot be denied- they forget to mention that
ARENA is the one that has been directing the institution during the last
decade. The allegations seem to indicate that corruption is a problem inside
the unions, and that those unions should be blamed for the crisis of the
ISSS. This is not true. Most of the responsibility belongs to its direction,
which has been in the hands of ARENA. To blame the unions for the chaos of
the ISSS is to overlook the perverse maneuvers performed by the directors
who were designated by ARENA. The important decisions, such as the destiny
of the ISSS funds, the bids, the budget, and the internal organization are
not the responsibility of the unions, but the responsibility of the
direction. In all of these decisions there has been plenty of space for a
corrupt performance and an inadequate administration because of the lack of
control procedures. The discredit the institution has been pushed into is
nothing but an excuse to justify the change. In any case, the contributors
wonder how a patrimony of $200 million has not been enough to provide a
better service along the last ten years.
By transferring the services of the ISSS to a number of private companies,
the costs will increase simply because those companies want a profitable
business. No private “health” company will render its services for free. If
those companies were happy with a profit of 10%, the cost of the health
service would increase in that proportion. Therefore, the service will be
more expensive than it was at the ISSS. When they expand the coverage of the
beneficiaries, including those children under 12 years old, the costs will
also increase. If the sums of money the people pay as contributions are not
going to increase, the ISSS will have to respond with its own resources to
the new demand –and those resources obviously have a limit-. When they run
out of funds, either the contributions will be increased or the services
will be reduced, even both things can happen at the same time. When this
moment arrives, the contributors will be the prisoners of the private
companies that might administrate the health sector, since by then the ISSS
will be ready to collapse, and the contributors will not be able to come
back to the ISSS. By then, their choices will come to an end. At this point,
only those who can afford the medical attention will be able to receive it.
Therefore, the expansion of the coverage and the possibility choose will be
nothing but an illusion.
It seems suspicious to say that the service of the ISSS will be able to
absorb both the rural and the urban independent workers, considering the
high unemployment and the underemployment levels. The domestic workers are
included, but nothing has been said about the women of the rural area, one
of the most vulnerable sectors. With the salary that those who work doing
domestic chores make, it is not clear how they will be able to contribute.
There is not enough information about the necessary requirements to receive
the benefits of this proposal. The only information available is that you
have to remain at least for a year with the same health care provider. The
so called democratization –indispensable by the way- involves plenty of
activities, but there is no information available about the procedures that
those actions will follow. Just like the foreign expert brought by the
government observed, the fact that the universal coverage is contemplated by
the law does not mean that some day it will become a reality. That is the
situation of the pensions.
The defenders of the solution that Flores presented sustain that this is not
a privatization. If this were so, what would be the point to veto a
legislative decree that forbids the privatization of the health system? The
business elite prefers to talk about modernization, that is, about a better
service; and about the elimination of both the deficiencies and the
institutional corruption, and the administrative chaos. No one can oppose to
that perspective. The fact is that, for the members of the business elite,
they are the only ones capable of ending with the vices, they seem to forget
that those vices take place a t a private level. The business companies talk
about creating an institution able to control them. None of the existing
organizations have been able to control the business companies. The existing
superintendence does not defend the rights of the users once the companies
are privatized. It does defend the owners of the new companies. The
competition factor, which allegedly obliges the companies to improve the
quality of their products and lower the prices, does not offer any kind of
procedure to control the large business companies because they form
oligopolies that make it impossible to develop a real competition. When both
the pension scheme and the electric energy distribution were privatized they
used the same discourse.
ARENA and its President understand freedom in a very odd kind of way. There
is freedom to use the currency one chooses to use, but technically there are
no Colones. The banks do not work with Colones anymore. Theoretically, a
person can change from one distributor of electric energy to another, but
technically that is not possible. Theoretically, the contributors could
bring their funds to the AFP they prefer, however there are actually only
two of them, and they are almost identical. Theoretically, there would be
lower and better prices; in fact, the prices are much higher and the quality
has not been improved. Theoretically, the doctors, the nurses and the
assistants can integrate their own companies to offer their medical services
and obtain profits; technically, this business is reserved for those who own
a considerable amount of resources, just like it happened in the case of
ANTEL. The ANTEL workers were soon obliged to return the shares that they
owned.
These suspicions lead us to conclude that the proposal of President Flores,
and the proposal of both the private business companies and the media are
nothing but more demagogy. Those who see one more lie in this proposal are
not completely wrong. In a few years, the ISSS will be history and the
contributors will be trapped in the private companies who will administrate
the health system. Therefore, only those who pay will receive a qualified
service.
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