- Necesidades y Acceso a los Servicios de Salud de la Población Adolescente en el Norte Argentino

Según la Organización Mundial de la Salud (OMS), la adolescencia es “la etapa de la vida comprendida entre los 10 y los 19 años, en la cual tiene lugar el crecimiento puberal y el desarrollo de las características sexuales secundarias, así como la adquisición de nuevas habilidades sociales, cognitivas y emocionales”.
Los y las adolescentes transitan un momento particular del desarrollo y, por sus necesidades específicas, deben ser abordados como un grupo diferente a los niños y los adultos, con experiencias de vida y necesidades diversas que varían según edad, sexo y contexto social y cultural.
Si bien los adolescentes integran un grupo poblacional caracterizado por indicadores bajos de morbilidad y mortalidad en comparación con otros grupos etáreos, presentan problemáticas y/o necesidades de salud particulares. La importancia de tales problemáticas se evidencia no sólo por la proporción de la población afectada, sino también porque involucran a una población con una amplia expectativa de vida productiva.
Se desataca entonces la necesidad de invertir en medidas de reconocimiento, protección y cuidado de esa población, para garantizar sus derechos de acuerdo a lo establecido en la Convención de los Derechos del Niño, al tiempo que constituye una estrategia eficaz de consolidar los logros alcanzados en la infancia, contribuyendo a reducir las disparidades socioeconómicas y sus consecuencias, desde un enfoque sanitario de ciclo de vida.
La literatura orientada a la evaluación de políticas de acceso al sistema sanitario permite diferenciar la presencia de tres instancias en la satisfacción del derecho a la salud.
La primera se asocia con la identificación de la necesidad de acceder al cuidado sanitario. En ocasiones, la escasa percepción de la necesidad afecta negativamente el acceso, a pesar de existir condiciones objetivas desde la oferta para la satisfacción de los requerimientos potenciales de los usuarios. Esta brecha entre la oferta institucional y la necesidad “traducida” en demanda del sistema sanitario requiere de un conjunto de acciones de política que exceden la órbita tradicional del ministerio sanitario, y avanza en atribuciones de otras áreas de las políticas sociales, tales como educación y acción social.
Particularmente, en el caso de la población adolescente, el acceso a la información constituye un desafío adicional, desde dos puntos de vista. El primero, porque establece la oportunidad de identificar mecanismos idóneos de transmisión de la información a partir de canales idiosincráticos del grupo etáreo bajo análisis, y que no necesariamente constituye el modo de comunicación tradicional aplicado para otros contingentes. En segundo desafío refleja la presencia de la familia como mediador, facilitador, o condicionante, según el caso, de la información.
La segunda instancia aborda el diseño de mecanismos que traduzcan la necesidad identificada en demanda efectiva. Ello plantea la presencia de diferentes barreras (culturales, geográficas, económicas, institucionales, etc.) que impiden el acceso y que se encuentran particularmente vinculadas con los modos de organización del sistema sanitario argentino, naturalmente segmentado y con profundas inequidades.
La tercera instancia se concentra en analizar y evaluar los criterios generados desde el sistema sanitario para facilitar la identificación de las necesidades, y que se traducen en acciones eficaces de política. La problemática adolescente requiere de esfuerzos de coordinación entre los ámbitos privados (individuo, familia, amigos, comunidad) con el ámbito público (centros de atención primaria, escuelas, hospitales, centros comunitarios); entre los espacios de promoción y atención; entre las órbitas nacionales y provinciales del sistema de salud; y entre distintas áreas ministeriales dentro de cada jurisdicción (salud, educación, acción social).
La relación entre información, necesidad identificada, traducción de necesidad en demanda, y posibilidad de acceso y diseño de políticas constituye la línea de trabajo que motiva el presente proyecto de investigación, orientado a conocer, y evaluar desde la perspectiva de las/los adolescentes la formulación de políticas públicas particularmente orientadas.
El objetivo general del estudio es identificar las barreras que dificultan el acceso a la salud por parte de la población adolescente en seis provincias del noroeste y noreste argentino: Tucumán, Jujuy, Catamarca Misiones, Chaco y Santiago del Estero. El plan de trabajo hace énfasis en las necesidades e intervenciones asociadas con la salud sexual y reproductiva; las adicciones, la alimentación; y la depresión, que constituyen los ejes centrales del Programa Nacional de Salud Integral en la Adolescencia para el 2011.
Para ello se identificarán las percepciones del estado de salud propio de los adolescentes, las principales necesidades de salud y su relación con el sistema sanitario a través del desarrollo de encuestas a estudiantes en el ámbito de la escuela pública. Asimismo, se indagará en la capacidad institucional existente a nivel local para cubrir dichas problemáticas, a partir de información relevada en los espacios institucionales encargados de diseñar e implementar dichas políticas.
En este marco, la metodología de investigación comprende:
- Revisión de literatura y relevamiento de información para la identificación de la normativa global, nacional y provincial vigente referida al abordaje de políticas sanitarias orientadas a los adolescentes, y el reconocimiento de los actores locales involucrados con el diseño de estrategias y políticas públicas destinada a esta población;
- Diseño y aplicación de una encuesta destinada a adolescentes a partir de una muestra de escuelas públicas secundarias de las provincias seleccionadas, a fin de obtener información sobre percepción de salud, necesidades y barreras de acceso de los adolescentes a los servicios de salud. La muestra propone el abordaje de escuelas secundarias en tres departamentos provinciales de distinto tamaño, incluyendo la ciudad capital, seleccionando en cada caso el primer y último año del ciclo. La selección final permite la construcción de una base de datos de aproximadamente 5500 observaciones de niños entre 11 y 18 años, residentes en localidades de diferente escala en seis provincias del norte argentino.
- Desarrollo de entrevistas a referentes provinciales (pertenecientes a los Ministerios de Salud, Educación y Desarrollo Social, Sociedades Civiles, Organizaciones no Gubernamentales, etc.), a fin de indagar sobre estrategias locales orientadas a la salud de los adolescentes y la percepción acerca de la capacidad local para abordar las problemáticas adolescentes (enfatizando en aquellas relacionadas con la salud sexual y reproductiva, la alimentación, el consumo de sustancias ilegales y el suicidio).
- La información cualitativa y cuantitativa recogida permitirá el análisis descriptivo y analítico de la situación de acceso de los adolescentes en el norte del país, respondiendo un grupo de preguntas específicas de investigación desarrolladas en la propuesta de investigación.



- Gastos Catastróficos Financieros en Salud en América Latina. Capítulo Argentina.



- Patterns&Regulation-Pharma-Argentina

Using a theoretical framework based on estimating demand functions under uncertainty, this paper proposes to highlight the importance of including economic variables of market structure and actors´ strategic organization in the design of regulations on the pharmaceutical sector, beyond the relevance of pharmacological and clinical tools. The specification of regularity standards in social health insurance schemes requires of dynamic tools to improve the decision making process within a framework of evidence-based medicine and cost-effectiveness analysis. With a sample of 9147 and 27647 observations on prescriptions by population covered by social insurance in Argentina, the paper two analyzes therapeutic groups: hypertensive and lipid lowering, respectively. Econometric implementation implied classical least squares estimation and logistic models for therapeutic group, product and brand. The data provides consistent messages about the presence of differentiation mechanisms that overshadow the traditional inverse relationship between price and sales. In particular, the interaction between brand and drugs, which can be extended to technological changes in a dynamic context, implies a complementary perspective in designing a regulatory framework. The power of negotiation and establishment of rules of producers must be considered in each particular therapeutic class, allowing coordinated incentives to encourage rational prescription behavior, moving in a pattern of more cost-effective and equitable use of resources.



- Development of a Regional Costing Methodology of the Argentine Compulsory Medical Program

Equity in access and asignative efficiency are clearly not questioned objectives in any health system, to the extent that since they promote the uniform guarantee for the population health care and restoration, while the capacity to prioritize objectives is valued, together with the allocation of resources and budgets managing as tools to achieve that security.
In an organizational structure such as the Argentine health system, achieving these objectives is a challenge for public policy, given that particular resourses allocation mechanisms coexist at a geographical level (provincial and municipal decentralization in health goals, collection and administration) and a deep fragmentation in the management of insurance funds that allow to reach the guarantee of care: more than nine hundred social funds with technical, financial and management operate simultaneously in the sector (Maceira, 2012).
In this context, the national health authorities have strong restrictions to ensure the homogeneity of care, and relatively limited resources to carry them out: less than ten percent of total health expenditure comes from the National Treasury, or approximately 16% of total public spending-including provinces and municipalities (Ministry of Health, 2009).
However, the National Government has a group of institutions with the capacity to establish wide ranging regulatory structures that, beyond its role of financing, they define insurance strategies, provision and services organization, and wide-ranging standards of conduct.
Particularly, the Superintendency of Health Services has among other responsibilities, with the power to define, fund and give effect to the Compulsory Medical Program (PMO), a large body of guarantees obligatory for all national institutions of social security (Union and Personnel Management National Social Work), and prepaid medicine companies, which is used as a parameter of attention, in content and price, to the provincial social security institutions.
Thus, the PMO provides a wide ranging mechanism to allocate resources, establish strategies for care and coverage, promoting a tendency towards equality of social insurance system and private sectors in the country.
Currently, the PMO has a single price, rested primarily on a homogeneous national perspective, regardless of the substantial differences between provinces and regions. Some jobs with higher specification attempted to organize a more refined side of the demand for health services, considering in some cases, the presence of heterogeneous demographic patterns by sex and age, which allow greater adherence of the theoretical costing to the local reality.
However, the marking criteria required for the establishment of an appropriate costing imply the inclusion of other relevant factors to give the instrument of distribution of social security funds different criteria related to epidemiological aspects and the the provider market structure. Failure to incorporate mechanisms that capture the differences between provinces and regions leads to an inefficient allocation of resources, while it does not incorporate the epidemiological weight of the various components of the package of services by health coverage area, nor can allow the possibility to discriminate the sanitary offer of each national submarket. The latter reports on the relative resource scarcity or abundance of them, which varies between geographic areas, affecting the negotiating capacity of the national social insurance systems, as well as the price fixing mechanisms in each jurisdiction.
The lack of adjustment of this type is not consistent with the various provincial realities of the country, restricting the regulatory action of the Superintendent of Health Services. This also hinders the capacity of the controlling authority to ensure standards that converge to an equity and uniform quality of services offered in the area of social security funding of one third of national coverage.
Recent studies on the structure of the provincial systems shows the diversity of offerings in public and private institutions, their mechanisms of contracts and payments, and their assistance dependence . It operates on the attention skills of each province, their modes of derivation and networking care organization , as well as cost differentials in each geographical area. Directly, such differences influence the identification of the influence of scale performance based on the costs, both in absolute terms, as weighted by specific epidemiological particular requirements.
This work suggests a standardized methodology that allows, from the information available from the Superintendency and the National Ministry of Health and that originated in the fieldwork conducted in the country Northwest as part of this pilot study, advance in a model of more efficient use of existing financial resources, facilitating the calculation and subsequent updates in a dynamic sector context.



- Food Expenditure and Poverty in Argentina

During the last thirty years, Argentina has transited in parallel with the consolidation of democracy restored in 1983 over multiple periods of macroeconomic fluctuations. Inflation , adjustment policies and sharp declines and increases in the product in relatively short periods of time, eroded the relatively equal distribution of income that characterized the society in Argentina. This note attempts to further analyze the link between income, poverty and food expenses during the period 1986-2005, to establish lines of future research agenda.
Specifically, the paper proposes to analyze the impact of such fluctuations on the evolution of expenditure on food and family health, measured as a percentage of income for the period. Since it is expected to describe the link between the participation rate of food expenditure on income of Argentine households, and poverty status of the latter based on the consumer price index and national and international income poverty line .
For this, the microdata provided by the National Survey of Household Spending (ENGH), developed by the National Institute of Statistics and Censuses of Argentina (INDEC) will be used. The survey provides information on the socio-economic status of households in terms of family composition, labor issues of its members, education levels, income, and expenditures disaggregated across categories and subcategories. This information is available for the period for the years 1986-2005 through surveys conducted in 1985/86 and 1996/97 and 2004/05.
While the first version of the survey included the Metropolitan region of Buenos Aires, the second and the third had a national character, incorporating all regions.
Historically, the Survey 1985/86 is performed during the first stage of the new democratic era in Argentina, economically characterized by strong inflationary process. Initially the Austral Plan (1984/5) manages to contain the inertia in the price level, and then give way to successive adjustments that led to the Convertibility Plan. This established a fixed exchange rate of Argentina's currency against the dollar at 1 to 1, leading to a period of price stability, output growth, labor market flexibility and foreign debt accumulation, which peaks in the 1998, captured by the second Survey 1996/7. Since 1998 the model shows its limitations and leads to the crisis 2001/2, involving a sharp currency devaluation and default on the national debt, impacting the crude product, which falls more than 12%. The average unemployment rate exceeded 25% and poverty levels involved half of the population.
Since then, the country's economy takes a path of sustained growth, involving active social policies in terms of income ( Home Chiefs Plan, Universal Allowance per Child), debt rescheduling and capitalization of international prices in the sector export, among other things. Survey 2005/5 reflects the beginning of this period.



- Organization, Procurement and Payment Mechanisms in the Neuquen Health System

Argentina has health coverage shared between the public sector, the Social Secure (national, provincial and retirees and pensioners) and the private sector, with strong relationships in the provision of services, funding and coordination in social insurance. In this decentralized system, the institutional responses that have developed various health authorities as well as the other actors in the health sector (private health sector and social security) vary between provinces.
Such a segmented structure generates a set of contracts between insurers (fund) and providers (doctors) of the health system in which each of the funders has a menu of offerers, while each vendor has several sources (public or private) financing and payment mechanisms (prospective or retrospective).
In this direction, the study aims to deepen the understanding of the association between market structure and health service providers, changes in provider payment mechanisms by the social insurance system and the response in terms of organization internal risk transfer and absorption in the Province of Neuquén. The intention is to contribute to the debate on reforms of incentives in developing countries where, unlike developed nations, more than sixty percent of the funding is done through social insurance schemes that manage the funds - directly or through intermediaries - and subcontract service provision.
The ultimate goal is to show how the implementation and impact of changes in monetary incentives implemented through payment mechanisms established in the contracts between funders and providers condition and are at the same time conditioned by the size and composition of the provider market and sources of funding, and therefore, of the relative power each of the actors involved (governments, social security institutions, insurance prepayments, institutional and individual providers and their representative organizations, the medical and clinical associations-).
To achieve this it will be discussed (i) the regulations on operation and provincial control and their regulation capacity, (ii) contractual structures between funders and providers, payment mechanisms and modes of care and (iii) historically recognized modes for decision-making among the various local players and their market structures. Each of these components will be raised by analyzing epidemiological patterns, structures, formal rules and contracts, local schemes for financing and insurance, delivery structures in the care market and mechanisms of each group. To this end the project will turn to the analysis of secondary sources of quantitative and qualitative information, prepared by own elaborated reports based on semi-structured questionnaires and multiple choice, then use techniques of descriptive statistics and logistic models.



- Argentine Health System, and Structure of Social Health Insuranced