Addressing Systemic Challenges to Social Inclusion in Health Care

7/29/2019 Addressing Systemic Challenges to Social Inclusion in Health Care

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Jason Marczak Nina Agrawal Gustavo Nigenda

Jos Arturo Ruiz Ligia de Charry


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Addessng sysemc cAllenges scAl nclusn n e Al cAe:

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ForewordLatin America remains the most unequal region in the world, presenting

signicant challenges to overall regional development. A number o groups

among them the urban and rural poor (33.1 percent o the population),

indigenous populations, Aro-Latinos, and womencontinue to lack access to

critical pillars o development, including quality health care services.

With this in mind, Americas Society (AS), with support rom the Ford

Foundation and leveraging the relationship with its sister organization Council

o the Americas (COA), is working to strengthen the voice o these

marginalized groups by presenting new research and promoting resh debate

on how the public and private sectors can address systemic challenges to social

inclusion. In addition to health care, our eorts also ocus on education andmarket access. The AS Social Inclusion Program involves in-country research,

three white papers, dedicated issues oAmericas Quarterly, and private

roundtable meetings and public conerences with high-level public- and

private-sector leaders on topics o inclusion.

This white paper presents the ndings and conclusions o Americas

Societys research on health care. The goal o this paper is to draw

attention to a sample o new practices that increase access to quality

health care or marginalized populations and spur businesses,governments and nonprot organizations to commit more to address this

issue. We are not seeking to evaluate individual programs but rather to

present a variety o health care initiatives that all have the same goal:

providing care or those that otherwise would not have access to it. It is

essential that we consider these cases in their larger regional context

and use the lessons learned to promote greater social inclusion.

To begin the research process, Americas Society ormed a peer

review committee that helped identiy areas or research in thiseld. The next step included collecting inormation rom corporations,

nongovernmental organizations (ngos) and oundations about existing

initiatives. Preliminary ndings were presented at a conerence in

December 2010 where diverse stakeholders provided eedback and

direction or the drating o this white paper. Researchers in Colombia

and Mexico then set out to identiy examples o private programs or

public policy initiatives that have expanded health care access.

We thank the members o the peer review committee or their invaluableguidance and support: Cristian Baeza, director, Health, Nutrition and


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Population, The World Bank; Thomas Bossert, director, International Health

Systems Program, Harvard School o Public Health; Gabriel Carrasquilla,

director, Center or Health Care Research Studies, Fundacin Santa F de

Bogot; Donika Dimovska, senior program ocer, Results or Development

Institute; Amanda Glassman, director, Global Health Policy, Center or Global

Development; Miguel ngel Gonzlez Block, executive director, Center or

Health Systems Research, Mexicos National Institute o Public Health; Gina

Lagomarsino, managing director, Results or Development Institute; and Bill

Savedo, senior ellow, Center or Global Development.

Jason Marczak, as/coa director o policy, leads the health care component

o our Social Inclusion Program in collaboration with Nina Agrawal, policy

associate. Our in-country counterparts include Gustavo Nigenda, director,

Innovations o Health Systems and Services Research, as well as his colleague,Jos Arturo Ruiz, at Mexicos National Institute o Public Health, and Ligia de

Charry, an independent researcher and epidemiologist in Colombia.

Christopher Sabatini, as/coa senior director o policy, directs the Social

Inclusion Program and Edward J. Remache provides project support.

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IntroductionUniversal health care has become an increasingly pressingalbeit elusive

goal in countries across the Americas. With transitions to democracy and the

adoption o pro-market reorms sweeping the region in the 1980s and 1990s,

many governments also began making eorts to improve equality and e-

ciency in their health care systems. Oten, reorm was shaped by national laws

that modied the existing nancing systems to increase insurance coverage or

the poor. This was the case in Colombia and Mexicothe two countries o

primary ocus or this white paper. In other countries, or example Chile and

Brazil, reorms centered on making use o the private sector within publicly-

nanced health systems. In Chile, this has meant strengthening the nationalpublic health insurer and establishing a strong regulatory regime that covers

both private and public insurers; in Brazil, recent eorts have ocused on

establishing regulations or private insurers and experimenting with various

state-level public administration models.

Regardless o the orm change took, coverage has indeed expanded and

progress has been made on key health indicators. In Colombia and Mexico, or

example, ongoing national eorts have signicantly increased health care

access or those traditionally let out o the health care system. By the end o2010, Seguro Popularhad reached 42 million o Mexicos 50 million previously

uninsured,1 and by2011, the subsidized regime o ColombiasLey 100 was

providing health insurance to 11 million people who otherwise would have

had no such insurance.2

Meanwhile, countries in Latin America have made notable advances in the

areas o child mortality, maternal health and inectious diseases. By2008, the

regional average or the under-ve mortality rate was 23 per 1,000 live births,

down rom 52 in 1990,3

while maternal mortality had decreased by nearly halover the same time period, rom 140 deaths per 1,000 live births to 85.4 The

incidence o both tuberculosis and hiv/aids has also decreased in most

countries.5

In spite o these advances, there remain gross ineciencies and disparities

in care and health indicators across and within countries. For example, 20

percent o the population in rural areas lacks potable watera number that is

10 times higher than in urban areas. Inant mortality rates are consistently

highest among indigenous and Aro-descendent populations.6 This persistentlack o access to good health services directly and negatively aects labor


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productivity, household income level and a amilys potential or upward social

mobility, impeding the development o a wide middle class and bearing

consequences or macroeconomic growth.

Given the social, economic and political ramications o inclusion, both

the public and private sectors have reason to invest in combating exclusion. To

some degree, this has been the case. Health reorm legislation and privateinitiatives in recent decades are tackling the challenge o greater social

inclusion. But more remains to be done. In particular, the private sectorin

this paper taken to include or-prot health insurers, or-prot health pro-

viders, or-prot rms that operate outside the health industry, and nongov-

ernmental nonprot organizationscan play a more signicant role in

expanding health care access or those let out o the system. Specically, the

private sector can ll some o these health care gaps by investing in inrastruc-

ture and human resource capacity, especially in inormation and communica-tions technology; educating the public; devising innovative nancing and

pricing models; and even providing aordable services directly. Most impor-

tant, though, is that the design, implementation and evaluation o health

policies and programs involve collaboration across sectors. By doing so, the

private and public sectors can nd new practices not only to provide care but

to do so in a way that is nancially sustainable.

The Americas Society set out to study select cases in which the private

sector is expanding access to primary health care among marginalized groups.We ocused specically on the private sector because o the unique resources

and perspectives it can contribute to expanding health coverage, and because

o the economic ramications o achieving universal health care. The cases

were selected or their geographic, strategic and institutional diversity in order

to provide a variety o examples to draw on or urther discussion. In these

instances we looked specically at the ways in which public policy can acili-

tate and help to expand the private sectors initiatives. Given that Colombia

and Mexico both recently enacted national legislative reorm to signicantlyexpand health care access, we decided to ocus on these two countries.

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Preliminary in-country research and survey data rom coa members

provided initial insight into the areas o health care where the private sector is

involved. This includes nancing health care provision through grants or

donations as a part o corporate social responsibility as well as insuring or

treating patients at low cost as part o a rms business model. The ollowing

matrixby no means comprehensiverefects this inormation (see fgure

1). Organized by country, it groups the initiatives included in the survey by

more specic areas o operation: health care nancing, paying or the

provision o care through subsidies, vouchers or insurance; direct service

provision, providing acilities where actual medical care is oered; low-cost

medical treatment, acilitating access to discounted treatment, including

services, pharmaceutical drugs and medical devices; eHealth/mHealth,

leveraging inormation and communications technologies to expand access tocare; preventative measures/healthy liestyles, educating communities or

better long-term health; and health care policy advocacy, collaborating with

policymaking organizations and raising awareness about health care issues.

The rms surveyed are generally most active in providing direct services,

expanding aordable access to treatment and promoting healthy liestyles.

This last area, which includes disease prevention, will assume increasing

prominence in coming years as the burden o disease in Latin America shits

to chronic, non-communicable diseases.Notably, only a ew o these programs made use o inormation and com-

munications technology or diversied nancing streams. This was surprising.

Many o the newest innovations in low-cost health care delivery that are

gaining public attention utilize inormation and communications technology

(ict) or pro-poor health market models.7 With its enormous potential or

expanding access to care and inormation in remote areas, connecting health

proessionals, tracking disease patterns, and monitoring patient ollow-up,

eHealth/mHealth is an area ripe or urther investment. Greater attentionshould be paid to the sccessul eHealth/mHealth programs that exist.

One point worth bearing in mind is that health care is a eld with

numerous and diverse stakeholders. Rather than seeing one another as com-

petitors, the private sector can work within the ramework o public policy to

reduce gaps in accessor example, by lowering the costs o health care,

administering services more eciently, subsidizing the treatment o poor

patients with higher ees paid by wealthier patients, and reducing or over-

coming physical barriers to health care.


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Figure 1

eAl nevenns, by yPe And cuny

Coom

Mco

Or Cor

Health CareFinancing

DirectService

Provision

Low-CostMedical

TreatmenteHealth/mHealth

PreventativeMeasures/

HealthyLifestyles

HealthCare PolicyAdvocacy

Fundacin SOMA Fundacin Grupo Nacional

de Chocolates

Fundacin Mayaguez

Pfzer Inc. Cerrejn

Fundacin xito

Colgate-Palmolive Colombia

Fundacin Siemens

Cerromatoso

Mineros S.A.

Fundacin Alpina

Fundacin Corona

Fundacin Pavco

Fundacin Sanitas

Fundacin Propal

Sesame Workshop*

Fundacin Mexicana para laPlaneacin Famil iar, A.C. (Mexam)

Farmacias Similares SA /Fundacin Best, A.C.

Fundacin Adelaida Lan

Fundacin Comparte Vida Sistemas Mdicos Nacionales,

S.A. de C.V. (SIMNSA)

Fundacin Mexicana de Fomentopara la Prevencin Oportuna

del Cncer de Mama, A.C.

Fundacin Gen, A.C.

Centro de Investigacin MaternoInantil Gen (CIMIGen)

Sesame Workshop*

Johnson & Johnson*

Pfzer Inc.*

Manpower Inc.*

Telenica*

Pfzer Inc.*

Johnson & Johnson*

Microsot Corporation*

Cisco Systems, Inc.*

PepsiCo*

Digicel*

Manpower Inc.* SwissRe Financial

Services Corporation*

*Inormation acquired through a survey returned by the company.


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Colombias HealthCare SystemOpening the DOOR fOR the paRtiCipatiOn

Of fOR-pROfit COMpanies

Colombian society is characterized by proound social exclusion, in marked

contrast to the guiding principles established in its Constitution o1991. The

availability and access to public services and standard o living vary substan-

tially, both between urban and rural populations and between distinct regions.

For example, while potable water is accessible to 90 percent o the population

in municipal areas, it only reaches 60 percent in rural areas. On the Atlantic

coast health services coverage barely reaches 43 percent, compared with anational average o51 percent. In the department o Cauca, the percentage o

the rural population that lives below the poverty line exceeds the national

average by33 percent.8

During the 1990s, the government undertook a process o social policy

reorm, including passage oLey 100 in 1993, which sought to enroll the

population in one o two insurance regimes: a contributory regime or those

able to pay and a subsidized regime or those that could not. Under these

reorms, a guiding policy or the organization o the health system waspromoting the inclusion o the most economically vulnerable sectors o the

population by ensuring their access to health care through the government-

subsidized insurance plan. Care not covered by the insurancesecondary-

level care including some surgeries and diagnostic exams, or exampleis

oered at public hospitals. In spite oLey 100s ocus on specically insuring

economically vulnerable sectors, experiences ollowing the laws

implementation have shown that being insured and actually accessing health

services are not one and the same.Due to the complexity o achieving universal coverage and the institutional,

operational and nancial ragility o Colombias social protection systems,

certain groups o the population remain excluded. The steps taken in the

1990s have proven insucient in guaranteeing real access to health care, as

geography continues to pose an obstacle and unequal service allocation

persists. People in the lowest income quintiles living in semi-urban or rural

areasar rom state capitals and metropolitan centers where the physical

inrastructure and human and technological resources or health care areconcentratedare the most aected.


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Ethnicity and race are actors that not only create disparities in dierent

groups standard o living but also impact their health and access to services.

Evidence shows that, at equal levels o income, ethnic and racial minorities

have less access to services and exhibit poorer health indicatorsor example,

high inant and mortality rates and low lie expectancythan their counter-

parts. Further complicating the issue is that these minorities are overly

represented among the poorpresenting a double challenge or access.9 Both

are true in Colombia. Additionally, the elderly poor in Colombia, who lack

knowledge o available services and oten work in the inormal economy

earning very low salaries, remain under covered in social security and

excluded rom social services as well.10

While Colombias General System o Socia l Security in Health, imple-

mented viaLey 100, has been successul in removing the economic barriers tohealth care access or populations in the lowest income quintiles, the system

has yet to ully reachand thereby reduce social exclusion ormarginalized

groups such as ethnic and racial minorities and the elderly poor. Although

these groups have government-subsidized social security, they still cannot

access necessary health care services due to geographic isolation or simply a

lack o coverage or certain procedures. Today, approximately39 percent o

Colombians are insured under a subsidized regime that covers a range o

services greatly inerior to those provided by the contributory one. Given thisreality, the case studies below describe how the private, or-prot sector can

contribute to the governments eorts to improve social inclusion.

OveRview Of exaMples

Within this context, and with special attention paid to the existing and

potential role o the private sector, we identied 15 health care initiatives

undertaken by or-prot companies or the rst phase o our research.O the 15 initiatives, our ocus on nutrition and ood security, ve on

public health education campaigns, ve on service provision, and one on

technology utilization.

We chose three or urther analysis based on their potential ability

to improve care or underserved populations and to be sustainable over

time. Each case study refects the eorts o a or-prot company that is

making important contributions to the communities where it operates

and its workers reside. In doing so, they are improving the health andthus productivity o their current or uture labor orce while also contributing


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to the overall well-being o those who may not otherwise be able to access

health services.

The rst, De Todo Corazn, is a program launched by Pzer Colombia in

strategic partnership with Mutual ser, a company managing ederal health

coverage or the elderly poor residing in municipalities o six states on the

countrys Caribbean coast. The second, Unidad Mvil de Salud, is run by the

mining company Cerrejn in conjunction with public hospitals in three

municipalities located in the department o La Guajira. It serves a majority

indigenous population. The third, Salud y Saneamiento Bsico, operated by

the oundation o the Colombian paper manuacturer Propal and our munic-

ipal governments in the department o Cauca, serves a majority Aro-Colom-

bian and indigenous population. Each is explained in more detail below.

All three initiatives either manage government health insurance or repre-sent a partnership with state-sponsored public entities such as mayoral oces

or public hospitals. They are models o how to integrate private-sector and

government eorts.

the thRee CasesexpanDing aCCess

Access to health care services can be dened and measured in distinct ways.

Some denitions ocus on use as a proxy or access. Others ocus on insurancecoverage or eligibility to receive health care services irrespective o whether

they actually use it. Here, we use service utilization and the number o people

receiving particular services to illustrate access.

PfizerMutual Ser: De toDo Corazn

A primary health challenge in a mountainous, geographically-challenging

country like Colombia is the physical inability o certain segments o the

population to travel in order to access certain types o care. De Todo Coraznseeks to reduce these geographical barriers or poor people over the age o45

who reside ar rom cities. Those enrolled in the program can access special-

ized medical services such as cardiology in their local communities, along with

critical ollow-up care.

The program began in 2004 when Pzer partnered with Mutual sera

company that manages the ederal insurance plan or people in the two lowest

income quintilesto develop a program to prevent and treat cardiovascular

and cerebrovascular diseases. For Pzer, this program is part o the companyseort to be a good corporate citizen. For Mutual ser, it is a means o pro-


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viding coverage or additional services.

De Todo Corazn reduces the impact o catastrophic illnesses and provides

health care or a segment o the population that would otherwise not have

access to a specic set o services, due to suering rom diseases that are not

covered by the subsidized regime o ColombiasLey 100. The program was

launched ater ndings rom a study o nearly70,000 Mutual ser patients

showed that high blood pressure was the seventh leading cause o medical

intervention and that cardiovascular and cerebrovascular illnesses were the

leading causes o death.

The program includes our components: ongoing training or medical

personnel; patient medical care; health education or patients and their

amilies; and recreational activities. The training program is directed toward

primary care doctors, specialists, community health promoters (promotores desalud), nurses, and bacteriologists, and provides instruction on cardiology and

the treatment o high blood pressure, diabetes, dyslipidemias, and the use o

health sotware. To date, De Todo Corazn is responsible or the training o

200 general practitioners, 20 specialists, 150 community health promoters, 180

nurses, and 50 bacteriologists.

The medical care component includes yearly checkups by a general practi-

tioner, laboratory tests, prescriptions, and the necessary reerrals to cardiolo-

gists or internists. Specialized doctors reassess any preliminary diagnoses,determine cardiovascular riskin part with the help o medical sotware

and develop a monitoring and treatment plan.

Health education is a critical aspect o the programs prevention ocus.

Mutual ser community health promoters and sponsors (community leaders)

accompany doctors during home visits to patients at high risk or heart disease

or those who have suered cardiovascular episodes. During these visits, the

sponsors inorm, train and educate patients and their amilies about healthy

liestyles, disease risk actors and the importance o ollowing a diseasemanagement plan. The programs prevention strategy also includes organizing

40-person clubs that meet monthly or workshops, games and recreational

activities that ocus on the importance o diet and healthy habits.

The number o people served by the program increased rom 4,000 people

in 2004 to 21,982 in 2007. Additionally, 69 percent o patients adhere to the

programs ollow-up and educational regimens. De Todo Corazn clubs have

also taken o in popularity. By the end o 2007, 322 o the 481 existing clubs

(67 percent) were meeting regularly.Similar improvements are documented in regard to the health o poor


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patients at high risk or heart diseasea number that has allen by

9 percentage points (rom 55 to 46 percent) within target communities. At the

end o2008, 74 percent o patients had reached an acceptable diastolic blood

pressure, compared to 32 percent in 2004. Likewise, the number o patients

who met their target ldl cholesterol levels rose by29 percentage points (rom

25 to 54 percent).

CerrejnPubliC HoSPitalS: uniDaDMvil De SaluD (uMS)

The department o La Guajira contains the countrys largest indigenous popula-

tion. Many rural residents historically ace barriers to medical accessa result

o geographic isolation, language barriers and high costs, among other actors.

Aware o these obstacles, the mining company Cerrejn acquired a mobilehealth and dental services unit to acilitate and improve health services or

people residing in the municipalities o Barrancas, Hatonuevo and Albania.

The Unidad Mvil de Salud (ums)launched in July2008operates a

mobile medical assistance program that provides individual, comprehensive

diagnoses and develops activities or promoting health and the prevention o

disease. Cerrejn coordinates the programs, maintains the ums vehicle and

provides medical supplies while regional hospitals are responsible or nding

the necessary doctors, nurses, lab technicians, and community health pro-moters. By the end o2008, ums had launched services in 30 communities

within the three target municipalities.

The ums developed as a collaborative agreement among Cerrejn, munic-

ipal secretaries o health and public hospitals, including Nuestra Seora del

Pilar in Barrancas, Nuestra Seora del Carmen in Hatonuevo and San Raael in

Albania. The support o the department-level Oce o the Secretary o Health

urther supports the ums mission.

The ums vehicle unctions as a mobile primary care center and oersgeneral medicine, gynecological and dental services. Medical sta rom public

hospitals (doctors, nurses, and paramedics) provide basic health services in the

areas o childhood care, adolescent medicine (10 to 29 years old), womens

health (pregnancy and amily planning), and adult medicine.

To guarantee that the neediest populations are being served, the ums

assesses its target communities on a monthly basis. A regional hospital then

sends a health promoter to each community to identiy patients, make

appointments and set-up educational and other activities in anticipation o thearrival o the ums.


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The umsrelying on $70,000 annually or upkeepis growing quickly. It

went rom serving 239 patients at its launch to serving 11,459 children, adults

and seniors by December 2009. In 2010, ums services ocused on primary

care (32.0

percent o interventions), oral hygiene (22

.5

percent), dentalservices (14.5 percent), nutrition, optometry (4.2 percent), child development

(4.7 percent), and amily planning (2.0 percent). In addition, 4.5 percent

o the women received pap smears to screen or cervical cancer; 10.0 percent

o these then received an additional ultrasound scan. Beyond that, the

ums provided 568 laboratory tests along with prenatal care or 40 women,

high blood pressure and diabetes treatment or 82 people and vaccinations

or 236 patients.

Besides strengthening ties to the community and its leaders, improvingpatient-doctor trust and building a collaborative relationship with the regions

institutional hospitals, the ums has yielded other impressive achievements.

The training o hospital doctors and nurses resulted in eective and timely

diagnoses, and educational campaigns taught people how to apply or govern-

ment health coverage to obtain medication. Epidemiologic data show that

illnesses relating to a lack o primary health caresuch as poor maternal and

child healthdecreased.

Although on a lesser scale, specialized medical services such as gynecology,ophthalmology, pediatr ics, orthopedics, and surgery (or 0.6 percent o

patients) were also oered. The campaign or early detection o cervical

cancer through pap smears stands out: it diagnosed 95 positive cases,

representing 9.45 percent o the women tested, who were then oered

additional treatment.

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ProPalMuniCiPal governMentS:SaluD y SaneaMiento bSiCo

Recognizing the poor living conditions o the communities where its plants are

located, Propal, a leading paper manuacturing company, launched a multi-

pronged eort to promote social development and improve the standard o

living. This included the creation o the Fundacin Propal to administer social

development projects. Fundamental to the Propal initiative is its belie that

greater results can be achieved in collaboration. To that end it works through

community participation and inter-institutional partnerships with the govern-

ment o Cauca department, city governments, international agencies, and

other local companies. Funding comes rom this broad range o sources.

Launched in 1993, Fundacin Propals Salud y Saneamiento Bsico

program includes a medical center, community health projects and basicsanitation. This program expands social inclusion by oering otherwise scarce

or non-existent quality care, including specialized medicine, to communities

that are vulnerable due to socioeconomic conditions (in the bottom two-ths

o the income hierarchy), race and ethnicity (Aro-Colombians and indigenous

populations), and/or social circumstances (mainly single, emale-run house-

holds). In Cauca department, Salud y Saneamiento Bsico ocuses on the

municipalities o Puerto Tejada, Gauchen, Villa Rica, and Caloto.

The medical center brings comprehensive general and specializedmedicineincluding diagnostic imaging, mammograms, etal monitoring, and

specialized lab workto the communities. At the same time, the community

health project ocuses on education campaigns regarding basic public health

and preventable illnesses. The basic sanitation componentdesigned and

administered with support rom Cementos Argos and Pavcois dedicated to

making drinking water widely available.

Although the program is airly new, results are already available. From

January to September 2010, the medical center recorded 113,800 healthconsultations. Services or most patients were paid or by the subsidized

insurance regime, but 835 people who have yet to be aliated to it received

care completely ree o cost. (By 2015, the subsidized regime is expected to

include all those who cannot aord to enroll in the contributory regime.) In

turn, the community health project completed an average o our days o

service per month, oering medical attention in the orm o pap smears, water

fuoridation, deworming, and medication dispensation. Additionally,

prevention and health promotion campaigns reached 4,962 people, includingpregnant women, the disabled, older adults, and children under age two. An


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additional 2,783 school-age children and adolescents also took part in the

education program. The basic sanitation project has yielded improvements in

11 water systems (beneting 180 amilies) and provided nine educational

centers with sanitary kits.

the thRee CasesiMpaCt anD sCalability

The experience o these joint ventures demonstrates the importance and

power o collaborative action between the private, or-prot sector and govern-

ment entities to improve health care or vulnerable communities. Over time,

the three programs have expanded their coverage to new populations and

geographic areas, thanks in large part to their strong working relationships

with local governments. While ocused on primary care, these programsventure as well into specialized medicine, mainly or illnesses o high inci-

dence and high mortality rates in Colombia, such as heart disease and cervical

cancer. They also serve remote locations with ongoing attention to health care

needs, or example providing screening tests such as mammograms and

laboratory testsnormally oered only in the largest citiesto populations

marginalized by geographic isolation. In this sense, they respond to the

non-communicable chronic illnesses increasingly aecting the Americas and

overwhelming traditional basic care programs.In spite o the successes achieved in making care available to vulnerable

communities, obstacles to access remain. Even with these programs, geo-

graphic isolation remains one o the greatest impediments or indigenous

groups, Aro-Colombians, the rural poor, and the elderly. Other challenges

include communication diculties due to linguistic and cultural dierences

(in the ums case, 44 percent o the population served is indigenous) and

limitations in the government-subsidized Mandatory Health Plan. Govern-

ment-subsidized health insurance is restr icted to primary-level interventions,excluding such secondary-level care as treatment or complications o chronic

conditions like diabetes and hypertension or visual and mental health care,

which disproportionately aect the elderly. While recently enacted laws

(Sentencia 760 rom the Constitutional Court andLey 1438 o2011) have

mandated the unication o the benets package or both regimes, it remains

to be seen when the social security system will, in practice, begin to provide

coverage or these diseases.

Further, i these programs are to bring about ar-reaching changes inColombias health system, they must achieve scalabilityunderstood here as


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the capacity to expand a process without diminishing the quality o the service.

Some have already begun to do so. Beore De Todo Corazn was implemented,

patients received only minimal health services in their local communities. Spe-

cialized medicine such as cardiology services was available only in cities, which

meant that patients would have to travel to receive medical care. But ollow-

up care was oten inaccessible as patients oten lacked the nancial means to

travel or additional doctor visits. This program directly addressed that barrier.

Patients could access cardiologists and nutritionists, specialized medical labo-

ratories, electrocardiograms, and drug dispensation in their own communities.

Since starting with 4,000 patients in 2004, De Todo Corazn has gradually

grown with annual increases o50 percent. Without private unding or oun-

dation support, the programs structure is one that can be replicated in both

urban and rural areas, either in Colombia or elsewhere, where geographic andother barriers result in inadequate care or vulnerable populations. One lesson

learned is the importance o enlisting the participation o community leaders

who live in the same areas as the patients. Another key practice is to pool

patients according to their place o residence, which acilitates the work o

health proessionals in providing ollow-up medical attention.

Similarly, other companies or the governmenteither in Colombia or in

countries with geographic and economic conditions similar to those o rural

La Guajiracan replicate the Unidad Mvil de Salud program. In contrast tothe De Todo Corazn program, the ums provides health care services in

dispersed communities where small population sizes oten do not justiy the

construction o permanent health centers. The mobile clinic provides a means

o taking health care straight to these residents homes. What is needed,

though, is an economic evaluation o the model to determine i it can be

easibly and justiably implemented elsewhere in the country.

For Fundacin Propal, Salud y Saneamiento Bsico has expanded the

reach o its community health projects in conjunction with municipal govern-ments. But it is also exploring options to augment service delivery through a

mobile clinic similar to the ums model launched by Cerrejn.

In each o these cases, however, the programs depend on a corporation to

cover essential operating expensesa worthy expense given the positive

community reaction to these initiatives. In the case oDe Todo Corazn the

necessary nancial resources to run the program are wholly underwritten by

Mutual ser and Pzer, since the subsidized government insurance plan does

not cover the targeted diseases. Cerrejns Unidad Mvil de Salud began witha $169,000 investment o corporate unds to buy the vehicle, supplies and


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17

medical equipment, and each year Cerrejn invests an additional $70,000 to

pay or vehicle maintenance, supplies, health proessional ees, a driver,

security guards, and uel. The nancing mechanism or the Salud y

Saneamiento Bsico program is slightly more diversied, with unds being

generated through a combination o company resources and reduced-rate

services to patients, but Fundacin Propal must still cover the expenses o a

large sta o general practitioners, specialists and assistants.

I, in shiting priorities or or any other reason, these companies were to

decide to ocus on another area or reduce their budget, the operation o the

programs would be jeopardized. Thus, broad-based nancing is a major

obstacle to scaling up interventions. Initiatives designed to expand access to

marginalized populations must seek diverse and sustainable sources o unding.

While or-prot companies like Cerrejn, Propal and Pzer are making animpact, this is not common or Colombia. In general, the countrys private

sector shows a growing interest in social inclusion, but with a greater ocus on

education and the environment. O the 15 health-related initiatives identied

in Colombia as part o this study, only three companies (15 percent) are part o

the health industry, despite health companies rising importance or the

national economy. An additional issue is how to design public-private partner-

ships so that activities extend beyond social responsibility. Working-level

discussions between the Ministry o Social Protection and groups involved insocial responsibilityincluding Colombia Incluyente and the Colombian

Business Council or Sustainable Developmentcould help promote greater

knowledge among corporations about the health needs o marginalized com-

munities and how to address them, spurring their involvement.

None o these case studies utilizes telemedicine or other eHealth initiatives

to improve access. But as seen in India and other emerging economies, the

eective harnessing o existing technologies can overcome some o the geo-

graphical and nancial obstacles to health care provision in remote communi-ties. Wireless networks can reach much deeper into a country than any other

technology to collect health data, support diagnoses and treatment, and

advance education and research.11 They make medical consultation, para-clin-

ical analysis and interpretation o imaging data possible without requiring the

physical presence o specialists. In so doing, they improve the local capacity or

medical response and ampliy the portolio o services available to these

populations. In turn, this reduces the need or reerrals, cutting costs, elimi-

nating the need or travel, and ultimately improving patients quality o lie.


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Mexico:a push tOwaRD univeRsal COveRage, but

wiDespReaD aCCess yet tO be ReaCheD

Mexicos health care dynamics have changed dramatically in the last decade.

Only10 years ago, nearly10 million Mexicans lacked any type o medical care,

and more than 50 million people were not covered by social security. For

those that did have insurance, coverage was regressive in that the poor aced

the greatest health care costs in proportion to their income. Compared to its

Latin American neighbors, Mexico spent below the regional average on health

care in 2003about 6.1 percent ogdp. Among other things these low levels

o unding prevented Mexico rom addressing the shiting burden o disease tochronic, long-term illnesses.12

But a ar-reaching reorm o the health care systempassed into law in

April 2003 and implemented in January2004established a new System or

Social Protection in Health (ssph). The ssph, which includes the Seguro

Popularpublic health insurance program, sought to ensure that all had the

right to health care as recognized in the Mexican Constitution. In the rst hal

o2011, nearly50 percent o the Mexican population is expected to be

aliated to Seguro Popular. The ssph has also improved public health centersand guaranteed quality servicesthrough new accreditation methods and

deployment o health quality indicatorsto those that historically lacked

access to health care.

Nonetheless, a lack o access to care and medication persists in highly

marginalized urban and rural areas today. This gap in Mexican health care

reinorces the exclusion o marginalized groups and thus the overall develop-

ment o Mexican society. Here, the private sectora signicant, untapped

resource in the delivery o carecan play an important role in the provision ooutpatient and hospital care or those aliated to Seguro Popularbut who

cannot access public health services.

OveRview Of exaMples

Given the impressive successes oSeguro Popularbut also the challenges that

exist in reaching certain marginalized segments o the population, our

research looked at nine examples o private organizations seeking to ll thegaps that continue to exist today. Again, these are simply a representation o


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19

eorts across geographic, thematic and industrial lines o private-sector

initiatives to increase access or marginalized groups in Mexico. O these nine

cases, three were selected or urther research based on geographic diversity,

the method used to support access to health care and intended beneciaries.

Each program is described in greater detail below.

In all three examplesas is the case or private organizations overallthe

strategies to expand health care access can be thought o as one part o a

nationwide strategy. Each also responds to an unortunate reality in Mexico:

the unequal distribution o disease, determined by a populations isolation and

level o poverty. For example, in areas with a high concentration o marginal-

ized groups, inectious diseases are the leading cause o inant mortality and a

lack o medical services and trained personnel result in high rates o maternal

mortality. This is not the case among middle- and high-income groups.Each case study shares a common goal: acilitating access to care or

groups who traditionally ace barriers. Target communities are selected i they

either all outside o the social welare system or the services oered by the

Secretary o Health, or i they lack the means to pay or conventional health

insurance. These examples were chosen because they acilitate access to

health care services or clearly identied populations that would otherwise

have great diculty in obtaining such access.

The rst case is Sistemas Mdicos Nacionales, S.A. de C.V. (simnsa), aprot-driven company established in 1992 that sells health insurance to

persons living in Mexico but working in the United States. It is the rst

Mexican health insurance rm authorized to do business in Caliornia. The

target clientele is Mexican workers in Caliornia who purchase hmo or ppo

plans either directly (supplemented by their employers) or through unions in

San Diego. These workers all in the middle-income range (with earnings

above the lowest-income levels in Mexico), but still cannot aord U.S. health

insurance plans. With simnsa coverage, they gain access to medical servicesin Mexican cities.

The second case is the initiative oFundacin Adelaida Lafn, an ngo that

runs a community clinic closely linked to Muguerza de Monterrey Hospital

now a part o the Christus Muguerza Group health care systemin the state

o Nuevo Len. Since its ounding in the 1930s, the hospital has recognized

the need to provide care or those o limited means and maintained a reserved

area or such patients. At the end o the 1990s, administrators expanded on

this service and began to oer care in a community clinic located in an inner-city neighborhood o Monterrey. The clinic is run byFundacin Adelaida


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Lafn, which also serves an indigenous community in San Luis Potos.

For both simnsa and Fundacin Adelaida Lafn, only limited coordina-

tion is carried out with public services. At a national level, no ocial body

exists at the Ministry o Health to regulate, coordinate or promote public-pri-

vate collaboration. This means that it then alls on state-level Secretariats o

Health to create any alliances with the private sector. But as discussed later in

this section, many opportunities exist or greater collaboration.

The third case is Fundacin Mexicana para la Planeacin Familiar

(Mexam), a non-prot civil society organization ounded in 1965 and

dedicated to promoting comprehensive amily planning. It provides

inormation along with educational and clinical services in sexual and

reproductive health to disadvantaged groupsmainly women and school-age

adolescents and youth. Mexam activities are carried out throughout thecountry but always in areas where approximately25 percent o the population

is considered marginalized.

the thRee CasesexpanDing aCCess

As in the case o Colombia, we dene access to health care services based

on utilization and the number o people receiving particular services.

However, this data does not allow or an accurate assessment o the levelo quality o each service.

SiSteMaS MDiCoS naCionaleS, S.a. De C.v. (SiMnSa)

Many low-wage documented Mexican workers who either reside in the U.S. or

requently travel between the two countries cannot aord to pay the high

costs o U.S. health insurance. The result is oten lack o access to preventative

care or debt-burdening payments at times o immediate need to critical health

care services. The Sistemas Mdicos Nacionales, S.A. de C.V. (simnsa) soughtto change this reality by oering discounted insurance policies to rms o

50 or more workers in the San Diego area.

The company or union can choose to buy an individual or amily plan.

According to simnsa, the company makes the decision and asks the worker to

pay a portion o the cost. Commonly, the employer agrees to pay or the

individual portion o coverage, while the worker assumes responsibility or the

amily portion. An individual plan costs $1,400 per year, while a amily plan

costs $3,900 annually. This ratealthough still costlyis more aordable orthe average plan participant whose income ranges rom $5 to $7 per hour.


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For these workers, the top health concerns are in the areas o reproductive

health and work-related injuries, but chronic illnesses are a growing health

need. In turn, the simnsa insurance plan covers services such as outpatient

treatment, prescriptions, hospitalizations, surgeries, laboratory tests, mental

health services, immunizations, cancer screenings, dental and optometry

services, and prenatal, labor and neonatal care.

All services, with the exception o emergency medical attention, are

provided in our cities on the Mexican side o the U.S.-Mexico border,

relying on two main hospital units and a network o about 200 doctors.

To stay competitive, simnsa partnered with Health Net, one o the largest

publicly-traded health insurers in the United States, in an agreement where

Health Net-aliated providers oer emergency services in the United States.13

Plan participants can still enroll in Seguro Popularwhen living in Mexicobut many remain with simnsa due to lack o knowledge about their

eligibility or low condence in the reliability or quality o services oered

under Seguro Popular.

In 2000, simnsa received approval to operate as a licensed hmo in the

state o Caliornia, although it had already been operating there or years (the

relevant legislation, the Knox-Keene Health Care Service Plan Act o1975,

did not have provisions or licensing oreign health plans). At the time, it

provided care to approximately10,000 members rom over 100 employergroups. In June 2004, simnsa had grown to 14,098 aliates. By October 2007,

the simnsa network had grown to about 20,000 members. O these, 17,000

obtained coverage directly rom simnsa or in Caliornia through its arrange-

ment with Health Net. The remainder was covered through U.S. insurance

companies that buy the service rom simnsa.

funDaCin aDelaiDa lafnMuguerza

De Monterrey HoSPitalIn Monterrey, as is the case in many areas o Mexico, the poor population is

oten dependent on the inormal economy. Many lack access to services

oered by ormal sector social welare institutions, and while they may be

eligible or Seguro Popular, the public insurance plan does not cover all o

their needs.

This creates huge disparities in health care access and is the principal

reason that the Muguerza de Monterrey Hospital in Nuevo Len launched and

backs Fundacin Adelaida Lafn. The community clinic serves the residentso a poor Monterrey neighborhood, who oten work in the inormal economy


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and can only access the minimal public services available. Seguro Popular,

which has still yet to reach its nationwide coverage goal, remains unavailable

or many in this zone.14

The Fundacin also runs a second clinic in San Luis Potos that serves an

estimated 25,000 people rom poor, indigenous rural communities where most

o the heads o households work in subsistence arming and earn small, irreg-

ular incomes. Both clinics are dedicated to both improving health care as well

as developing initiatives that support the communities overall social and

economic development.

The Fundacins health care centers are primary-level acilities that oer

services 24 hours a day in amily medicine, pediatrics and gynecology. Patients

have access to the ollowing: diagnostic testing through x-rays, ultrasound and

laboratory tests; emergency services; general surgery; psychology; nutrition;and speech and physical therapy. The San Luis Potos clinic serves clients

whether or not they are aliated to Seguro Popular. However, no relationship

exists with the state Secretariat o Health since the public sector perceives the

eort as competition rather than as a potential collaborator.

A primary care consultation costs about 50 pesos (about $4), compared to

150 to 200 pesos at private institutions ($12 to $16). The cost o an x-ray or pap

smear is about the same. The low ees at the clinicwhich do not vary

according to the patients socioeconomic levelare structured to be aord-able, while still covering about 75 percent o operating costs. Muguerza

Hospital covers the remainder. Patients that cannot aord to pay are reerred

to the social service oce and may be exempted rom payment. In return, the

patient must commiteither personally or through a amily memberto

volunteer at the health care center or in the community as a orm o compen-

sation. The Christus Muguerza group in turn benets through increased brand

recognition and positive brand association.

funDaCin MexiCana Para la PlaneaCinfaMiliar, a.C. (MexfaM)

The ounding oFundacin Mexicana para la Planeacin Familiar, A.C.

(Mexam) in 1965 resulted rom a need to create greater awareness o and

access to amily planning options in the most marginalized areas o the

country. More than 40 years later it continues to oer new services designed

to respond to Mexicos changing health needs.

Mexam serves three primary constituencies: disadvantaged groups(low-income individuals, women, adolescents, and youth); marginalized people


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without access to social welare services; and proessionals in the health and

education elds (youth and community advocates, educators, doctors, nurses,

social workers, and psychologists). It operates in 19 o Mexicos 32 states

(including the Federal District), in which 25 percent o the countrys most

marginalized people reside.Activities are concentrated on our programs. The Programa Comunitario

Rural trains community advocates (promotores comunitarios) on issues o

amily planning, contraceptive use and other health issues. In turn, the

promotores lead community discussions, participate in health airs, conduct

home visits, and distr ibute posters and brochures at strategic community

locations. The Programa Comunitario Urbano is similar to the Programa

Comunitario Rural and is implemented in outlying urban areas, poor inner-

city neighborhoods and squatter settlements. The main dierence betweenthe two programs is that the urbanpromotores link up with existing initiatives,

conduct the training sessions in schools and distribute contraception at

medical clinics, whereas the ruralpromotores lead the initiatives and work in

more community-based settings.

The other two initiatives incorporate service delivery at clinics. The

Programa Gente Joven targets youth and carries out its activities through

workshops and cultural and academic activities designed to improve their

physical, emotional and social well-being. It includes Centros de ServiciosMdicos Gente Joven, which are youth-ocused acilities that serve the

program objectives. The Programa de Centros de Servicios Mdicos includes

Mexam clinics that provide general and specialized medical care in seven

areas related to reproductive health: gynecology, pediatrics, urology, gastroen-

terology, dermatology, internal medicine, and surgery.

The number o services provided by Mexam continues to rapidly expand.

From 2006 to 2008, Mexam saw a 34 percent increase in the number o its

beneciariesrom 3,278,900 to 4,394 ,135. These numbers include peoplewho received medical services, participated in a contraceptive consultation or

t rod cor rodd sm or

soc proco h (Seguro Popular)

r oor or r orzo

o rod cc o rc or mrzd

oo comm ck c.


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distribution program or participated in a training or inormation session. In

2008, Mexam provided contraceptive counseling to 467,000 individuals,

screened 131,000 people or breast and cervical cancer, trained 157,000 youth

through its Programa Gente Joven, oered 18,571 people services related to

hiv/aids testing and prevention, perormed 10,000 pediatric consultations,

and delivered 2,392 babies.

Like its services, Mexams operating budget generally continues to grow,

albeit at a slower pace than its increase in services. However, rom 2006 to

2007, net revenue decreased by12 percentrom $11,587,516 to $10,342,645.

The majority o these unds came rom oundation grants and philanthropic

donations, subsidies, and interest earned on income. Mexam also earns

some revenue through the sale o contraceptives and other medications at its

clinics and centers.

the thRee CasesiMpaCt anD sCalability

Despite the implementation in recent years o a national health plan striving

or universal coverage, major inadequacies and challenges persist. Isolated

communities, highly marginalized sectors and/or indigenous communities

continue to be excluded rom social services. Even under Seguro Popular,

coverage remains low in certain areas (or example, 39 percent in the state oNuevo Len in 2008). Furthermore, even under a policy o social inclusion, it

will be a challenge to achieve and maintain universal coverage (public or

private) that provides care or a broad number o illnesses while doing so with

high-quality service delivery.

All three cases described in this paper have improved the health and

overall quality o lie o their program beneciaries, although through distinct

methods and with diering target populations. The successul experience o

the Fundacin Adelaida Lafn clinics is attributed to the support (nancial,human, and technological) received rom the Muguerza de Monterrey

Hospital and its collaborative work with local communities. Similarly,

Mexams success lies partly in its community advocates and education cam-

paigns in local neighborhoods, as well as its ability to consistently update its

methodologies in response to changing health needs. simnsas success, in

contrast, arose rom its ability to identiy and market to a specic market

niche: documented Mexican workers employed in U.S. border communities

who are unable to pay the high costs o U.S. health coverage.While these programs have signicantly expanded the health care options


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or some o Mexicos neediest people, the true test or them and or Mexicos

overall health care will be whether they can meet continued obstacles to

access and expand their operations. As in Colombia, nancing is precarious or

these three programs. Lacking broad corporate support, Mexam relies on

grants and donations, but has recently broadened its ocus to research and

other activities in order to attract greater nancing. In the case osimnsa and

Fundacin Adelaida Lafn, which combine high patient volumes with low

costs, nancing o operations largely comes rom the beneciaries themselves,

showing how the private sector can serve marginalized groups in a sel-sus-

taining business model. And unlike the programs in Colombiatwo o which

are administered by companies outside the health sectorthe initiatives in

Mexico are largely run by oundations or businesses that specically operate in

the health industry, meaning they may have a greater long-term stake increating models to expand access to health services.

Beyond nancing, both simnsa and Fundacin Adelaida Lafn ace

distinct constraints to access. simnsas activities and strategies are restricted

to a specic geographical region and to only those who can aord to pay the

reduced health insurance rates. Its principal challenge is in increasing

coverage and nding ways to oer services to non-aliated populations.

In the case o the Fundacin Adelaida Lafn clinics, obstacles to access

arise when individuals lack sucient resources to pay even the nominalservice ees and do not qualiy or exemption through social service.

Additionally, duplicating or expanding the Fundacins network o low-cost

clinics to other areas with high concentrations o marginalized groups

would require the support o large hospital rms, many o which are generally

not receptive to such projects and partnerships. Nonetheless, the Christus

Health Group may have an answer, as going orward it plans to establish

a Fundacin clinic in each municipality where the consortium opens a

highly special ized hospital. In this way, as the or-prot hospitalnetwork grows, so will the number o low-cost Fundacin clinics.

At the moment, plans to open highly specialized hospitals are concentrated

in the northern states o Nuevo Len, Coahuila, Chihuahua, and Tamaulipas

with a project in the works to also open a hospital in the southern state

o Chiapas. The model would appear to be replicable as long as patients

can continue to und the majority o operating costs and at the same

time the clinics strengthen brand association o the new hospitals.

Collaborations between the Fundacin and the public sector, especiallymunicipal governments, do exist, but a stronger working relationship would


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acilitate replication. In San Luis Potos, or example, the clinic treats patients

covered bySeguro Popular, but no ormal agreement exists. There, as in the

city o Monterrey, it would be conceivable to sign agreements where the

private clinics would provide care to people covered bySeguro Popularor

specic health issues and receive payment or that treatment through the

System or Social Protection in Health.

For its part, simnsas endeavor could be expandedeither bysimnsa itsel

or another organizationinto the main cities along the U.S.-Mexico border.

Doing so would mean extending health care access to a sector o the popula-

tion (and their amilies) that, while not the most indigent, cannot easily

acquire private health insurance due to an inability to pay or an absent culture

o being insured. Given the prole o workers enrolled in simnsa, the strategy

seems to be easible in the main border cities. What is more, growth in themedical tourism industry could trigger a spike in demand among workers in

the United States. simnsa recently began to negotiate with other rms to

promote the sale o its policies in the United States and to strengthen its

capacity to respond to Mexicos health needs.

simnsa could also potentially engage in collaborative eorts with the

public sector. Under the ramework o the ederal Seguro Popular, simnsa

could work out an agreement by which its members receive care at health

acilities run by border states Secretariats o Health. These publicly-runmedical centers would be able to compete with the private entities now under

simnsa contract.

Mexam, which is now active in more than hal o Mexico and has long

been recognized or its work with marginalized groups, has already demon-

strated a notable capacity or expanding its strategy and services. It has also

historically maintained a broad partnership with the public sector to develop

programs and public health policies pertinent to reproductive health at the

local, state and ederal levels. When it was ounded, Mexams servicesincluded amily planning, maternal and child health, and sexual and reproduc-

tive education. Forty-ve years later, its services have been expanded to

include raising nutrition awareness, building latrines in marginal zones,

treating parasites, organizing amily vegetable gardens, and implementing

sanitation projects. It could achieve even greater coverage and expand to state

health care domains and medical acilities where operations do not currently

existboth by pursuing some o the strategies it has ollowed in the past and

by creating new structures o collaboration with the government. This couldentail joint eorts in administration o the health care system and expansion o


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coverage by the System or Social Protection in Health.

All three o these entities ace common challenges o access and scalability,

providing valuable lessons or other organizations in Mexico and beyond, which

seek to improve health care access and overall social inclusion. First, private

entities should maintain regular contact with health ocials and public

institutions to coordinate similar or complementary eorts. Second, the public

sector should view corporations and ngos as a source o support and collabora-

tion rather than as competitors or patients or clients. Third, the broad

coverage provided by the System or Social Protection in Health (Seguro

Popular) presents an opportunity or private organizations to provide access to

services or marginalized populations in communities lacking health acilities.

Legal and administrative opportunities exist or striking partnership agree-

ments between the public and private sectors. Fourth, even with SeguroPopular, eorts are needed to provide access to care or people o limited

resources. Finally, private organizations should conduct systematic evaluations

to be able to then share successul experiences and lessons learned, as well as

the causes o unsuccessul eorts. Such evaluations should also look at the

quality o service both in terms o its technical aspects and o meeting the

needs o those served.


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ConclusionsRegionally, and specically in Mexico and Colombia, it is clear that new

practices are increasingly allowing marginalized populationsalbeit through

targeted interventionsto access primary health care services. But the case

studies presented demonstrate that challenges remain or eectively

addressing systemic challenges o society-wide health care inclusion. Heres

what we ound:

First,even in countries with health care models that seek to broadlyexpand access or even achieve universal access, signifcant gaps in

access still exist or certain populations. The private sector can help to ll

this void through health care nancing, direct service provision, low-costmedical treatment, eHealth/mHealth, and prevention programs and education.

The public systemwhether through Seguro Popularin Mexico orLey 100 in

Colombiadoes not reach the entire population due to insucient allocation

o unds, the physical distribution o health care providers, lack o knowledge

and awareness o the benets available, and social stigma, among other

reasons. In act, or geographically isolated communities, the urban or rural

poor, or indigenous and Aro-Latino populations, inclusive public policies can

actually hamper their ability to receive quality health care services i suchpolicies then yield an attitude o complacency rom the health care industry.

Second,cross-sector collaboration increases an initiatives scal-ability and sustainability. Involvement o the public sector, hospitals

and community leaders in the design and implementation o a

targeted health program will lead to greater buy-in o the desired

outcome and results. This is also true insoar as the need to bring together

multiple stakeholders to provide the unding or a program to ensure itslong-term sustainability and scalability. As seen in the case o the Salud y

Saneamiento Bsico program run byFundacin Propal, the eective engage-

ment o local and regional government along with other businesses and even

multilateral agencies will increase the potential longevity o an initiative.

Much o the success o the Fundacin Adelaida Lafn and Mexam programs

is a result o their community-wide collaboration both in terms o their

nancing and programming models. At the same time, broad-based collabora-

tion also helps to ensure that an intervention is responding to some o themore pressing local health needs.


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Third,the private sector has yet to ully appreciate the potential orproft when investing in health care initiatives that reach excluded

groups. None o the examples involves or-prot service provision to margin-

alized populations. In Colombia, companies like Cerrejn and Propal

launched their health care eorts to respond to the needs o the local popula-

tion where corporate operations exist. But neither company is in the health

care eld. In act, the majority o health investments come rom businesses

that traditionally have worked in isolated or vulnerable communities. More

can be done by health care companies to better serve marginalized groups in

a way that not only responds to corporate social responsibility goals but also

directly or indirectly drives prots. The PzerMutual ser program is one

example o a program that indirectly benets the companies through positive

brand association. Companies in the health industry can also expand theirmarkets by nding ways to provide low-cost services to populations who have

the potential to become part o their consumer base. A rst step could be to

conduct a broad search or services that the poor want and can be adminis-

tered at low cost with potential nancial returns or the rm.

Fourth,health outcomes are oten measured in terms o access tocare rather than access to quality care. But both indicators are critical to

determining whether an intervention is in act improving the overall care o

the targeted population. Each program analyzed has shown great increases inthe number o patients reached or number o services used. But the unda-

mental question o how these interventions have aected the overall health o

the population remains. This is what matters or creating the opportunities

that will lead to greater socioeconomic mobility and overall social inclusion.

Fith,health delivery interventions have greater society-widebenefts when combined with public education eorts. While huge

advances have been made in reducing inectious diseases and inant mortality,health care systems and providers are acing a growing burden o chronic,

non-communicable diseases such as diabetes, cardiovascular and respiratory

disease, and cancer. Education ocused on improved diet and health practices

is critical or increasing awareness about the risk actors or these diseases.

Each o the case studies presented (with the exception o the simnsa insur-

ance regime) incorporated education as a key component o the programs.


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RecommendationsFirst,greater utilization o inormation and communications tech-nology (ICT), through eHealth and mHealth initiatives, can expand

access to quality care, reduce inefciencies and cut costs. India is a

prime example o howicts can expand health care access, but this approach

has yet to catch on throughout Latin America. In this, partnership across

sectors and providers is crucial to generate impact, sustainability and scal-

ability. Companies are using video and mobile platorms to provide consumers

with inormation; to connect clinics, physicians and patients otherwise sepa-

rated rom one another; and to track population migration and the spread o

disease. Better optimization oict

s will enhance access but will lead to evengreater eciency gains in the quality o care that is delivered, especially in

remote areas. For example, eHealth and mHealth oer the ability or highly-

skilled doctors located in urban areas to remotely diagnose and treat patients.

Second,a regional clearinghouse o or-proft models that servemarginalized populations can be an eective strategy or consoli-

dating eorts. This study is not wholly comprehensive o the types o health

interventions in the region, but it is representative o the eorts being carried

out in Mexico and Colombia. Here, individual eorts are producing importantlessons learned that could be good reerence points or the larger health

community. But a region-wide platormboth online and through working-

level discussionsdedicated to or-prot models that address the primary

health needs o excluded groups could lead to identication o a series o

shared, cross-cutting best practices. One model or this is the Center or

Health Market Innovations.

Third, regular dialogue between health ministries or local depart-ments and the private sector is necessary to harmonize health caredelivery eorts. As in the area o education, which is also studied in the

Americas Society Social Inclusion Program, a certain level o distrust exists

between the public and private sectors. Greater condence in working

together is seen at the local or state/department levels, but still, the two

sectors could more eectively address the primary health care needs o

excluded groups with better triangulation o: a) their service delivery eorts;

b) the on-the-ground policy dynamics; and c) the actual health needs as shownby national health data. This can only be achieved through regular dialogue.


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nAves e PvAe sec

31

In the end, access to quality health care is a undamental prerequisite or

an individuals social mobility and labor productivity, and or societys ultimate

economic growth and competitiveness. Put in a global context, this is precisely

why three o the eight Millennium Development Goalsreduce child

mortality, improve maternal health, and combat hiv/aids, malaria and other

diseasesare ocused on these critical health improvements.


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enDnoteS

1 Julio Frenk, Assessing Mexicos Health System Reorm (Keynote Remarks, Health Care in the

Americas: Public-Private Eorts to Increase Access, Americas Society, New York, NY, December 8, 2010).

2 Pol De Vos, Wim De Ceukelaire and Patrick Van der Stuyt, Colombia and

Cuba, Contrasting Models in Latin Americas Health Sector Reorm, Tropical

Medicine and International Health 11 (10) (2006):1604-1612.

3 United Nations, The Millennium Development Goals Report 2010(New York: United Nations, 2010), 26.

4 World Health Organization, Trends in Maternal Mortality:1990 to 2008

(Geneva, Switzerland: World Health Organization, 2010).

5 PAHO Health Inormation Platorm, Basic Health Indicators Most Requested: Indicator Series,

http://ais.paho.org/phip/viz/mr_indicatorserietable.asp (accessed February 17, 2011).

6 Latin Americas Bill o Health, Americas Quarterly4 (3) (Fall 2010):55-59.

7 Joel Selanikio, The Mobile Revolution in Health Care, Americas Quarterly4 (3) (Summer 2010):64-

65; Donika Dimovska, Filling the Gap, Americas Quarterly4 (3) (Summer 2010):66-71.

8 Luis Jorge Garay, Crisis, exclusin social y democratizacin en Colombia

(working paper, Universidad Nacional de Colombia, 2003).

9 Cristina Torres, Descendientes de aricanos en la Regin de las Amricas y equidad enmateria de salud, Revista Panamericana de Salud Pblica 11 (5/6) (2002):471-479.

10 Luz Dary Salazar lvarez, El envejecimiento en Colombia: una construccin social 1970

2000, Red Latinoamericana de Gerontologa, http://www.gerontologia.org/portal/

inormation/showInormation.php?idino=1649 (accessed February 17, 2011).

11 David Aylward, Beatriz Leo, Walter Curioso, and Fabiano Cruz. Can You

Heal Me Now?, Americas Quarterly4 (3) (Summer 2010):90.

12 Felicia Marie Knaul and Julio Frenk, Health Insurance in Mexico: Achieving Uni-

versal Coverage through Structural Reorm, Health Affairs 24 (6) (2005):1467.

13 Health Net is the biggest health insurance company in the United States, oering its members a variety

o plans. It oers many individual and amily plans. It covers people working in small companies and

people who are sel-employed or temporarily out o work. There are ways or choosing dierent optionsor each amily member. Health Net has a broad range o associates that in turn count on providers

practically throughout the United States, especially in Arizona, Caliornia, New Jersey, and Oregon.

14 In 2008, the Seguro Popularcoverage in select states reached 39 percent in Nuevo Len, 50

percent in Baja Caliornia and 55 percent in San Luis Potos. Even when Seguro Popularreaches its

nationwide coverage goal, a clinic similar to that o Fundacin Adelaida Lafn is likely to remain

necessary since people may not afliate themselves and all services may not be covered.

Documents

Addressing Systemic Challenges to Social Inclusion in Health Care