Achieving quality universal health coverage is one of the goals that seems unattainable for some public health systems. For Ruelas, former secretary of the General Health Council of the Presidency of Mexico and director of the International Institute for Health Futures, achieving this requires not only increasing the budget, but also a paradigm shift in health in the region.
Universal access to health care and optimal quality of service are the goals pursued by most Latin American public systems. Achieving this is no easy task. It requires financing, management capacity and a radical change in the vision of health, virtues that many health systems in the region lack.
Regarding these major challenges, AméricaEconomía spoke with Enrique Ruelas, president and director of the International Institute for Health Futures (IIFS) . Ruelas has vast experience in the health sector. He has been secretary of the General Health Council of Mexico, a position he held during the AH1N1 influenza pandemic; undersecretary of Innovation and Quality in the Federal Ministry of Health of Mexico, from where he implemented the first national strategy to improve the quality of health care. Additionally, he is the founder and president of the first consulting firm for improving the quality of medical care in Latin America, Qualimed.
“ If countries do not increase the percentage of public spending on health, the population's access to services will be very limited. On the other hand, we must talk about access to good quality care, which is another fundamental issue. It is one thing to talk about universalization and another to universalize good services that really meet the objective of providing effective, timely, equitable and safe care. Latin American countries face these two challenges when talking about universalization. One is budgetary and the other is the quality of services,” says Ruelas Barajas.
However, the doctor points out that there are countries in the region that have made significant progress, such as Colombia and Chile, which allocate between 9% and 11% of their GDP to health, a figure close to the average of OECD member countries. However, many Latin American countries still have difficulties in reaching these levels due to a lack of resources.
In this sense, one of the great challenges is at the first level of health care in most of the region. “ The Achilles heel of our health system is in primary care . There we have a serious problem due to the combination -again- of lack of budget with lack of managerial capacity and lack of quality,” he says.
For Ruelas, the lack of budget for this level of care is due to the fact that other areas, such as the treatment of diseases, absorb most of the available money. “On the other hand, the professionals are not the best trained either, because most doctors and nurses want to work in hospitals or want to be specialists. A long-term but very constant strategy is required to strengthen primary care, which would also have to involve a reconceptualization of health because it is always seen as the opposite of illness. Health is rarely seen as a noun per se . What do we have to do to create health or so that people do not get sick, but live healthy?” he says.
However, Ruelas says that more financial resources do not mean the solution to the problem. “ It is not possible to think that an increase in the budget will automatically lead to better health conditions. Nor is it possible to want to improve quality if you do not know how to do it. The managerial challenge in the region is enormous. What to do? To begin with, a policy that requires that certain levels of management should be in the hands of people who have become professionals in the field of management. That does not mean that there cannot be doctors in those positions, but that these personnel are trained in health management. This must go hand in hand with an educational offer; they do not have to be masters or doctorates, but short, well-founded and directed courses that allow the development of the necessary skills to manage financial resources well, better guide human resources, and manage physical resources. Without that, our health systems will hardly prosper, even if the budget is increased, which will increase waste,” explains Enrique Ruelas.
Culture of prevention
Regarding prevention, Ruelas points out that a paradigm shift is necessary. Health systems in Latin America continue to focus on treating illness, when the key to improving collective well-being lies in prevention, and even further back. "We have to be very disruptive and give ourselves enough time to start developing truly innovative ideas that go even further back than prevention, towards the creation of health. This is where we are moving, for example, in England the trend is that health is created at home, not in hospitals. This is not easy. How can we send 95% of general practitioners or nurses, whose training is oriented to diagnose and cure, to do prevention? We continue to think that the health system reaches the most sophisticated cure and not prevention. And if it is decided, with what resources or budgets? ", he questions.
According to the Mexican specialist, promoting a culture of prevention will require not only resources, but also new types of professionals such as anthropologists, nutritionists and sociologists.
Likewise, extending this vision would help to have a better reaction to possible pandemics. The Covid-19 pandemic made the precarious situation of public health systems more visible. Despite this tragic episode, Ruelas believes that the lesson has not been learned.
“During the pandemic, there was a lot of talk about the resilience of health systems, but little has been done to strengthen it. At any moment we could have another pandemic and the situation has not changed. I don’t see many manifestations of strategies to make systems more resilient. We returned to the same old inertia. We were scared and said that we had to be resilient, but the only lesson that this left us is that we have to be better prepared,” concludes Enrique Ruelas.
