Health Care

The responsibility for satisfying health care needs, as well as thoseof education, housing, sustenance and others, belongs primarily to individuals.Health is a state of well-being and therefore constitutes a good which willinevitably be in demand by individuals who seek to improve their qualityof life and postpone their death. Moreover, health is a determining factorin the productive capability of human beings, in their capacity to generateincome and constitutes, therefore, an investment in human capital. Thus,we may conclude that health care should be a primary concern of individualsthemselves.

Nonetheless, in underdeveloped countries such as Chile, where levelsof poverty exist that limit individuals' ability to adequately satisfy theirhealth care needs, the State must play a role in bolstering existingresources to complement individual efforts.

The action of the State is also justified in materials which constitutea part of the public good such as those aimed at eradicating preventableillnesses, controlling pollution and regulating the quality of foodstuffsas well as those aimed at improving human capital and the productivity ofindividuals who are unable to do so for themselves. The State's role inthese areas is justified because the benefit to society is greater thanthe benefit for the individual.

When we speak of privatizing the health care industry, we mean transferringto the private sector some of the activities in which the public sectorhas traditionally engaged and can, because of their very nature, be performedbetter by the private sector.

The task of privatizing is slow and difficult; it is often misunderstoodand exploited politically. Such conditions mean further delays in its implementation,despite the fact that benefits and strategy may be perfectly clear. Nonetheless,incorporating private sector-type initiatives into the public sector, inan effort to achieve greater efficiency in the use of resources, is alsoan important step toward privatization.

For the purposes of this analysis, we shall classify the activities ofthe health care industry as follows:

- Regulatory Activities: establishing, enhancing, modifying andeliminating legal statutes and regulations and overseeing compliance withexisting legislation;

- Implementation Activities: implementing health care services,both out-patient and hospital care and overseeing the corresponding biomedicalvariables;

- Financial Activities: collecting health care contributions,charging fees for services provided and financing partial or complete healthcare for a certain sector of the population.

Of these three activities, the State should have full responsibilitysolely for the regulatory activities.

The private sector may participate in the implementation activities involvedin providing services to individuals, while the State retains responsibilityfor controlling the biomedical variables. Furthermore, the financial activitiesor the collection of premiums, fees for services and the administrationof those resources can be easily done by private organizations. Responsibilityfor the distribution of subsidies to support the most needy, as well asthe financing of measures in the public interest, must fall upon the State.

The first step toward privatization is making a distinction between thefinancial role of the State -- the redistribution of income, through State-financedsubsidies, to complement the personal resources of the most needy -- andthe role of administrator of those resources. The latter can easily be delegatedto other institutions. Second, regulatory and oversight activities mustbe separated from implementation activities. The State forms policies, developsplans and programs, establishes regulations and oversees the activitiesin which public, municipal or private institutions engage. The first steptoward privatization, then, is to differentiate clearly between the subsidiaryand regulatory role of the administrator, in terms of both services andfinancing.

To those individuals who lack resources of their own, privatization meansthe justify to choose a health care provider, either public or private, withoutloosing the State's subsidy. The most needy may, initially, choose theirhealth care provider from among different public or municipal institutions.Later, the individual may choose between public institutions and privateones, achieving better quality care as a result of competition to attractpatrons. Ideally, the institution an individual selects should benefit financiallyfrom that choice so that a greater incentive is created to provide goodservice.

For those individuals who have resources of their own, privatizationmeans allowing them to associate directly with the organization offeringhealth care services in a free and competitive marketplace. In this case,privatizing means the opportunity to select health care establishments,both in terms of physical and financial services, with the clear optionof moving to another institution if adequate service is not provided.

- Leaving the poor without health care: People are often fearfulprior to privatization. Some believe that if the State does not manage healthcare the poor will be left unattended. This presupposes that the State willnot fulfill its role in guarantying a minimum level of satisfaction of thepopulation's needs. Privatizing is not releasing the State of its obligations;rather, it is limiting its field of action to the areas in which its participationis truly necessary and allowing the State to concentrate on providing optimumservices in the tasks it undertakes.

- Diminishing the State's control over health care: Some peoplemay believe that with privatization the State loses control over healthcare-related activities. This is not the case. In fact, the regulatory andfinancial roles are separated and only a portion of the latter are privatized.

Thus, allowing for private sector participation in the health care sectordoes not mean that the State's responsibility -- both in terms of the formulationand oversight of regulations and support for the most needy -- ceases toexist. Furthermore, by diminishing its implementation-oriented and financialroles, the State may concentrate on reviewing, modifying and overseeingcompliance with existing regulations, on development and protection and,in matter of the public interest, on providing services to the neediestsectors of the population.

- Exploitation of health care professionals by health care entrepreneurs:In general, the salaries of health care professionals are determined bythe market, that is, the relationship between the availability of professionalsand the need for their services by public or private institutions or byindividuals who request their services directly. Health care entrepreneurswill have to compete, through salaries and other working conditions, tosecure and retain the most qualified personnel possible. At present, salariesamong the private sector are higher than those in the public sector.

A lack of concern about infectious-contagious diseases: The preventionof these diseases constitutes a public interest and therefore the Statecontinues to be responsible for planning, formulating and financing programseven though it is the private sector that implements them under the expressdirection of the Ministry of Heath.

- Layoffs: In the Chilean health care sector there was no excessof personnel and therefore privatization did not produce wide-spread layoffs.Nonetheless, employment stability under the new system depends on the qualityof services rendered, a situation common in other productive sectors. Thisis diametrically opposed to the old "tenure" system.

- Public health measures will not be taken: All activities forwhich it is difficult for private persons to obtain individual benefitsconstitute matters of public interest. The responsibility for schedulingand financing these actions continues to reside in the public sector. Thisis another area in which the State can be more efficient if it privatizesand concentrates on those fields in which it is irreplaceable.

- Poor service at an excessively high cost to the user: Many peoplefear that businessmen, in an effort to increase profits, will offer sub-standardhealth care and charge excessive prices for these services. This situationcannot arise if competitive conditions exist and users are given freedomof choice. Even in places where health care tends to be a monopoly, competitionamong health care-financing institutions will improve conditions for users.Furthermore, we cannot forget the regulatory role of the State -- whichcan be vastly improved if it is relieved of its responsibilities in thearea of implementation -- which ensures freedom of choice and competitiveconditions.

The concept of permitting private participation in health care is basedon the fact that a purely state-run system or one in which the State hasexcessive influence poses risks in terms of the quality of attention, coverage,the efficient use of perennially limited resources, monopsonic State controlover the salaries of health care workers, the influence of political criteriaover technical recommendations, and the limited participation of professionalsin the investment decision-making process, among others. Thus, the presenceof a private, competitive health care sector is advantageous. Such a sectorcan grow, take advantage of the benefits of private administration and achievecoverage levels to the extent that individual resources and subsidy policiespermit.

- Activities are conducted on the basis of the proper incentives whichnaturally leads to increased efficiency. In a private company, the ownerdecides what type of activities the firm will engage in, what type of resourceswill be allocated and how those resources will be organized in order tomaximize benefits. In this case, the way to obtain increased income is toobtain the predilection of the beneficiaries or "clients" by providinggood services. The results obtained from these decisions and the activitiesimplemented are the responsibility of the entrepreneur and those he/shecharges with the implementation of those policies. Naturally, the same groupis subject to the consequences and results of those decisions. This responsibilityis therefore an important incentive to maximizing efficiency. In the publicsector, on the other hand, the responsibility for decisions is diluted,as are the consequences and results of management. Therefore, in the publicsector there is no such natural incentive to be efficient.

- The increase in competition resulting from private participation breaksthe State's monopoly in health care services and provides an incentive forefficiency by establishing competition to attract clients. This means areduction in costs and an improvement in the services provided. The presenceof alternatives to state-run health care centers imposes a competitivenesson the public sector which means that quality, coverage, opportunity andefficiency increase. Similarly, the presence of private health care centershelps to identify and resolve inefficiencies in the state-run system.

- Efficiency is augmented by permitting and fostering the participationof new health care centers and new entrepreneurs in the marketplace. This"new blood" brings organizational and production capabilitiesto the industry, increases competition and raises returns. In other words,the number of people seeking better ways of "doing things" increases.

- In addition to enhancing management capabilities and increasing investmentand new business options for the private sector, an incentive for the participationof new capital is generated and sources of financing for the industry'soperations and investment are diversified. Moreover, by permitting privateresources to be utilized in the realization of health care industry projects,the work of the State is reinforced. A lack of a strong private sector meansthat a large portion of the population receives its medical attention exclusivelythrough state-run agencies. People are, therefore, unable to support themost effective and efficient health care provider through the option offree choice.

- Improvement are made in infrastructure. The broadening of opportunitiesfor doing business in the industry provides an incentive to a larger numberof investors to participate. This means an expansion in the number of projectsdeveloped and an increase in the infrastructure available for medical care.

An increase in new technology and in the demand for supplies, medicalproducts and hospital-based support services also expands interest in participatingin the health care market while simultaneously fostering variety and competition.

- The quality of investment improves. The presence of an array of technologicaloptions makes it difficult for public officials to select and prioritizethose most urgently needed in each region of the country. Furthermore, theuse of new technology means assuming certain costs, such as training forusers and repair personnel. The participation of the private sector reducesthe risks incurred by the State in the decision-making process over whattype of equipment to acquire and involves a greater number of professionalsin that selection process.

- Areas of specialization are improved. Specialization and sub-specializationare more and more common in medical fields. This means that specializedinstitutions must also be created to attend to specific needs. If the Stateis the sole entity taking responsibility for this diversification, the complexityof the health care network will increase, further attenuating efficiency.

- The State -- a monopsonic employer which sets rules, determines payscales and working conditions unilaterally -- is replaced by a variety ofprivate employers who compete in order to attract the best personnel.

- Work opportunities increase with the expansion of the industry andthe participation of a larger number of related businesses. The easier itis and the more freedom there is to create private health care-providingentities (or instances of financial support for those services), the largerthe ranks of such institutions will be and the demand for qualified professionalswill be all the greater, as will the trend to increase their wages.

- There is greater demand for specialized personnel. The opening of theindustry to more participants means an increase in competition to bringin additional technology and, consequently, an additional demand for theprofessionals trained to use such equipment.

- Development of the teaching field. Lastly, academic centers are neededin order to prepare and provide additional training for medical personal.A larger number of hospitals and health care centers will increase the supplyof potential training sites.

- Freedom of choice is consolidated for the population at large, forprofessionals and for potential investors in the health care industry.

- Private participation fosters more equitable taxation. Distributionfund systems frequently mean that the benefits obtained are of low qualityas compared to the premiums paid. This leads many contributors to believethat their contributions are not bringing them benefits. Thus, they areunjustly assessed a tax in excess of that established by law.

- Competition increases and serves as an incentive to reduce costs andincrease quality through innovation.

A case study review will give us a better feel for the impact of healthcare industry reform as well as its projections for the future and the timerequired to implement the changes.

In order to understand the reasoning behind the modifications to theChilean health care system, it is important to understand the evolutionof the industry and the problems it faced at the time of the reform. Thefirst part of this chapter, then, will provide background information onthe Chilean health care system, while the second will focus on the objectivesthe reform sought to attain through the policies that were implemented.

Prior to 1952, Chile lacked an umbrella organization responsible forregulating, administering, planning, financing and overseeing the healthcare system. Rather, up to that date, a variety of organizations, both publicand private, provided health care services. There was no real concern forthe most needy nor was protection against the risk of illness broadly promoted.However, in 1952, with the creation of the National Health Service (knownby its Spanish acronym, SNS) under the auspices of Law 10,383, the publicheath care system was born, directed by a single organization in which theState's role for financing and administering health care was preponderant.The SNS was responsible for providing health services to Chile's manuallaborers and indigent population who received both initial services andmedication free of charge.

The National Health Service was organized through the creation of 13Health Zones located throughout the country. Each Zone was administeredby an non-career official dependent on the Ministry of Health. The systemwas financed by premiums paid by workers (15%), with contributions fromthe national budget (54%) and income derived from the use of assets. Thepopulation covered by the system was approximately 60% of the national total.

Later, in 1968 new legislation was introduced (Law 16,781 on CurativeMedicine) to make distinctions between manual laborers -- who continuedto receive the same SNS benefits -- and "employed persons" (whitecollar workers) who would receive treatment from the National Employees'Medical Service (SERMENA), an agency created under the auspices of the newlegislation. The primary function of the Service was to provide financialsupport for the medical attention required by "employees" andits statutes called for it to operate through a mechanism known as FreeChoice. Under this system, beneficiaries were entitled to select their ownmedical professional, who would see them on an out-patient basis, from amongthose registered with the service. For in-hospital care, the SNS' centerswere available. Financing for the system was drawn from premiums paid bybeneficiaries and by fees charged when services were provided (fees werecapped at 50% of the cost of the service. This system covered approximately25% of the population.)

During this time period, the private health care industry experimentedmoderate growth, providing out-patient and hospital care to the wealthyand rounding out state-run ambulatory care services among the rest of thepopulation.

Thus, in the early 1970's, Chile's health care system was composed primarilyof three agents: the National Health Service (SNS); the National EmployeesMedical Service (SERMENA); and the private sector.

The SNS was responsible for attending to the health care needs of workers-- who paid an obligatory premium -- their dependents and the indigent population.Beneficiaries could not select the health care institution of their choice(they had to use the one closest to their place of residence), nor the doctorthey would see.

SERMENA was responsible for financing the health care services selectedby employees and their dependents and on rare occasions provided servicesdirectly.

The private sector attended: SERMENA beneficiaries who opted to see privatedoctors or utilize private hospitals within the bounds of the Free Choicesystem; sectors of the population that did not have any other kind of healthinsurance but had the resources to pay for services directly; and individualswho belonged to some type of private health insurance program such as theBankers' Caja or security mutuals.

Type	Care Provided at	Financing
Worker	Nat. Health Service	State Sub. + Obligatory Premium
	Private Sector
Employee	Nat. Health Service	Personal + State Sub.
	Private Sector	Obligatory Premium + Subsidy
Other	Private	Personal + Private insur.

This system meant that workers could only receive subsidized treatmentat the SNS centers and impeded them from seeking treatment in non state-runinstitutions even when they had the resources to pay for a portion of theservices such private institutions might grant. In order to see physiciansoutside the SNS system, workers were obligated to pay the full cost of treatmentthemselves. This was not the case for SERMENA beneficiaries, who received,on the one hand, a lower State subsidy for services provided in SNS institutions(this was true even if a SERMENA beneficiary's pay was lower than a worker's)and had the option of having their subsidy applied to services providedoutside the SNS system, on the other. Moreover, alternatives to the state-runhealth insurance program were generally limited.

In the 1960's, the level of well-being among Chileans was low on theLatin American scale, occupying 9th place -- as shown in Chart 1 below --on the basis of the infant mortality rate.

Country		1970
	Inf. Mort.		Ranking
Argentina	59		4º
Colombia	70		7º
Costa Rica	62		5º
Cuba	38		1º
Chile	79		9º
Ecuador	77		8º
Peru	65		6º
Paraguay	94		10º
Uruguay	43		2º
Venezuela	49		3º

The level of well-being in a country is influenced by a variety of factors.These factors were taken into consideration in seeking to design a strategyaimed at modifying health conditions in Chile. That health care strategyresponded to a set of objectives, policies and measures which sought toimprove the status of the Chilean population's health as quickly as possible.In order to facilitate analysis and focus on the measures taken, we cansummarize this multiplicity of factors along four key lines: level of socioeconomicdevelopment, environment, characteristics of the population and measurespertaining to the health care industry.

A strategy for the industry was designed in accordance with these guidelinesand within the framework of the socioeconomic development policies -- emphasizingsocial issues and economic freedom -- being implemented at the time. Thenew approach served as the basis for a large portion of the measures takenwhich, as a whole, sought to modernize the health care industry. Nonetheless,the implementation of these policies was difficult and often incompletegiven the numerous obstacles which arose. Among these we should highlighta lack of understanding among beneficiaries, the economic recession of 1982-1985,the opposition of health care workers and perhaps most importantly, thelack, during the first few years the policies were in place, of an overall,persuasive and viable solution to the industry's multiple problems.

1. To achieve longer life expectancy among the population, especiallylower income groups.

2. To maximize Chileans' physical and mental well-being throughout theirlifetimes, beginning at conception.

3. To provide equal opportunities among Chileans in terms of both accessto medicine and, particularly, a degree of physical and mental developmentto enable them to participate normally in national life.

The basis for social development and, therefore, the basis of the newhealth care strategy, is economic growth aimed at increasing employmentand the population's income, making it possible for individuals to satisfytheir basic needs on their own.

The State provides subsidies to those who through their own efforts areunable to reach a minimally-acceptable standard of living.

In Chile, continual efforts were made to ensure that subsidies were concentratedprimarily among the most needy in order to avoid excessive social spendingthat would be a drain on the nation's growth. In the long run, such a drainwould only serve to deplete the very social development the spending soughtto enhance. Clearly, to the extent that resources were not diverted to thosecapable of paying for their own health care, the funds available for subsidiesto the most needy would increase.

The basic cleanliness if people's surroundings was also considered apriority health issue. Here, the measures taken by other actors, such asproviding drinking water, solid waste and garbage management, basic hygieneand cleanliness within the home, etc., were as important as those adoptedby the health care industry.

Setting priorities is inevitable given that there never are, nor everwill be, sufficient resources to do everything one would like to do. Thus,priorities must be established as conscientiously as possible in a scientificfashion, in order to ensure that the tasks that remain to be done are notmore important than those that are being undertaken. Responsibility forsetting these priorities should be given to the most suitable person ateach level.

- Measures aimed at fostering health and the prevention of illnesswere given top priority. Recovery and rehabilitation were considered secondarysince the most important issue was to avoid illness and reduce pain. Moreover,recovery and rehabilitation measures are usually less efficient and moreexpensive than prevention.

- Primary care was considered a priority over secondary and tertiarycare. This enables the system to receive a larger number of people, reduceunit costs and provide timely solutions to the majority of health care problems.

- Mothers and children from the time of gestation were consideredpreferential beneficiaries as compared to the rest of the population. Thisdecision was based on the concept that health care problems in early childhoodcan have life-long impact and thus should be avoided or treated early-on.

- High-risk groups were targeted and given a high priority inorder to increase the efficiency of the program.

- Priority care for the most needy rather than for those capableof paying for their own medical treatment was granted, thereby rationalizingstate expenditures.

In sum, an constant effort was made to ensure that the impact of availableheath care funds would be as great as possible. This was achieved throughlow cost unitary measures benefitting the largest possible number of peoplefor whom the effects would be the greatest over an extended period of time.

People are exposed throughout their lifetimes to a series of risks totheir health. Thus, families should take measures to be protect themselvesfinancially against potential accidents and/or temporary disability. Suchaccidents frequently mean additional expenses or a drop in family income.

Thus, the creation of a health-preparedness or insurance system was fostered.Particular emphasis was placed on initiatives by the private sector as asource of insurance for those in a position to pay for health care services.

The State provides health care subsidies to families lacking sufficientresources to obtain a minimum level of heath care that the country is ina position to grant without assistance.

Indigent citizens receive health care free of charge and are fully subsidizedby the State. Families that are better off, on the other hand, have slowlybegun to finance their own health care, leaving the State's limited resourcesavailable for allocation to the most needy.

Those who are in a position to finance only a portion of their families'health care needs receive a partial subsidy from the State.

Services that receive implicit subsidies and are considered part of thepublic interest, such as vaccinations, continue to be provided by the State.

Considerable progress has been made in implementing the new system. However,continued work is needed in order to enhance the system's mechanisms forfocusing on the most needy.

The State finances both explicit and implicit subsidies through incomefrom the national budget (without falling into crossed subsidies). The basesfor this policy are:

Equality: Chileans are subject to a tax system which providesfor a global taxation structure. Without entering into the discussion overthe need to refine this system, it is unfair that certain individuals areagain taxed through implicit sectoral duties. This distorts the basis ofsocietal equality and the overall efficiency of the general taxation structure,as occurs in any system involving crossed subsidies.

Transparency and efficiency: Crossed subsidies tangle up the originand destination of funds and make it impossible to understand the pricesbeing charged for services. Thus, it is impossible to ascertain what servicesare lacking. Under these conditions, identifying and selecting subsidiesis difficult and the incentives for the optimum allocation of resourcesare rendered inoperative.

Effectiveness: with crossed subsidies, people are obligated tocontribute more than they will receive and therefore have a strong incentiveto dodge the system. This tends to led to chronic financing difficultiesin this type of system.

The State provides health subsidies, both implicit and explicit (as isthe case of services provided free of charge), whether the provider is apublic or private institution. A structure was established to channel subsidiesto beneficiaries in such a fashion as to ensure the participation of privateentities in providing services (under conditions equivalent to the publicsector).

The State must offer the population uniform, non-discriminatory alternativesfor satisfying its health care needs. Thus, systems which discriminate onthe grounds of activity or any other arbitrary basis must be eliminated.

Chileans should be able to select their health care institution freely,whether public or private, in which they will be able to ensure coverageof health-related expenditures and receive proper care. Although advancementshave been made to achieve this equity, there is still much to be done.

In an effort to improve the administration of resources, the SNS wasdecentralized both in terms of its regulatory/ oversight responsibilityand in providing services.

The system's chain of command was consolidated prior to initiating theeffective decentralization of policy making, oversight and implementationsub-divisions. Furthermore, the budget was also decentralized to allow fora greater correlation between areas of responsibility and decisions on expenditures.

Subsequently, the administration of public health care centers was transferredto the municipalities. Moreover, the pyramidal structure was strengthenedthrough the implementation of derivatory systems between the primary, secondaryand tertiary care levels.

The system used by the Ministry of Heath in distributing resources soughtto serve as an incentive to state-run establishments to provide better qualityservices at a minimum cost.

The following is a brief summary of the key measures taken and the goalsthey sought to achieve:

1. In 1979, Decree Law 2,575 was passed to enable workers to participatein the Free Choice system, including the justify to establish agreements withprivate hospitals. Thus, the discrimination between blue collar and whitecollar workers was eliminated and the health care options of a vast portionof the population markedly increased.

2. Within the state-run sector, there was a pressing need to modernizeinstitutions and organizational structures to enhance their functioning,adapt them to the regional structure and avoid duplication of effort. Inorder to do this, the regulatory, implementation-oriented and financialaspects of the system needed to be separated and administration needed tobe decentralized (the Ministry of Health would continue to serve as thekey oversight agency).

In 1979, the Ministry of Health and the SNS were restructured in accordancewith Decree Law 2,763, to separate regulatory, financial and implementation-orientedactivities. Thus, the National System of Health Services (SNSS), composedof 27 autonomous agencies responsible for providing preventative and curativeservices in pre-determined geographic areas, was created under the tutelageof the Ministry of Health.

These measures were aimed at decentralizing administration and providingincreased decision-making power at the local level to complement the municipalities'increased responsibilities. These objectives represented the first stepstoward the incorporation of proper incentives into public administration.

3. In 1980, the system's financial responsibilities were transferredto the National Health Fund (FONASA), responsible for receiving and distributingresources donated by the State as well as administering premiums paid byaffiliates and the payments beneficiaries make through the Free Choice system.Moreover, FONASA is responsible for administering the services providedunder the Free Choice system. Premium-paying individuals participating inFONASA may seek health care at any of the SNSS' centers or at the healthcare establishment of their choice so long as the center or physician selectedis registered in the FONASA system. FONASA then pays for 50% of such servicesin accordance with the approved rate schedule in effect at the time.

4. In 1980, Decree Law 1-3036 was enacted to regulate the transfer ofso-called medical "posts" (postas, basic health care centers)and consultorios (equipped medical centers) to the Municipalities.This was done to enhance decentralization by bringing decision-making tothe local level so that priorities could more accurately reflect actualneeds.

In 1981 transfer commenced of primary care establishments (rural andurban consultorios, rural medical stations and rural postas),from the Ministry of Health's services to the local authorities (this processwas completed in 1988.) Some municipalities chose, in turn, to shift responsibilityfor the administration of these institutions to private, non-profit corporations.

5. In 1981, legislation was enacted to allow for the creation of PrivateHealth Preparedness Institutions (ISAPRES). The obligatory premiumwhich workers had been paying into the state-run system could now be freelyredirected by the beneficiary to a private insurer (or continue to be paidto FONASA). This option increased freedom of choice among workers, createda competitive insurance field and, furthermore, diminished the number ofbeneficiaries in the public system.

ISAPRES relieve the State of the obligations which can undertaken byprivate individuals; they do not receive State subsidies and operate withina competitive environment.

The ISAPRE system is based on an insurance scheme whereby beneficiariesin a position to pay for their health care do so through prepayment or periodiccontributions (premiums). So financed, they select the health care facilityor physician of their choice and expenses are charged to the ISAPRE. Deductiblesor partial payment for certain services may also be required.

Thus, in cases of emergency, an ISAPRE finances the health care providedto an individual beneficiary with the premiums being paid into the systemby remaining beneficiaries not making use of the system at the time. Lastly,each ISAPRE has a patrimony that can be utilized for expenditures beyondthe resources it generates. If these funds are not used -- in compensationfor the risk they incur -- interest can be earned on unspent monies.

Participants in this system are free to choose the ISAPRE from whichthey wish to receive coverage. Furthermore, within any given ISAPRE theymay choose the health care plan under which they will receive coverage.Thus, ISAPRES must compete for affiliate preference by designing competitively-pricedplans that suit individuals' needs.

ISAPRES have been criticized for not being solidary institutions. Thatis, for not imposing solidarity among their affiliates in an effort to subsidizethe most needy. The response to this argument is that it is the State'sresponsibility to redistribute income through the tax system. Therefore,it is inappropriate to finance subsidies with premiums. Moreover, if suchsubsidies were to be permitted, crossed subsidies would be generated, producinga plethora of problems. ISAPRES represent a legitimate option for usersto finance better quality health services.

6. In 1985, Law 18,469 created the Health Services Regimen which categorizedSNSS beneficiaries according to their level of income and provided subsidiesin an inverse proportion to that income (the neediest were granted freetreatment). FONASA beneficiaries were also permitted to choose the publichealth care establishment where they wish to receive treatment.

The State, through the Health Services Regimen ensures individuals aminimum level of health care in accordance with available resources. Thus,each beneficiary must pay for services to the best of his/her ability andlevel of income. Those beneficiaries seeking treatment at public healthcare centers are divided into four groups as follows: Group A, indigents;B,C,D, premium payers. The level of coverage is determined on the basisof these categories, fluctuating between 100% for Groups A and B, 75% forgroup C and 50% for those belonging to Group D. Thus, resources are allocatedprimarily among the most need. Furthermore, for services provided underthe Free Choice System, a three-tiered system of Levels was devised. Underthis system, all of the levels are reimbursed in the same amount. At present,for example, the reimbursable amount is equal to 50% of a Level 1 service.Thus, a beneficiary who selects a more expensive Level 3 service receivesthe same refund as a beneficiary having the same procedure done at a lessexpensive establishment. The assumption here is that the person opting fora Level 3 establishment or physician is in a position to pay the cost differentialout of his/her own pocket.

7. Furthermore, measures aimed at creating a system of incentives toimprove management efficiency at public sector institutions was also implemented.Such measures included decentralization, resource allocation mechanisms,training and the use of new administrative tools.

The National Health Fund was charged with implementing resource allocationsin accordance with directives received from the Ministry of Health. Thus,funds were forwarded to the nation's 26 health services and The EnvironmentalHealth Service1 to cover the following line items:

Through 1978, resources were allocated on the basis of past expendituresby state-run establishments. This system created a dramatic incentive toincrease expenses that went beyond any sense of social profitability. Asof that year, a series of mechanisms were introduced which sought to createincentives which would foster more efficient behavior, emulating as muchas possible the private sectors' profit incentive. In essence, the publichealth industry, because of its complexity, size, variety of services offered,the large number of employees, extraordinarily high presence of governmentalspending and social role, constitutes one of the most difficult organizationsin the nation to manage. Moreover, the public health industry requires decentralizedadministrative structures; managing this mammoth directly is quite impossible.

Thus, administrative decentralization commenced and was gradually followedby budgetary decentralization. The latter is still incomplete, but the systemdoes contemplate a variety of mechanisms which seek to achieve the greatestpossible efficiency rather than serving as a mere validation of existinglevels of expenditures.

In order to provide an incentive for improved use of the funds allocatedfor Salaries, Subsidies and the PNAC (which always seemed to be insufficientand whose budget consistently ran a deficit making it impossible to ensureefficiency at the central level), the following set up, in use through 1989,was established:

- The Ministry of health established an itemized budget in accordancewith expenditures from the previous year and performance. Thus, in devisingthe salary budget for example, performance and the need for additional humanresources were considered, as were the institutions which had been transferredto local authorities. In setting the budget for subsidies, statistics onmedical leave were taken into consideration when necessary. In order toset the PNAC budget, the nutritional condition of children under 6 yearsof age at the respective Service was factored into the calculations.

- Resources were forwarded by FONASA to dependent agencies in pre-determinedmonthly stipends.

- Health Services were obligated to spend in accordance with their annualbudget. In an effort to rationalize administration, a variety of measureswere taken to optimize the use of resources and decentralize the managementof the budget. Furthermore, incentives were created to foster better resourcemanagement, including a "prize" for those institutions comingin under budget and "punishment" for those exceeding authorizedspending levels. Thus, institutions spending less than their authorizedlevel were permitted to utilize the excess resources as they best saw fit.Those running a deficit, however, were required to make up the differencewith funds from their respective Service. This system created an incentivefor quality management and allowed for transference of funds from one lineitem to another. While this system was in operation, the number of patientsseen increased, as did overall nation-wide indicators of well-being.

In terms of the funds allocated for investment, the Ministry of Healthmoved to decentralize the decision-making process, assigning a portion ofthe authorized budget for large-scale infrastructure acquisitions (whichrequired the approval of governmental planning and financing instances)and distributing the remainder among the Heath Services.

In order to perform this distribution, the Ministry of Health calledfor studies and proposals to be elaborated on projects relating to the maintenance,replacement or acquisition of medical equipment and vehicles. If approved,the Ministry also provided any training that might be needed to the Servicesreceiving new equipment.

The total funds allocated to each Health Service depended on the investmentprojects they presented, the quality of support studies and the financialsituation of each Service.

In addition, the funds allocated to the Supplies and Services line itemwere distributed in accordance with the number of services provided (70%)and quality indicators (30%). The funds distributed in this fashion constitutedan additional incentive to efficiency among public health care centers.

The payment for services is known as Invoicing for Services Provided(FAP) which establishes service categories in accordance with their complexity.The respective Service receives a certain percentage of the Services RateSchedule established in Law 18,469. A full 100% of the rate is not paidbecause, as we have seen, financing for personnel, subsidies and investmentis provided elsewhere. Thus, the FAP constitutes solely a source of moniesfor the acquisition of supplies and services for each Heath Service. Giventhat the FAP was intended to increase the number of services provided andnot results, a set of indicators was devised to evaluate quality while measuringefficiency in the use of resources. Thus, the resources utilized for servicesdetermined on the basis of four bio-medical and three financial criteriawhich are weighted accordingly.

The resources allocated to each Health Service in accordance with preexistingindicators help correct problems which may arise with the FAP and constitutesa good incentive for technical and administrative efficiency.

In addition to these incentives, a Management Information and MonitoringSystem (SIGMO) was implemented in 70 hospitals throughout the country accountingfor 83% of hospital-oriented expenditures. The SIGMO is of use in analyzingthe administrative management of human and material resources at healthcare centers and provides systematic, organized insight into hospital expenses.With the SIGMO, it became possible to evaluate periodically results obtainedas compared to objectives, identify reasons for discrepancies and introducemeasures leading to a more efficient use of resources in a timely fashion.

8. Public health care establishments were authorized to attend non-beneficiaries,and special rates for such private individuals were established by eachcenter on the basis of operating costs. Thanks to this program, privateparties can make use of public infrastructure, so long as an appropriateprice is paid. This payment structure prevents such services from causinga drain on benefits provided to subsidized beneficiaries.

9. In an additional effort to increase efficiency, state-run agencieswere authorized to hire private specialists to engage in a variety of activities,including providing health care services and complementary fields. However,a expenditure cap of approximately 10% of the supplies and services itemwas established for such subcontractors.

10. Public assets were sold to the private sector to obtain resourcesand reduce operating costs.

The results achieved through the policies and measures described aboveare as follows:

The private sector has developed substantially, creating alternativesand options so that people may choose the health care facilities which bestsuit their needs. This has been achieved through a reduced role for theState in health care thanks to policies of subsidies, fostering responsibilityamong individuals and freedom to select a health care option in accordancewith one's resources. Industry growth can be measured in terms of the evolutionof the number of beneficiaries and the number of health care institutionsin operation.

Prior to the reforms of 1980, the SNS provided coverage to approximately60% of the population while SERMENA accounted for approximately 25%2 (see Chart 1).

In 1987, beneficiaries in the private system totaled 25% of the population3 , of which 8.7% belonged to ISAPRES (see Chart 2). Atpresent, ISAPRE beneficiaries represent fully 16% of the population (seeChart 3).

With the creation of the ISAPRES, there is a clear reduction in the numberof public sector beneficiaries4 .

b. Extraordinary increase in the number of participants and beneficiariesin the ISAPRE system

As of June 1991, premium-paying participants in the system totalled 951,814while total beneficiaries numbered 2,282,1645 . Growthin this industry has been constant as can be seen in Chart 4.

In the early stages of the implementation of the ISAPRE system, somecritics sustained that its impact would be minimal, accounting for just20% of the wealthiest population and 8% of the remainder. Their calculationswere based on the assumption that the system would function only among themost affluent. In fact, ISAPRES now cover people from a wide range of incomelevels: 32% of participants have incomes below $80,000 pesos and only 35%earn more than $160,000 pesos (see Chart 5).

The increase in the number of beneficiaries has meant a rise in the diversificationof risk and the attainment of economies of scale which, when coupled withthe level of competition in the marketplace, has made it possible to reducerates and allow for ever larger portions of the population with limitedresources to participate in the private system.

In any case, the trend is definitely for ISAPRES to cover an increasingnumber of people with smaller incomes, as reflected in Chart 6 showing theevolution of the average premium. As can be seen here, premiums have continuedto drop even as real wages have risen in comparison with their 1987 levels.This can only be explained by an increasing presence of affiliates withlower incomes.

The number of health preparedness or insurance companies currently totals35, providing for a highly competitive market in terms of the quality andcost of services offered. Clearly, this works to users' advantage (see Chart7).

In 1990, the system provided over 20 million health care services, resultingin an average of 9.6 services per year per affiliate; a 22% increase overthose provided in 1985 (see Chart 8).

Another criticism that was formulated at the inception of the ISAPREsystem was that their creation had not led to an increase in private investmentin the industry and, therefore, private infrastructure was not being developed.Nonetheless, since its foundation, demand for health care services has risen,resulting in increased utilization of private infrastructure. This, in turn,has generated increased economic benefits for these companies and fosteredthe implementation of new projects aimed at modernizing equipment, developinginfrastructure and utilizing new technology.

Chart 9 shows the evolution of the number of beds available in the privatesector from 1975 to date. Clearly, growth in this field accelerated withthe creation of the ISAPRE system, reaching a total of 10,298 beds in 1990.

Moreover, an important increase has also been registered in the numberand type of health care facilities available (see Table 2).

Private Infrastructure	1982	1989	% increse
Hospitals	16	24	50
Private Clinics	134	170	27
Med. Centers	289	385	33
Laboratories	335	389	16

During the period 1982-1985, the constructed area of municipal healthcare facilities increased by 45% (see Table 3) and the number of examinationrooms rose by 38.3%. These statistics do not include repairs or additionalconstruction on existing structures.

In terms of equipment, the number of consultorios and postaswith one or more dental facilities increased by 75%. Sterilization equipmentincreased by 85%. Prior to the transfer there were no laboratories for processingtest results; in 1985 there were 7.

A large number of accessories that are difficult to enumerate, includingstretchers, scales, refrigeration equipment, furniture, etc. also increasedsignificantly.

In rural areas, primarily, it is important to note the availability ofbasic services, such as water, electricity, telephone and heating. At thetime of transfer to the municipalities, fully 82% of these health care facilitieshad no communications equipment (telephone or radio) and almost 59% lackedany type of heating. By 1985, these percentages had fallen to 39% and 14%respectively.

	Urban area	Rural areas	Total
Constr. area (m2)	76.0 %	24.7 %	45.5 %
Exam. Rooms	58.0 %	26.0 %	38.3 %
Dental equipment	-	-	75.0 %
Steril equip.	-	-	85.0 %

The cost of administration and sales shows a steady decline from 23.6%of revenue in 1986 to 17.7% in 1991 (see Table 4). This is a result of theeconomies of scale obtained thanks to the increase in the number of beneficiariesand greater efficiency as a result of competition.

	1986	1987	1988	1989	1990	1991
Total System	23.6	24.2	21.7	18.5	20.1	17.7

As noted earlier, the participation of private health care facilitiesin the market enabled the public sector to focus its resources on attendingthe needs of the most impoverished sectors of society while increasing itsown operational efficiency and effectiveness. Nonetheless, the system'sdetractors sustained that the mass exodus of people from upper income categorieswould result in the bankruptcy of the public health care system since thehighest premiums would no longer enter public coffers.

In effect, the premiums paid by the moneyed classes were transferredto the private sector. With them, however, went the higher expenses thataccompanied the demand for costly services that this sector of the populationgenerated. Thus, this shift in premiums is no longer considered an obstacleto the success of the program. Moreover, the redistribution of income isconducted by the State and paid for from the national budget, and here thewealthy continue to pay their share through higher rates of taxation. Furthermore,one must consider the reduced expenses or savings generated by FONASA withthe withdrawal of individuals from higher income groups. First, there isa savings in the subsidy granted for each service provided, as well as thesubsidy for days of work missed. Second, an additional savings is generatedbecause the affluent tend to utilize heath care facilities with greaterfrequency than those with more modest incomes.

The evolution of public spending has tended to increase in both absoluteand "per capita beneficiary" terms. Thus, from 1974-1988, theformer increased by 51%8 while the latter rose by 45%(see Chart 10).

Considering that the population with lowest incomes has remained as abeneficiary of the public system and that the per capita expenditure inthis sector has increased, one can say that a concentration of public spendingon the most needy has effectively taken place.

In addition to the efforts undertaken to allocate the largest possibleportion of resources to the public health sector, as of 1980 a series ofmodernization measures were implemented. These steps included administrativedecentralization, modifications to the system used to transfer resourcesand incentives for good management which, despite their recent implementation,have had notable effects on the efficiency of resource utilization. Thus,despite the inevitable reduction in resources available to the heath careindustry as a result of the recession, progress in the well-being of Chileancitizens continued to be achieved. In fact, this efficiency enabled theindustry's productivity (measured through the Central Bank's Gross Valueof Production in Domestic Accounts -- VBP) to rise even as income fell (seeChart 11).

It was therefore possible to modify the composition of that income byincreasing premiums and reducing State contributions to focus expenditureson the most needy. This was accompanied by the efficiency described earlierand reflected in Chart 11 in conjunction with the positive evolution ofthe VBP.

Because families are the key support structure for the well-being oftheir members, they have been responsible for paying an ever larger shareof their income for systematic health-care savings. The increasing concernamong individuals in participating in financing of their families' healthcare requirements can be seen in the rise in premiums and the reductionof State subsidies.

b. ISAPRES do not receive State subsidies of any type. That is,close to 1 million premium-payers and 2 million beneficiaries use this systemwithout recurring to State subsidies.

c. Beneficiaries of the public health sector finance a larger portiontheir health care. State contributions to the public health care systemfell from 56% of revenues in 1980 to 39% in 1990. The remainder of the system'sresources, primarily user payments, rose from 44% of revenue to 61% duringthat time period (see Chart 12). This was possible thanks to an increasein the premiums paid by affiliated workers and the requirement that userspay for the services provided to the best of their ability.

Treatment and care are always difficult to measure. However, some datais available thanks to on-site research.

According to the results of polls taken in 1977 and 1983, the care componentof health services improved notably between those years.10

- The number of patients receiving what they perceived as satisfactorytreatment rose by 14%. There was a significant increase in the rate of reportedsicknesses and treatment for chronic illnesses. It is important to notethat Chile's population is aging and therefore there are an ever risingnumber of medical queries arising from chronic complaints (fully 31%).

- Increase in the types of treatment available including: 80% for chronicillnesses; 29% for acute illnesses; 16% for check ups, including healthy-babyprograms and adult care; and, 11% for dental care.

- In 1983 there was a significant increase in the number of people seekingtreatment and a drop in medication-related questions directed to the staffof pharmacies.

b. Better doctor-patient relationship in the private sector than inthe public health care system11

- "Private centers are known for having flexible regulations, physiciansand the staff establish direct and informal relations with patients, whichtend to produce a comfortable and friendly environment where patients anddoctors work together to obtain and provide health care. Patients are usuallypleased with the service provided and return to the health care center.In state-run medical centers, however, the institutional organization whichenvelops doctors and patients alike is characterized by routine care andmedical practices and by rigid administrative procedures. The doctor-patientrelationship becomes impersonal. Physicians identity patients by numberand rarely see the same patient twice. This prevents communications frombeing established between patient and physician and thus feelings of satisfactionor pleasure are less likely".

Over 2 million people associated with the ISAPRE system choose the healthpreparedness institution which will best insure their health.

Some 6 million people affiliated with the public system may at leastopt for private sector institutions and physicians through the Free Choiceprogram implemented by FONASA. The only limitation is that their own resourcesmay not be sufficient to cover certain types of private care.

Three million beneficiaries receive free medical care at the public healthcare center of their choice.

- The number of treatments provided to beneficiaries in the public sectorhas risen

As noted earlier, with the implementation of the ISAPRE system therewas concern in some circles about ending up with a public system with reducedresources responsible for treating people from lower income groups. Thefollowing describes the activities conducted and resources available tothe public health care sector, by beneficiary, for the years 1975-1979:

Once again, there is a slight drop between 1980 and 1987 (see Chart 13).This was caused by the economic recession which affected Chile at the timerather than the introduction of the reforms given that for the period 1987-1989,despite the growth of ISAPRES, the number of treatments per beneficiaryin the public sector also rose.

The trend for an increase in the number of laboratory exams and pathologicalanatomy per beneficiary is clear throughout the period in question.

The increase in the efficiency of the system is reflected in the numberof discharges per bed.

The economic and social development policies implemented in Chile madeit possible for the population's overall healthfulness to improve at a muchfaster rate than in the rest of Latin America. Thus, Chile rose from ninthplace in the infant mortality ranking for the region in 1970, to third placein 1986.

The data shows a clear trend toward a drop in infant mortality throughoutthe region, except for Peru. Nonetheless, the velocity of this change variesgreatly from country to country. Thus, only Chile, Costa Rica and Paraguayimproved their relative position in the ranking and the improvement in Chilewas the most spectacular (plummeting from a rate of 79.3 children per 1,000live births in 1970 to 19.1 in 1986 and 17.1 in 1989).

This achievement was not due solely to the changes implemented in thehealth care industry, but rather to the set of consistent policies adoptedin both the economic and social arenas.

From this data, then, we may conclude that the gradual incorporationof the private sector into the implementation of tasks traditionally reservedfor the public sector not only did not have a negative impact on the population'soverall well-being -- as some of the detractor of privatization predicted-- but rather coincided with improvements in this field whose speed outstrippedthat of the rest of Latin America.

Despite the efforts made in the public sector, the lack of incentivesto achieve greater efficiency in the use of resources persists. This, coupledwith the inherent problems of administrative inflexibility and the limitedor non-existent responsibility of individuals in the decision-making processimpede progress and sustain, and in some case intensify, the following problems:

- Overuse of the system resulting from a lack of decision-making abilityat the health care facilities. This produces an excess of derivations, resultingin the wasting of resources and poor service.

- Progressive increase in expenses resulting from a lack of incentivesto rationalize and prioritize expenditures in accordance with availableresources. This is compounded by the increasing cost of new technologiesand the increase in life expectancies (the elderly tend to become ill moreoften and require more frequent and extended treatment).

- Lack of financing in the industry as a result of increasing "musthave" items beyond the country's real needs. This leads to growingdiscontent among both personnel and beneficiaries.

- There are still 6 million people, namely contributors to the publichealth care system and their families, who lack effective freedom to choosethe system which best suits their needs according to their preferences (accessto the private system is difficult because of their limited incomes). Furthermore,there are almost 3 million people with limited resources who do not paypremiums, receive state-subsidized health care and have no way of improvingtheir situation through a more efficient use of the resources made availableto them.

These problems frequently go unnoticed in light of more obvious difficultiessuch as depressed wages and, in some cases, insufficient infrastructure.Both sets of problems have their roots in a public sector with monopsoniccharacteristics in the labor market, a persistent lack of resources andthe effects of the reduction in public spending implemented during Chile'srecession of 1982-1985. The drop in industry resources began to be reversedin 1986, but this has not kept working conditions and hospital infrastructurefrom being the target of political attack. Such criticism has often servedto cloud analysis of the industry's problems and thwart the search for realsolutions.

The industry's problems are frequently oversimplified, focusing on theamount of resources available with no concern for concept that no matterhow much money is allocated to the system, the need to find ways of improvingthe use of those resources and bolstering efficiency in order to enhancethe well-being of all Chileans continues to persist.

The advances made by the private sector have been noteworthy. Howevercertain problems must be addressed if the system is to be consolidated.Among these are:

- As with the public free choice system, the misuse of identificationcards in order to secure benefits for non-affiliated individuals has beendetected. Furthermore, the number of doctor-authorized work absences hasincreased wildly. This results in payments by the health insurer for daysof work missed.

- Dependence on legislation that more often responds to political thantechnical criteria. Stable rules of the game need to be established.

1. To enable all Chileans to effectively choose their health care systemand receive better quality care.

2. To control the increased costs generated by technological developmentsand the increased demand for services resulting from access by new sectorsof the population to the system and the increased life expectancy amongbeneficiaries.

Considering the tremendous efforts undertaken to introduce incentivesinto the management of the public health sector, it is clear that the successobtained has been slow in coming and less than wholly satisfactory. Furthermore,the measures taken in the public sector are vulnerable given that they aresubject to the criteria of the personnel on each rotation. In order to moveforward in solving the problems that persist, ways need to be found of introducingprivate-sector incentives into the administration of public resources.

The incorporation of these incentives must take place whether or notpublic spending is increased and must take advantage of all of the sectorsresources, both physical and human. Moreover, efforts must be made to fosterpreparedness and personal responsibility for well-being.

In order to attain these goals, a resource allocation system must bedesigned which contains sufficient incentives to allow for the best possiblemanagement of available resources. This can only be achieved through a competitivesystem, where users can select the type of institution where they believethey will receive the best coverage of risks to themselves and their families.

The State must provide support to the most needy through a subsidy which,in conjunction with contributions made by the beneficiaries themselves,allows them to select the health care institution of their choice.

Health care establishments, therefore, should obtain their financingby securing the preferences of users. This can be achieved by competitionamong private and public centers and through their revenue and the occasionalsale of shares. The periodic revenue should be drawn from subsidies andpremiums channeled to the health care establishments in accordance withusers selections.

State-run establishments should be organized as self-financing autonomoushealth companies earning attractive profits. These companies may be public,municipal or private property; the key is that they function according tothe norms of the private sector. Moveover, they may be privatized over timewith the participation of the health care team in both ownership and results.

In implementing a system of subsidies according to beneficiary preference,it is important to keep the State from having to finance the establishmentsit currently operates -- in addition to the subsidies -- without takinginto consideration the relative success achieved in attracting the preferenceof users.

This privatization process would conclude in the ideal situation of familiesbeing responsible for the health and well-being of their members, allocatinga portion of their resources to systematic savings or premiums to coverillness and health services provided by competitive institutions freelyselected by the users.

Under this ideal scheme, the State would define and monitor health careprograms at the national level, taking responsibility for those actionsdeemed in the public interest that are beyond the responsibility of individuals.Moreover, the State would continue to support families with limited incomesthrough subsidies which, when combined with personal resources, would enablethem to obtain an acceptable level of healthfulness compatible with thenation's level of resources.

2 Tarsicio Castañeda, "ElSistema de Salud Chileno: Organización, Funcionamiento y Financiamiento".

4 Ministry of Health "Estimacionesde la Población Beneficiaria a Base de los Controles de NiñoSano 1986-1988.

The estimates for 1990 assumes that the population seekingtreatment as a private individual remains constant.

6 Catholic University of Chile "Muestra de 30 Municipalidades.Evaluación de los Traspasos".

7 Source: Superintendency of ISAPRES.Data for 1986-1990 as of December 31 of each year. Data for 1991 as of June30.

8 The years which do not fit intothe historic trend, 1981 and 1982, was a time in which expenditures in theindustry rose extraordinarily before falling during the recession, althoughthe decline was less than that of overall Internal Expenditures. Recoverycommenced in 1986 when spending reached levels higher than those of the1976-80 expansion reaching its maximum level in 1988.

9 The Per Capita Beneficiary Expenditureis the ratio of Public Health Expenditures over the Beneficiary Populationin the public sector.

10 Revista Médica de Chile113. Drs. Ernesto Medina and Ana María Kaempffer and Mr. FranciscoCumsille, "La Atención de Salud en la Región Metropolitana:Comparación de las Encuestas de 1977 y 1983".

11 Source: University of Chile. M.Soledad Fuenzalida Puelma and Alicia Pincheira Muga, "La ComunicaciónMédico-Paciente y su Relación con la Atención Médica.Un Análisis Sociológico en el Sistema Estatal Privado".1983. Thesis for degree in sociology.