Argentina's mid-term congressional elections on 22 October strengthened president Mauricio Macri's centre-right coalition, which outperformed expectations by winning seats in 13 out of the country's 23 provinces. With the government's mandate boosted, Macri's pro-market reform plan is likely to gain traction. Addressing the nation on election night, Macri renewed his commitment to push on with the agenda, which – alongside labour and tax reforms – includes a revamp of the public healthcare system. Although announced back in 2016, the ambitious project has proven to be more difficult to implement than anticipated, with little progress made in over a year. Things seem to have accelerated, however, when two weeks before the election the Ministry of Health (MoH) announced the rollout of a local pilot of the scheme in Guaymallénm, a department of the Mendoza province. Days after the vote, Macri also appointed a new health minister, Adolfo Rubinstein, following the forced resignation of Jorge Lemus. So what exactly is on the cards for the public healthcare system in Argentina?
Universal Healthcare Coverage finds not-so-universal support
In August 2016, Macri unveiled his Plan for Universal Health Care (Cobertura Universal de la Salud, CUS) with the aim of providing healthcare coverage to the estimated 15 million people not affiliated to workers' unions insurance funds (obras sociales) or private insurance schemes, who rely on public hospitals for healthcare. Although the government already provides free-of-charge access to public health facilities and subsidised medicine programmes, there is a heavy focus on curative care and a lack of a co-ordinated structure. Key elements of the new plan, according to the MoH, include: the strengthening of primary care; creation of digital patient records, including clinical history, with improved information sharing across services; and enhanced access to services and medicines, including electronic prescriptions and remote health services (telemedicine). Another key issue that the MoH has vowed to tackle is "double coverage", occurring when insured individuals access public health services free of charge. Once improved monitoring is in place, the cost of treating insured patients in public hospitals will be charged to their obra social or private insurance provider.
After the reform appeared to be stalled for over a year after it was first revealed, the launch of the Guaymallén pilot was announced by health minister Jorge Lemus as the "kick-off" of what he described as a "change of paradigm" for the provision of healthcare in the country. However, a national roll-out of the system across the 23 provinces promises to be a challenging task, not least because opinions on it are largely divided. According to the MoH, the scheme's aim is to ensure that "all individuals, especially those most vulnerable, have access to quality services whenever they need them during their whole life (…)". Yet some in Argentina see the plan as a disguised attempt to scale back the public provision of healthcare by limiting access to state-funded services. These feelings are perhaps best summarised in statements recently made on TV by a representative of the Health Workers Union of Buenos Aires, who said that the reform "does away with health as a universal right and turns it into a market commodity (…). You will get your health as long as you can pay". Along with other organisations, the Union is planning a national march on December to protest against the reform and in "defend the public health system". The statements were made after the 22 October elections, when it became clear that the election boost would likely prompt the government to accelerate the reform.
HTA agency faces hurdles in Senate
While cost-containment does no feature much in official communications about the reform – beyond the issue of "double coverage" – it is no doubt a large part of the rationale behind it. Along with plans to establish a universal healthcare system, in 2016 president Macri also proposed the creation of a national agency for health technology evaluation (AGNET), tasked with the systematic evaluation of state-funded technologies, including drugs, in terms of cost-effectiveness. Currently, the Superintendency of Health Services is responsible for drawing up the Mandatory Medical Plan (PMO) that defines the minimum compulsory coverage that providers in all sectors of the healthcare system must ensure, including a national formulary of essential medicines. Officially, the creation of AGNET would "facilitate access to high-cost medicines that bring therapeutic value", but opponents of the proposal fear it will lead to costly treatments being excluded from reimbursement. As with the healthcare reform, critics of AGNET have accused the government of attempting to reduce health coverage, which is enshrined in Argentina's constitution as a basic right. Compared to the core public healthcare reform, much less progress has so far been made with respect to this proposal – a bill creating the agency has been stuck in Senate, where still no party has a majority even after the recent election. If the draft law is not adopted this year, it will automatically lose parliamentary status and will have to be presented again in 2018 for a new debate in the Senate committees. Should the government not be able to push the bill through, there have been media reports that president Macri is considering issuing a presidential decree to create the agency (which would most probably require retroactive congressional approval).
President appoints new health minister
Just days after the election, president Macri accepted the resignation of Jorge Lemus and appointed Adolfo Rubinstein as Argentina's new health minister. Although Rubinstein – previously a vice-minister – is not exactly a newcomer, his appointment is nevertheless a sign that the president is keen to see change happen more quickly. The resignation of Lemus, who had been health minister since 2015, appears to have been positively received by the health sector in Argentina. Elías Hurtado Hoyo, the president of the Argentine Federation of Health Professionals (FESPROSA), stated that Lemus "did nothing but regress the public [health] system" during his 22 months in office. Lemus has faced criticism regarding the MoH's response to a dengue fever outbreak last year and the management of various public health programmes. Some media reports have also suggested there was tension over the implementation of the healthcare reform, with Lemus allegedly frustrated over his lack of say. The ousting may perhaps have happened sooner, were it not for the personal relationship shared by Lemus and Macri, who have known each other for years. Lemus not only attended Macri's wedding, but famously saved his life during the event when the future president decided to surprise his bride with a Freddy Mercury imitation that went terribly wrong. While vigorously performing a Queen number, Macri swallowed part of his fake moustache and collapsed, unable to breathe. Fortunately, Lemus was quick to apply his first aid skills and saved the day.
Loyalties aside, however, the president was not going to waste the favourable political climate to make cabinet changes that he felt would help advance the reforms. The new health minister – who will assume the role officially on 20 November – has already stated that the public healthcare reform is the ministry's top priority. The zeal will be needed, as the task will require close cooperation with other parts of the government involved in the project, mainly the Ministry of Employment, as well as provincial authorities, and opponents of the plan have not had their last word either. As for AGNET, in an interview after his appointment Adolfo Rubinstein made it clear that he sees the creation of the agency as integral to the reform. Overcoming opposition on this front may be a bigger test for the MoH and Macri – and if they succeed, it promises to have major consequences for the pricing and reimbursement of drugs in Argentina.
Ewa Oliveira da Silva is a Research Analyst with the Life Sciences group at IHS Markit
Posted 13 November 2017