A black hole is a finite region of space within which there is a concentration of mass high enough to generate a gravitational field such that no material particle, not even light, can escape from it.
The gravity of a black hole, or “space-time warp”, causes a singularity surrounded by a closed surface, called the “event horizon”. This is predicted by Einstein’s so-called “field equations”. The event horizon separates the region of the black hole from the rest of the universe, and once inside it, no type of particle, material or electromagnetic, can leave, not even photons.
If we make a parallel with this conjecture, the same thing that the theory states occurs with the funds that enter the Argentine health system. And the term “event horizon” might be equated to patches being developed in a system that has increasingly less coverage for patients, underpays doctors and faces serious financing problems.
In May 2021, the World Health Organization (WHO) formed the Council on the Economic Aspects of Health for All.
This new institution aims to reframe health for all as a global goal and to ensure that national and global economies and finances are structured to meet that goal. The idea is to determine new formats for measuring and assessing health for all, guaranteeing that financial systems invest in creating health.
The ambitious challenge will require a transformation of health financing, viewing it not as a cost, but as a long-term investment in favor of a “healthy society” and confirming the fundamental truth that health and the economy are interdependent. .
In the same sense, the WHO suggested as a goal following the pandemic that nations allocate 6% of their gross domestic product (GDP) to health.
Argentina spends an average of 9.4% of its GDP in the area, if we take the last decade as data. 2.7% of GDP corresponded to the public sector, mainly the provinces, which is consistent, since the largest number of providers is in the provincial sector.
However, public spending should exceed six points of GDP and in our country it does not reach 3%. International experience indicates that the countries with the highest level of equity in health are those whose expenditures in this area exceed 6% of GDP only in the public sector.
With regard to Argentina, it must be taken into account that not all provinces have the same infrastructure; therefore, the Nation should achieve greater equity and greater development in each jurisdiction. There is a great fragmentation in this sense.
But, in addition –and this is perhaps the distinctive characteristic of our health system and part of the causes that can be related to the concept of black hole–, there is a total lack of control of the funds delegated in the so-called “social security ”, mostly union social works that approximately handle regarding 3% of health spending. This denotes a significant lack of control over spending.
The obras sociales have serious sustainability problems and the Executive Branch included a new budget line to transfer more than $150 billion to them to cover their expenses on disability and other indecipherable items.
However, nothing is said regarding the fact that 70% of the nearly 300 trade union obras sociales are very small and have unstable risk funds, which makes them unfeasible from the performance and financial point of view. But since they are political boxes of the unions, they continue to be subsidized without any substantive measure being taken
It is estimated that the remaining 3.8%, approximately, is spent by families. This includes the purchase of medicines, facing copayments and coinsurance, the acquisition of services directly or adherence to some type of prepaid medical plan.
Unfortunately, there is no direct relationship between spending and results. Therefore, it is necessary to consider other aspects, such as the relationship between income per capita and level of access to health. Among other causes, we can underline the lack of system integration.
At the provincial level, the Autonomous City of Buenos Aires is the one that spends the most of its public budget (almost 20%). Caba has its own financing for this through the Gross Income Tax (almost 62% of the total budget).
As far as the Province of Buenos Aires is concerned, it is the jurisdiction that spends the least in terms per capita.
On the other hand, social security spending, mainly from Pami, is stipulated at 0.9% of GDP, which means that the social work for retirees and pensioners is practically an unfeasible entity in actuarial terms. Pami is a problem, since they try to give retirees everything possible, and this is impossible.
The situation of the system is very serious. Many medical specialists in the private sector, who care for nearly 60% of the population that has social or prepaid insurance plans, withdraw from the system, and some emigrate abroad, fed up with a permanent and unresolved crisis situation.
This is deepened if we add the low and outdated fees that private clinics and sanatoriums receive and the unsustainable payment terms in the context of an inflationary economy and with volatility in exchange matters. This has a direct impact on the lack of care, delays in appointments and waiting lists, as direct consequences of these structural asymmetries.
In summary, the doctors’ crisis, the increase in prepaid fees, the obscene underfunding of union social security projects, and the increase in the price of medicines and supplies – product of inflation and exchange rate volatility – describe the consequences of an explosive cocktail , with prospects of serious problems by 2023.
It is time to incorporate the debate on health financing and the administration of these funds in an effective and transparent manner. This should be a critical issue on all the agendas of those who intend to govern the next term in our country.
Of course, the challenge will be to approach it with political determination, technical ability and a true conviction that we must end Einstein’s field equations, the event horizon that causes enormous amounts of funds to go down a black hole without any control and threatening public health and the quality of life of the population.
* General Secretary of the Chamber of Ophthalmological Medicine
