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Enhancing the Political Feasibility of Health Reform: the Chile Case

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Enhancing the Political Feasibility of Health Reform: the Chile Case 40 Enhancing the Political Feasibility of Health Reform: The Chile Case Enhancing the Political Feasibility of Health Reform: The Chile Case Alejandra González-Rossetti, M.Sc., M.P.A. Harvard School of Public Health Tomas Chuaqui, Profesor Adjunto Instituto de Ciencia Política Pontificia Universidad Catolica de Chile Consuelo Espinosa Independent Consultant Santiago, Chile June 2000 This publication was produced by the Data for Decision Making (DDM) project, which is funded by the U.S. Agency for International Development under Cooperative Agreement No. DPE-5991- A-00-1052-00 with the Harvard School of Public Health. It was done in collaboration with the Latin America and Caribbean Regional Health Sector Reform Initiative, funded by USAID under Contract No. HRN-5974-C-00-5024-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. TABLE OF CONTENTS ACRONYMS................................................................................................................................... ii ABSTRACT.................................................................................................................................... iii Introduction ............................................................................................................................ iii Political Economy Context .......................................................................................................... 1 Policy Process........................................................................................................................... 2 Change Team and other Political Strategies ............................................................................ 3 INTRODUCTION............................................................................................................................ 6 POLITICAL ECONOMY CONTEXT .................................................................................................. 8 1. Introduction ......................................................................................................................... 8 2. Regime Composition and General Ideological Framework .................................................. 9 3. Institutional Organization of The Regime.......................................................................... 13 4. 1973-1980: THE ODEPLAN YEARS: ..................................................................................... 17 5. 1980-1989: FROM OPTIMISM TO CRISIS AND REBIRTH..................................................... 26 6. DEMOCRATIC TRANSITION: CHANGE AND CONTINUITY................................................... 32 POLICY PROCESS ........................................................................................................................ 34 1. Introduction ....................................................................................................................... 34 2. Reform Description ............................................................................................................ 34 3. Policy Process..................................................................................................................... 40 4. Conclusion: Key Policy Nodes and Actors........................................................................... 58 THE CHANGE TEAM AND OTHER POLITICAL STRATEGIES......................................................... 64 1. Introduction ....................................................................................................................... 64 2. Change Team Characteristics ............................................................................................. 64 2. Change Team Political Maneuvering .................................................................................. 76 2. Change Teams Process Strategies ...................................................................................... 85 5. Corollary: A Change Team During the Democratic Transition ........................................... 92 6. Conclusions ........................................................................................................................ 94 ANNEX ........................................................................................................................................ 97 REFERENCES............................................................................................................................. 100 References - Chapter II ......................................................................................................... 100 References - Chapter III........................................................................................................ 103 References - Annex I............................................................................................................. 105 i ACRONYMS Acronym Spanish English Translation Sector SEGPRES Secretaría General de la Executive Office of the Presidency Public Presidencia SNS Sistema Nacional de Salud National Health System Public SO Seguro Obrero Pension and Health Care Plan for Public Blue-collar Workers SNSS Sistema Nacional de Servicios National System of Health Services Public de Salud SERMENA Servicio Médico Nacional de White-collar Workers Medical Public Empleados Service MINSAL Ministerio de Salud Ministry Of Health Public SS Servicios de Salud Health Services Public/Regional CM Colegio Médico Medical Association Professional Association COAJ Comité Asesor de la Junta Advisory Committee for the Junta Public COAP Comité Asesor de la Advisory Committee for the Public Presidencia President ISAPRE Intitución de Salud Private Health Plan Private Previsional AFP Administradora de Fondos de Pension Funds Third Party Private Pensiones Administrator SERPLAC Secretaría Regional de Regional Office of Planning and Public/Regional Planificación y Coordinación Coordination ODEPLAN Oficina Nacional de National Office of Planning Public Planificación DIPRES Dirección de Presupuesto, Office of the National Budget, Public Ministerio de Hacienda Ministry of Finance FONASA Fondo Nacional de Salud National Health Fund Public OPLAP Oficina de Planificación y Office of Planning and Budget, Public Presupuesto, Ministerio de Ministry of Health Salud DFL Decreto con Fuerza de Ley Executive Decree DL Decreto Ley Act ANEF Asociación Nacional de Civil Servants Association Union Empleados Fiscales CEPCH Caja de Empleados ? Particulares de Chile FENATS Federación Nacional de National Federation of Health Union Trabajadores de la Salud Workers ii ABSTRACT INTRODUCTION For almost two decades now, several countries in the Latin America Region have embarked in a period of State reform with consequences for their social, political and economic spheres. In the case of the health sector, while there has been increasing consensus among policy makers, providers and users about the need for structural change, there has been no similar understanding on the content of a health reform agenda. The definition of the problems to be solved, the means to solve them, as well as the speed and scope of policy change continue to be contentious issues, as they each affect the interests of different groups and individuals. As a result, the political dimension of health reform formulation and implementation has come to the foreground as it has proven to be a key factor in determining the feasibility of health policy change as well as its final outcome. The Chilean health reform implemented in the early 80’s has brought the attention of academics and policy makers alike. Although the fact that it took place under a military regime makes it an exemption in the Region, the Chilean reform process has been emulated to some degree or another, both in process and content. Discussions about the effectiveness and appropriateness of the strategies used by the team of reformers in contexts with more open political systems have not reached an end, and continue to influence on going policy processes. The careful analysis of the political context and the policy process within which health reform initiatives evolved in Chile, as well as of the actors involved, hopes to bring to light important lessons about the political strategies that have been put in motion by policy makers elsewhere in the Region interested in increasing the political feasibility of current health reform efforts. iii POLITICAL ECONOMY CONTEXT The study of any aspect of the various socio-economic reforms which were carried out during the 70s an 80s in Chile must take into consideration the institutional context within which these reforms were formulated and implemented. There is widespread agreement that a fundamental factor in successfully bringing about the quite sweeping reforms of the period was the fact that Chile was governed by a military regime which was able to present itself as a cohesive unit. It must be stated at the outset, however, that the military regime’s cohesiveness was only apparent, and that reform policy proposals had to go through a quite strenuous process of discussion and alteration within the state apparatus before they reached final form. It is indeed one of the greater successes of the military government that it was able to appear to its opponents outside of the state apparatus as a "monolithic, fissure-less entity." One of the factors which contributed to this appearance of lack of disagreement within the government was the fact that
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