Ernesto Báscolo presenta el proyecto Desarrollo y aplicación del Marco Analítico de Gobernanza a los procesos de implementación de políticas de extensión de la protección social en salud en Latinoamérica, desarrollado entre mayo de 2007 y mayo de 2011 en tres municipios de Argentina y dos de Bolivia. Su objetivo principal fue elaborar un marco analítico de gobernanza para los procesos de implementación de políticas y Atención Primaria en Salud (APS), utilizando el abordaje Investigación Acción Participante (PAP) como metodología. El estudio comprendió cuatro fases: 1) contextualización; 2) caracterización de los servicios de salud; 3) evaluación de servicios de APS del punto de vista de poblaciones vulnerables; y 4) análisis de gobernanza de las políticas de APS. Entre los resultados, se observó diferentes cambios entre los países. En Bolivia, por ejemplo, hubo cambios formales, que no resultaron en cambios prácticas, dado que los profesionales estaban comprometidos con el status quo. Por otro lado, en Argentina, los servicios se nutrieron con el discurso sanitarista brasileño, contrariando las reformas que ocurrían en el propio país. Esta presentación es parte del Taller sobre la Gobernanza de la Salud, del Ambiente y del Desarrollo Sustentable, organizada por ISAGS en conjunto con IDRC, de Canadá. Ernesto Báscolo presents the project Development and application of the Governance Analytical Milestone for the implementation processes of the social protection expansion policies in health in Latin America, developed between May 2007 and May 2011 in three municipalities of Argentina and two of Bolivia. Its main objective was to prepare one governance analytical milestone for the implementation processes of policies and Primary Health Care (PHC), by using the Participatory Action Research (PAR) approach as methodology. The study comprised four stages: 1) contextualization; 2) characterization of the health services; 3) evaluation of APS services from the point of view of vulnerable populations; and 4) analysis of governance of APS policies. Among the results, we noted different changes between countries. In Bolivia, for instance, there were formal changes, which did not result in practical ones, since professionals were committed to the status quo. On the other hand, in Argentina, the services were strengthened by the Brazilian sanitarian discourse, opposing to the reforms that occurred in their own country. This presentation was part of the Workshop on Governance of Health, Environment and Sustainable Development, organized by ISAGS in partnership with the IDRC, from Canada.

1. CENTRO DE ESTUDIOS
INTERDISCIPLINARIOS
PHC governance and performance in Latin
America: methods, results and lessons learned
from a research experience funded by IDRC
Ernesto Báscolo y Natalia Yavich

2. Estructura
A) una síntesis del proyecto: objetivos y conclusiones.
B) ¿en qué medida y de qué forma el proyecto promovió el análisis, diseño y/o
implementación de una respuesta intersectorial a los determinantes
sociales y ambientales de la salud?
C) un análisis de las características más relevantes del proceso de gobernanza
de la experiencia presentada, teniendo en cuenta las dimensiones
analíticas e interrogantes antes reseñadas;
D) En relación con lo anterior, una reseña sobre cómo el proyecto armonizó o
podría vincular la gobernanza del nivel local con los niveles estatales-
provinciales y con el nacional (y sus implicancias para la replicación e
influencia en políticas públicas)
E) ¿cuál fue la estrategia del proyecto para difundir la investigación a
tomadores de decisión y actores sociales, con el propósito de facilitar el uso
de los resultados? ¿Cómo y cuándo se involucraron los actores no
académicos?

3. Una síntesis del proyecto: objetivos
y conclusiones.
• Desarrollo y aplicación del Marco Analítico de Gobernanza a los
procesos de implementación de políticas de extensión de la
protección social en salud en América Latina. Project Nro. 103998-
001.
• IDRC officers: Roberto Bazzani (Uruguay); David Zakus (Ottawa);
Marie-Gloriose Ingabire (Ottawa).
• Responsible Institution: Instituto de la Salud Juan Lazarte, Rosario,
Argentina
• Collaborator institution: Instituto para el Desarrollo Humano,
Cochabamba, Bolivia
• Period: May 2007 to May 2011.
• Support: IDRC; Instituto de la Salud Juan Lazarte, Municipalities,
Agencia Nacional de Ciencia y Técnica.

4. Project overview
• Rationale
Weaknessess of policies implementation in Latin American health
systems due to issues of governability, fragmentation,
descentralization → Governance analysis give as clues for
intervention and enhance the comprehension of the policy results.

5. Project overview.
Purpose, objetive and methodological approach
• General purpose
Contribute to enhancement of social protection in health policies implementation
and development.
• General Objetives
– Enhance the comprehension of the factors and procesess that
affects the effectiveness of the policies based on PHC strategies in
Latin America (and how these aspects affect the effectiveness).
– Develop a governance analytical framework to study those
procesess.
• Methodological approach
PAR as the umbrella methodological apprach.
Design: Multiple-case study → Argentina 3 municipalities (2 Provinces)
Bolivia 2 municipalities (1 Department)

6. Case studies phases
• Contextualization: political, socio-economic,
health status, health system structure and
policies.
• Health care services characterization (focus
on primary care level)
• Evaluation of primary health care services
performance from the point of view of the
most vulnerable population.
• Governance analysis of the PHC policies.

7. Methods and activities
2007-2009: started the pilot case: Rosario (Santa Fé Province).
Design of tools and theorical exploration.
Secondary data collection
Primary data collection
Analysis
2008-2010: started with other 4 cases: 2 in Argentina and 2 in
Bolivia.
Tools review and adaptation for Bolivia and
Buenos Aires.
Secondary data collection
Primary data collection
Analysis
2010-2011: Health system perspective reseach
Tools design
Primary data collection
Secondary
(health
accounts) data
collection
Analysis
Results presentation to policy makers and technical teams - Meeting with managers - Workshop with practitioners –

8. Socio-economic and demographic context
Socio-economic and demographic
indicators
% population Child mortality
Municipality % Population
structural rate
without
Population poverty
health
(unmet basic
insurance
needs)
Argentina 36.260.130 17,7 48,05 13,3 (2007)
Rosario 909.397 13,5 39,12 11,5 (2008)
Gral San Martín 403.107 13,0 48,30 9,2 (2008)
Vicente López 274.082 4,8 27,22 9,7 (2008)
Bolivia 8.274.325 58,6 70,9 44, 78 (2008)
Cochabamba 517.024 33,8
Quillacollo 104.206 30,8 75,1 48,09 (2008)

9. Context – Health services network and resources
Estructura de Servicios Pública
N° of
N° of primary % Budget
Health
Heal level allocated to health
centers
Municipality th physicians N°. of expenditure
per
Cent per hospi (public sub-
10.000
ers inhabitants tals system).
inhabitant
N° without
s without
insurance
insurance
Argentina 10,1 del PBI (2006)
Rosario 81 2,28 1,417 14 30.07 (2007)
Gral San Martín 19 0,98 0,729 4 22.53 (2007)
Vicente López 20 2,62 1,194 6 32.03 (2007)
Bolivia 6,6 del PBI (2006)
Cochabamba 28 0,72 0,27 5 7.75 (2007)
Quillacollo 7 0,89 0,191 1 7.9 (2007)

10. Household survey / Organizacional census of HC
Vicente Gral. San Quillaco- Cochabam-
Rosario López Martín llo ba
Municipio n=450 n=450 n=450 n=460 n=450 Mean
Children that didn’t
receive care in the last
12 months 4,7 9,1 4,0 30,7 28,2 15,3
Children that used
primary health
services 57,8 49,7 47,1 19,0 44,4 43,6
Rate of medical
consultation in primary
health services 4,4 3,9 3,3 0,5 1,7 2,8
General rate of
consultation 7,6 7,9 7,1 2,8 3,8 5,8
Needed Needed
Prefer to urgent or urgent or No conocía No conocía
Why didn’t use the use it SS specialized specialized el CS de su el CS de su
NHC (main chosen insurance care care barrio barrio
response)? 19,6% 28,1% 22,3% 50,4 42,5%
Average of semanal
office hours 59,3 46,9 45,4 35,3 46,9 46,8
% multidisciplinary
teams in the HC
network 83,3 60,0 75,0 28,6 57,1 60,8

11. Evolución de la cantidad de CS a medida que crece la
población
0,800
C a n tid a d d e C S p o r
0,700
0,600
Vicente López
cada 10000
h a b ita n te s
0,500
0,400
General San Martín
0,300 Cochabamba
0,200 Quillacollo
0,100
0,000
76
78
80
82
84
86
88
90
92
94
96
98
00
02
04
06
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
Años

12. Until 1990 1990‐1994 1994 ‐ 2000
Rosario
Secretaria Secretaria
Secretaria
PHC
Hospital PHC
Hospital Direction
Hospital
Direction
Health Social
Post Health Social Center Organizations
Center Organizations
Health

13. 2000 ‐ 2004 2004‐2007 1994 ‐ 2000
Rosario
Secretaria
Secretaria
Secretaria
Hosp PHC Hosp
PHC
Hosp Direction Dtion Direction
PHC Dtion
Direction
Dtion
Cemar Cemar
Cemar
Hospital Hospital
Hospital
Health Social
Health Social Organizations
Health Social Center
Center Organizations
Center Organizations

14. Until 1990 1990‐1994 1994 ‐ 2000
Vicente
Lopez Intendente Intendente
Secretaria Secretaria
Secretaria
Hospital
PHC
Hospital Hospital Direction
PHC
Direction
Social Post Social Social Health
Health Organizations
Organizations Health Organizations Center
Center

15. Until 1990 1990‐1994 1994 ‐ 2000
Cochabamba SUMI.
Ministerio Ministerio Program
Municipio Sedes Municipio Sedes Municipio Sedes
Hospital
Hospital Hospital
Comunity Post Comunity Post Comunity Post
Health Health Health

16. 1990-1994
PAHO guides, promoted,
legitimized and implemented in
provincial health servicesf Santa
Fe).
C) un análisis de
las
características
más relevantes
New professionals located in the PHC
department and inserts in general Based on vertical programs, implemented
medical specialization in relationships
with social movements. .
in HC, with guidance oriented to mothers
and children health in order to improve del proceso de
the access conditions and improve ties
Structure Formal de
PHC.
with the community gobernanza de la
New HCscreation. experiencia
presentada,
teniendo en
Autonomy most influential of
the PHC department.Conflict
cuenta las
for compliance about
schedules and standards of dimensiones
care in the HC.
analíticas e
interrogantes
Management and
health care norms in antes reseñadas;
the HC.
New prevention
practices in HC.

17. 1994 - 2000
The influence from the Brazilian
sanitarian movement, through
academic (cognitive) activities Focused on strengthening the first level
with health teams. as a healthcare system reform strategy,
and considering professional
involvement and social movements as
PHC attributes
Health teams of HC, and
technical and political
personnel of the
department conducting
PHC, with alliance with 1) GPs and hospital
social movements. specialists for incumbency
of medical practices, and 2)
HCs creation with an expanded between PHC department
coverage in time and health team and other health secretary
(general, pharmacists,
agencies because the PHC
psychologists and social
workers).New decentralized growing influence in the
management structure in the municipal health policy
PHC department with zonal
districts, and management
collegiate models.
Expansión de las
prácticas de primer
nivel de atención.

18. 2000-2004
The local process resists pressure from the Santa Conflicto con las
Fe Ministry of Health to implement a PHC (WB lógicas impuestas
por el nivel
funded), with a logic of minimum package of
provincial.
benefits for primary care and economic incentives. PHC perspective as strategy to
coordinate the healthcare
system.
Equipos del primer nivel,
gestores y movimientos
sociales.
New diagnostic and practice
ambulatory org, with a key role in
the second health care level and in
Menor conflicto por la
the coordination role of the Regulación y gestión del acceso a los
legitimidad ganada en
healthcare system. servicios de salud desde el primer nivel períodos anteriores
de atención, con participación de
organizaciones sociales

19. 2004-2007
The leadership of the health secretary
is legitimized from the support of
PAHO, taking the Rosario case as a PHC
case emblematic of an integrated and
integral healthcare system.
PHC logic as a coordination strategy
health care system in order to build a
Interaction between the HCs managers, district network of health services.Clan model
coordinators and managers from different health is mixed with regulatory
organizations to improve continuity of care.Low
participation and influence of social movements.
It extends the management participation in
districts (decentralized territorial spaces), with
managers and professionals of all healthcare
organizations.
Wage claims conflict
between driving health
department professionals
Patients are "decentralized" (from
(HCs and hospitals), which
hospitals to care in HCs). 2. Health
weakens the alliance said
teams of HCs manage access to
the development process
diagnostic services and specialists.
of PHC in the municipality.

20. ¿en qué medida y de qué forma el proyecto promovió el análisis,
diseño y/o implementación de una respuesta intersectorial a los
determinantes sociales y ambientales de la salud?
A través del análisis de:
1) los actores involucrados.
2) las innovaciones organizacionales
producidas, qué tipo de prácticas
realizadas y en qué tipo de
organizaciones.
3) sus efectos sobre las condiciones de
acceso a los servicios.

21. D) Sobre cómo el proyecto armonizó o podría vincular la gobernanza del nivel
local con los niveles estatales-provinciales y con el nacional (y sus implicancias
para la replicación e influencia en políticas públicas)
Vicente Lopez Bolivia (Cochabamba y
Rosario Quillacollo)
Actores estratégicos Liderazgo locales con Actores con influencia en la
con mayor influencia definición de qué tipo de lógica formulación de la estrategia
se introducen los casos nacional.
Mecanismos Cognitivos y valores Regulatorios vinculados con las
institucionales incorporados en actores reformas nacionales
utilizados para estratégicos.
Dimensión influencia Actores estratégicos locales Modos de gobernanza
por el nivel impultados
nacional/provinical
Respuesta local De reacción (oposición) o Aceptación y rechazo solapado.
acepción dependiendo del caso
y etapa.

22. E) ¿Cuál fue la estrategia del proyecto para difundir la investigación a
tomadores de decisión y actores sociales, con el propósito de facilitar el uso de
los resultados? ¿Cómo y cuándo se involucraron los actores no académicos?
• Learning through previous project.
• Importance of early involvement of
stakeholders and articulation of the knowledge
process between diferent “logics”

23. Disemination: strategies based on product adapted
to users and contexts
• New products tailored to policy makers:
Newsletters, (paper and virtual),
dissemination in the media (radio, television,
newspapers), virtual forums.
www.aps-gza.com.ar

24. Product Innovations: media
Newpapers Radio
Television

25. Change in the logics of the
knowledge processnocimiento
Innovations in:
• Actors
– Issues
• Methodologies
– Exchange spaces
2010
Decision making
processes in health Human resources
services management training
Reseach on policies and
health services
management
2011

26. Innovations in actor roles to
promote knowledge exchange
Human Resources
Decision making Decision makers training
processes in health integration as
services management lecturers
Proffesors
involvement in the
Decision makers
research activities
integration in
and researchers
research
involvement in
activities
teaching
Policy and Health Services
Management research

27. Innovations in actor roles to
promote knowledge exchange
Human resources
Decision making Decision makers training
processes in health integration as
services management lecturers
Proffesors
involvement in the
Decision makers
research activities
integration in
and researchers
research
involvement in
activities
teaching
Policy and Health Services
Management research

28. Management tools
design (evaluation)
Subjetcs linked with the
contexto, governance Human resources
Decision making and performance training
processes in health evaluation
services management
Integration of subjetcs Research findings
liked with the context, integration.
governance and
performance
development.
Policy and Health Services
Management research
Innovations in subjects to promote
knowledge exchange

29. Innovations en los abordajes y
metodologías
Tutorial guides Human resources
Decision making and intervention training
processes in health focused thesis.
services management
Integration of the
Problems identification theorical and
and analysis methodological
workshops approaches used
in the research.
Policy and Health Services
Management research

30. Virtual space
(Laboratory
of
Decision making Management Human resources
processes in health innovations) training
services management
Conferences
and forums
(face to faces
. New Reseach and virtuals) Researches and
findings proffesors workshops
“Laboratory of Class as a data
presentation for exchange of
Management colection source,
and methodologies and
Innovations” analysis and
discussion knowledge
findings
management validation.
board
meettings
Policy and Health Services
Management research
Innovations in the exchange
spaces

31. Some lessons learned from KT
strategies
• If KT can turn into a component of the
governance model, KT mechanisms are
more effective.
• Nevertheless, it’s necesary a huge
integration decision makers and research
producers effort to integrate different
logics (actors, subjects, methodologies
and exchange space).

32. ¡Thank you!
Ernesto Báscolo
Email: ebascolo@gmail.com