This document discusses the challenges of running public hospitals in Argentina. It provides statistics on poverty, inequality, demographics, mortality rates, and health spending that demonstrate the context facing the public health system. It then describes the management of the Ramos Mejia Hospital in Buenos Aires, including its services, staffing, and approaches to clinical, administrative, and financial management. Challenges include integrating different sectors, technology distribution, staff concentration, and drug spending.

1. Challenges and opportunities of
running a public hospital in
Argentina
Cdra. Teresita Cecilia Durañona Sanabria
Lic. Ariel Mario Goldman
2014
Ramos Mejía Hospital

2. Economics
Evolution of the poverty and indigence. 1988 – 2010
Source: U.C.A. and INDEC graphics
http://noelmaurer.typepad.com/aab/2013/04/-observatorio-argentino-19-poverty-in-argentina.html

3. Economics
Inequality. Distribution of family labor income equivalent. Share of deciles and
income ratios. 2004-2010
2004 1,0 2,2 3,4 4,6 6,0 7,6 9,7 12,5 17,7 35,2 36,7
2005 1,1 2,4 3,6 4,8 6,0 7,6 9,6 12,4 17,2 35,4 33,2
2006 1,1 2,5 3,7 4,9 6,3 7,9 9,8 12,7 17,4 33,9 31,7
2007 1,2 2,6 3,8 5,1 6,3 7,8 10,0 12,9 17,5 32,9 27,8
2008 1,3 2,8 4,0 5,2 6,5 8,1 10,1 12,9 17,3 31,8 24,7
2009 1,3 2,8 4,0 5,2 6,6 8,1 10,1 12,9 17,4 31,6 24,6
2010 1,3 2,8 4,1 5,4 6,7 8,2 10,1 12,8 17,2 31,3 24,5
Share of deciles Deciles
1 2 3 4 5 6 7 8 9 10 10/1
Source: CEDLAS and World Bank. http://cedlas.econo.unlp.edu.ar/esp/pantalla.php?
seccion=estudios_especiales&idP=88

4. Demographics
Population pyramid. Argentina Republic 2010
Source: INDEC. Censo Nacional de población. Hogares y viviendas 2010
Population pyramid. Buenos Aires City 2010

5. Health
Source: INDEC, Dirección de Estadísticas Sectoriales en base a información suministrada por
el Ministerio de Salud de la Nación, Dirección de Estadísticas e Información de Salud (DEIS).
Age group (years)
Mortality rate per thousand population
1980 1990 2000 2006 2007 2008 2009 2010 2011
Total country 8,6 8,0 7,5 7,5 8,0 7,6 7,6 7,9 7,8
Under one year 33,2 25,6 16,6 12,9 13,3 12,5 12,1 11,9 11,7
1 to 4 1,5 1,1 0,7 0,6 0,6 0,6 0,5 0,5 0,5
5 to 14 0,5 0,3 0,3 0,3 0,3 0,3 0,3 0,3 0,3
15 to 24 1,0 0,9 0,9 0,8 0,8 0,9 0,9 0,9 0,9
25 to 34 1,5 1,2 1,2 1,0 1,1 1,1 1,1 1,1 1,1
35 to 44 3,1 2,5 2,2 1,9 1,9 1,9 1,9 1,8 1,8
45 to 54 7,1 6,0 5,2 4,7 4,8 4,7 4,7 4,4 4,4
55 to 64 15,2 13,8 11,9 11,4 11,8 11,2 11,2 11,1 10,8
65 to 74 34,6 29,5 26,5 24,8 26,2 24,6 24,2 24,9 24,5
75 and over 102,8 100,8 91,5 88,0 95,4 87,6 86,5 92,2 90,6
Mortality rate per thousand population, by age group and sex. Total country.
Years 1980, 1990, 2000, 2006-2011

6. MOTHER´S
RESIDENCE
JURISDICTION
1990 2003 2004 2005 2006 2007 2008 2009 2010 2011
Argentina 25,6 16,5 14,4 13,3 12,9 13,3 12,5 12,1 11,9 11,7
C. de Buenos Aires 16,8 10,3 8,7 8,0 8,3 8,4 7,7 8,5 7,0 8,8
Buenos Aires 24,2 16,3 13,0 13,0 12,5 13,6 12,4 12,5 12,0 11,8
Catamarca 34,6 20,1 21,8 16,8 15,4 14,9 15,3 14,5 15,4 14,0
Córdoba 22,2 14,3 12,7 11,9 11,6 12,7 12,1 10,7 11,1 10,8
Corrientes 31,7 21,1 19,3 18,2 17,5 15,6 17,1 15,3 16,8 15,7
Chaco 35,8 27,7 21,3 19,9 18,9 21,2 18,0 17,8 14,7 11,4
Chubut 20,6 15,1 11,8 11,7 11,5 11,0 10,4 9,4 9,8 10,2
Entre Ríos 24,3 17,2 15,5 13,2 12,6 11,9 13,5 11,8 11,6 11,0
Formosa 33,2 25,0 25,1 22,9 24,2 22,9 19,2 20,5 17,8 21,2
La Pampa 22.2 12,7 14,6 11,4 10,0 11,8 14,9 13,7 7,0 10,4
Jujuy 35.8 19,2 17,8 16,1 17,0 15,2 14,0 11,5 13,4 12,9
HealthInfant mortality rate by jurisdiction
Source: Secretaria de Políticas, Regulación e Institutos. Dirección de Estadísticas e Información
de Salud. http://www.deis.gov.ar/Publicaciones/Archivos/Serie5Nro55.pdf

7. Health
MOTHER´S
RESIDENCE
JURISDICTION
1990 2003 2004 2005 2006 2007 2008 2009 2010 2011
La Rioja 28,8 17,3 18,2 13,8 14,1 12,9 15,0 14,6 12,6 16,5
Mendoza 21,1 11,1 13,5 11,3 11,9 11,3 10,8 9,9 11,7 9,7
Misiones 31,8 20,2 16,6 14,6 17,1 14,6 13,9 13,0 13,2 13,7
Neuquén 16,9 10,8 11,1 9,9 9,8 9,6 7,4 7,6 9,2 7,5
Río Negro 23,1 15,9 14,1 9,4 9,3 9,8 11,7 8,8 9,4 9,6
Salta 32,3 16,9 15,4 14,3 14,9 15,4 14,4 14,0 12,8 14,0
San Juan 24,4 19,6 16,4 16,7 14,0 13,2 14,4 11,0 11,0 9,9
San Luis 29,7 17,4 15,2 16,0 12,8 15,7 13,1 12,9 10,7 12,3
Santa Cruz 20,7 15,5 11,9 11,0 15,4 12,9 10,6 10,3 9,7 9,7
Santa Fe 28,3 13,9 12,0 12,4 11,0 11,6 11,5 11,1 10,3 10,8
Santiago del Estero 28,3 14,2 13,8 11,7 12,1 13,8 10,4 12,1 14,0 11,7
Tucumán 28,5 23,0 20,5 16,2 13,5 12,9 13,8 13,1 14,1 14,1
Tierra del Fuego 27,9 8,4 4,1 6,7 10,9 10,2 6,8 4,6 9,9 7,1
Source: Secretaria de Políticas, Regulación e Institutos. Dirección de Estadísticas e
Información de Salud. http://www.deis.gov.ar/Publicaciones/Archivos/Serie5Nro55.pdf

8. Health and Poverty

9. Health System
Sub - sector Public Social security Private
Funders Government +
others funders
National Social
Insurance + Province
Social Insurance + other
Law Social Insurances +
I.N.S.S.J.P. + Work Risk
Insurance
Private insurance
Providers Public hospitals +
primary health care
centers + GPs
Private health centers
and public hospitals
Private health
centers and
public hospitals
Regulators Nation, provinces
and municipalities
S.S.Salud + S. ART. S.S.Salud
Population in
charge
100% Workers and their
families
Clients
Others COFESA – COFELESA
Supportive Redistribution Fund

10. Health System
SpendingSpending
 Exclusive public subsector: 2.75% of GDP (28.50%)
 Social security subsector : 3.6% of GDP (37,.31%)
 Private subsector: 3.3% of GDP (34,20%) includes private
insurance, drugs and direct services
ResourcesResources
 Establishments with hospitalization : 3300 (1310 public subsector)
 Establishments without hospitalization: 14500 (6600 public
subsector)
 Beds: 153000 (80000 public subsector)
 Doctors: 120000 (1/1000) – nurses 82000
Estimated demandEstimated demand
 Exclusive public subsector: 42%
 Social security subsector: 47%
 Private subsector: 11%

11. Health System
 Emphasis on health recovery processes, instead of
promotion, prevention and rehabilitation.
 Lack of integration between sectors
 Unplanned incorporation and distribution of
technology. Emphasis on high complexity.
 Concentration of physicians, generating excess and
deficit depending on the region.
 Lack of nursery personnel
 Excessive spending on drugs

12. Public system Vs. Private system
 Efficiency: More
production with a fix
budget.
 Offer: Depending on
“physician power”
 Quality: Expectations of
competence,
bureaucracy and
discomfort
 Efficiency: Necessary
production, saving
money
 Offer: Depending on the
profit rate
 Quality: High
expectations of
competence, speed in
the answer and comfort

13. USA - Argentina numbers
Argentina EEUU
Population (in thousands) total 2012 WHO 41087 318000
Population proportion under 15 (%) 2012 WHO 24,42% 19,63%
Population proportion over 60 (%) 2012 WHO 14,97% 19,61%
Per capita total expenditure on health (PPP int.$) 2011
WHO
U$S
1.433,70 U$S 8.607,90
Per capita government expenditure on health (PPP int.
$) 2011 WHO U$S 869,40 U$S 3.954,20
General government expenditure on health as a
percentage of total government expenditure 2011 WHO 20,40% 19,80%
Total health expenditure (% of GDP) 2011 World bank 8.10% 17.9%
Life expectancy 2011 WHO 76 79
Infant mortality rate (per 1.000 live births) 2011 WHO 11,7 5,98
Maternal mortality ratio (per 100 000 live births) -
Interagency estimates 2011 WHO 77(67-87) 21 (18-23)

14. Public Hospital Health Management
Guarantee health right
Principles
 Holistic health concept
 Universal coverage of the
population
 Gratuity of the health services for
everybody
 Development of the primary care
strategy
Financing
State budget
Billing to social security and
private insurance
Mental Health Centres 2
Health Centres and Community Care 43
Neighbourhood Health Centres 35
Dental Centres 2
Levels
First Level: Cobertura porteña
Buenos Aires city public health system
Law 153: Buenos Aires city basic health law
Second and third level
Acute Care hospital 13
Specialized Hospital 20
Zoonosis Prevention and
treatment Institute 1

15. Public Hospital Health Management
Hospital General de Agudos J.M. Ramos Mejia
It was created in 1868 to give attention to the cholera epidemic patients and
give support to soldiers.
In 1914, the hospital was named in honor to Dr. Ramos Mejia as a
recognition of his work as a doctor
Nowadays
 404 beds
 2200 employees (temporary and permanent staff).
 Allergy, Cardiology, Internal Medicine, Dermatology, Endocrinology,
Physiotherapy, Phoniatrics, Speech Therapy, Gastroenterology,
Gynecology, Nephrology, Pulmonology, Neurology, Obstetrics,
Ophthalmology, Oncology, ENT, Proctology, Psychiatry, Rheumatology,
Orthopedics, Urology, General Surgery, immunocompromised,
Neurosurgery, Radiotherapy, Mental Health and pediatric medical specialties
Allergy Clinic, Dermatology, Neonatology and Traumatology.

16. Public Hospital Health Management
 Medical Management
 Clinical Management - Protocols for services
 Control through indicators
 Administrative Management
 Human resources – Central Ministry Management
– Unique hospital function: control of personnel
absenteeism
 Buying
 Expenditure recovery

17. Buying
Processes analyzed Virtues Deficiencies Observations
Competitive tendering
or bid in the hospital
Transparency
Budget Control
Opportunity
Efficiency Supply of common
and normal inputs
Acquisition through
emergency mechanisms
Efficiency Opportunity Transparency
Budget Control
Overuse
Purchases through the
Health Ministry with
stock
Budget Control
Efficiency
Opportunity Uncertainty
Purchases through the
Health Ministry without
stock
Efficiency Budget
Control
Opportunity
Opportunity Problems for single
supplier. Different
results
Petty Cash Efficiency Transparency Limited in amount.
Not always
available

18. Buying
 It doesn't exist a single ideal process, considering that in the practice all of
them show their virtues and deficiencies.
 The causes of the deficiencies are multiple, they involve all the participants and
the revision of the regulatory. It is necessary to have a specific set of purchases
processes for health.
 The health system is an "intensive labor system" where the 70% of the budget
are salaries. The emphasis in the purchasing system is on the public expenditure
control, suffering a lack of cost control per patient
There are necessary and relevant instruments to improve processes regardless
the method chose. Ex: Registration of suppliers, supplies catalogs, etc.
There isn't a discussion on critical issues such as minimum quality standard or
stock management.
New trends:
- Green Purchases (included in the new National law since August 2012)
- Electronic purchases

19. Expenditure recovery
Three Steps
 Detection: The detection is done on guard, appointment and
hospitalization areas. It is done through consulting at social security
database or through voluntary statement from the patients having
private insurance
Billing: We need the document of the beneficiary and the service. We
can only bill what is included in the “Obligatory Medical Program”
collecting: Outsourced

20. Challenges
 Accelerated aging of the population - epidemiological transition
 Health judicialization
 The public structure has deteriorated and its technology is
outdated
 Lack of political consensus for a new Health Plan
 International economic crisis
 Transnational health problems - Migration and immigration
 Create consciousness in the society about the importance of
the hospital
MORE SERVICES
MORE MONEY
MORE EFFICIENCY

21. Opportunities
 Development of Information Technology
 Excellent human resources with great
prestige
 Inclusion of professionals in health economy
and hospital management

22. Public Hospital Health Management
Mistakes
1) Financial Managers have the final
decision of purchasing
2) The administrative work is wrongly
consider less important than medical
work.
3) Lack of information in the decision
process