La autonomizacion de hospitales publicos y sus consecuencias sobre la demanda de atencion de salud, Lima, 1988-1997

Between 1988 and 1992 public hospitals in Peru were affected by major changes: the operational collapse of the health services, a profound State budgetary crisis, and a series of adjustments aimed toward self-financing. These changes all came before the health sector reform laws of 1997. In recent years, the changes in financing policy have renewed the operational potential of hospital activity and of the entire health sector. On the other hand, there have been some signs that with hospitals generating their own resources through fee collection, there has been a shift in the proportion of hospital users from different socioeconomic strata, to the detriment of poorer persons, especially those who need free services. This study tried to determine if there had been such changes between 1988 and 1997 in the socioeconomic strata of persons using five large public hospitals in Lima, and the association that that could have with the current transition toward the new model of the autonomous hospital, particularly with the new policies on hospital financing. Changes in hospital usage were studied through in- depth interviews with key informants, collection of statistical data in the selected hospitals, and an extensive bibliographic and literature review. Changes in hospital usage were studied through 1 012 surveys done with hospital users from the years 1988, 1992, and 1997. In order to classify those persons by socioeconomic stratum, cluster analysis and discriminant analysis were used, based on six variables suitable for determining socioeconomic level. The resulting model, of three strata grouped according to the dichotomized variables, exceeded the 75-point minimum required for the discriminant analysis to confirm the classification test. The main results showed that among the users of the five Lima hospitals, those in the highest stratum increased their relative use of the hospitals from 35.4% in 1988 to 52.6% in 1997. Proportional usage by those in the lowest stratum declined in the same period, from 25.4% to 20.5%. Usage by those in the intermediate stratum also declined, from 39.2% to 26.8%. It is clear that the trend in hospital financing has been toward an increase in user copayments, with public funding making up a smaller proportion of hospital budgets. This study verifies the results found in the 1991 and 1994 National Surveys of Standards of Living, which showed that the proportion of hospital usage by 'poor' persons declined from 37.3% to 34% between 1991 and 1994 and that usage by persons above that 'poor' economic level increased from 34.8% to 43.8%. The authors conclude that without a holistic approach to reform, microreforms produce both microefficiency and systemic inequity. In those circumstances, output and yield become more important than the impact and effectiveness of services for the population served.