The Unified Bolivian Health Care System or SUS

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The SUS or Unified Health System bill was passed on February 20, 2019. It is supposed to provide free health services to a population of 7,225,000 people. However, the bill was born against a fierce opposition of a wide range of medial professionals and practicians, who saw the bill did not fund it properly. They argued the system did not have enough material, medicines and technology to deal with the increase in care. They only saw the bill as the government's intention to solidify its electoral support, ignoring the warnings of medical professionals.

Law 475 can be seen here.

Coverage of the Unified Health System

According to the data available to 2017, the population affiliated with the other health schemes or Short Term Social Security reached 4,235,000, while the population not protected reached 7,225,000. This is the universe of beneficiaries the Unified Health System is supposed to cover. They are to receive comprehensive health care, free of charge.

The potential universe of beneficiaries, includes 2,966,000 people divided among the functioning public insurance schemes: the Maternal and Child Insurance (SUMI), the Health Insurance for the Elderly (SPPAM) - both integrated in the Integral Health System and Universal Health Insurance of Tarija (SUSAT). This implies that the population not protected reaches around 37% of the Bolivian population. It should be understood that the SUS is designed to provide all the necessary medical services, although progressively.


Financing

The SUS bill is to be financed in part by the national treasury or TGN.  The government will finance the third and fourth levels of health care in the Bolivian system and will cover the medical personnel and will guarantee the fuctioning of the services. For the first and second levels, which function at the more local level, the bill provides the financing through the municipal and indigenous governments. This will be with 15.5% of the Co-Participation or the IDH tax and, if need be, they will allocate a higher percentage.

Outstanding debts

It is surprising that the creation of the SUS is happening when the system already has difficulties to guarantee the benefits of SUMI and SSPAM. The expansion of the system to cover people with disabilities, without the corresponding financing has already created bottlenecks in hospitals and health centers, for resources not transferred to their administration and for outstanding debts. It is known, for example, that the debts to the General Hospital in La Paz and to the San Juan de Dios Hospital in Santa Cruz amount to more than one hundred million Bolivianos. In addition, in the department of Santa Cruz there is a deficit in the municipal accounts that, for the year 2017, reached 81 million Bolivianos. In fact it has been demonstrated that the resources that the municipal governments allocate for the care of pregnant women, children, the elderly and the disabled is insufficient.

The cost of a universal system

There are three sources of financing: Short Term Social Security, the Government and what is known as "out-of-pocket expenses", which people make, both in private services and in public services. Employers contribute 10% of the workers' salaries; while retirees contribute 3% of their pensions. These two contributions are equivalent to 1.9% of GDP. The population, on the other hand, has an out-of-pocket expense equal to 1.8% of GDP. Thus, the sum of the contributions of workers, retirees and out-of-pocket expenses, amount to 3.7% of GDP. This is a percentage higher than the contribution of the public sector, equivalent to 2.4% of GDP. The total public and private spending is estimated at 2,472 million dollars, which is equal to 6.1% of GDP.

The cost of Social Security benefits has an estimated cost of US$ 400 per person. Taking this value as a reference, and applying it for a population of 4,259,000 (the number of people that would join the SUS), an estimated expenditure of US$ 1,703 million per year is obtained for the provision of benefits.

Given that current health spending equals 6.1% of GDP, the expanded coverage of a universal system would lead to an increase in health spending of 4.2% of GDP.

More doctors and nurses


The number of physicians per thousand people in Bolivia is a quarter of the average number of doctors in Latin America. The indicator of the number of doctors in the country, which is included in the Sectorial Health Development Plan of the Ministry 2016/2020 differs from the international figure, but is still insufficient.

The ratio of doctors per 1,000 people defines the capacity of the medical resource for the care of outpatient services and hospitalization. According to the Health Development Plan, the indicator in Bolivia (as of 2015) reaches 0.8 doctors per thousand inhabitants; this is less than the three doctors per thousand established by the international indicator of PAHO. With these data, the SUS would be born with a deficit of more than 15,000 doctors.

The International Technical Indicator also establishes that three nurses are required for each doctor, and one Nursing Assistant for every 4 doctors. Therefore, it would be necessary to hire 5,000 nurses and 3,750 additional nursing assistants.

A study by the Medical College of Santa Cruz has estimated a requirement of 26,453 new jobs for the 49 new hospitals -consigned in a government construction plan-, and a budget of 276 million dollars per year, which, by the way, does not foresee the SUS draft law.


Problems and questions

The ambitious objective of the law contrasts, on the one hand, with the ambiguity and gaps in the legal text, which leaves in the shadows critical questions: what specific benefits will the SUS provide its insured members? What is the budget that demands a system so widespread in its population coverage ?, where does the sufficient financing come from, that ensures its effectiveness and sustainability? On the other hand, the contrast is evident with the current deplorable state of the public health system and its deficient budget, human resources, hospital infrastructure, equipment, medication and managerial management.



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