SISTEMA NACIONAL DE SALUD Y PROPUESTA DE REFORMAS

Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS
SISTEMA NACIONAL DE SALUD
Y PROPUESTA DE REFORMAS:
MÁS ALLÁ DEL RUIDO Y LA FURIA1
...it is a tale
Told by an idiot, full of sound and fury,
6LJQLI\LQJQRWKLQJ
...es un cuento
relatado por un idiota, lleno de ruido y furia,
VLQVLJQL¿FDGRDOJXQR
William Shakespeare. Macbeth (Acto 5, Escena 5)
Juan Oliva
Departamento de Análisis Económico y Seminario de Investigación en Economía y Salud.(UCLM)
Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC).
Salvador Peiró
Centro Superior de Investigación en Salud Pública (CSISP)
Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO)
Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC).
Jaume Puig-Junoy
Departamento de Economía y Empresa. Centro de Investigación en Economía y Salud (CRES) Universitat Pompeu Fabra.
ÍNDICE
,1752'8&&,Ï1
/$635238(67$6
5HGXFLUHOGHVSLOIDUUR
)LQDQFLDU\XWLOL]DUUDFLRQDOPHQWHEDViQGRQRVHQUHVXOWDGRV
&RRUGLQDFLyQHQWUHQLYHOHV\VLVWHPDV
%XHQJRELHUQRGHODVDQLGDG\FRPSOLFLGDGGHORVDFWRUHV
&21&/86,21(6
5()(5(1&,$6(03/($'$6
RESUMEN
(O6LVWHPD1DFLRQDOGH6DOXGYLYHPRPHQWRVGH
IXHUWHWHQVLyQSUHVXSXHVWDULDRFDVLRQDGDSRUODVLWXDFLyQHFRQyPLFD6LQHPEDUJRPiVDOOiGHODFULVLV
GHVGHKDFHWLHPSRVHDSXQWDEDHOHPHQWRVGHWHQVLyQ
HQHOVLVWHPDVDQLWDULRTXHUHTXHUtDQGHFDPELRVHVWUXFWXUDOHV SDUD DSXQWDODU VX VROYHQFLD (VWH HVFULWR WUDWD GH WRPDU SHUVSHFWLYD GH UHFLHQWHV UHIRUPDV
UHDOL]DGDVSRUODXUJHQFLDGHOPRPHQWRSDUD¿MDUVX
DWHQFLyQHQODVUHIRUPDVTXHHQRSLQLyQGHORVDXWRUHVKDEUtDTXHDFRPHWHUSDUDJDUDQWL]DUODVROYHQFLDGHOVLVWHPDVDQLWDULRS~EOLFRHQHOPHGLR\ODUJR
SOD]R/DSURSXHVWDVHDUWLFXODVREUHFXDWURJUDQGHV
௘(VWHDUWtFXORVHEDVDHQXQWUDEDMRSUHYLRSXEOLFDGRHQODUHYLVWD(FRQRPLVWDV\KDVHUYLGRGHKLORFRQGXFWRUSDUDODFRQIHUHQFLD
LQDXJXUDOGHO;;,,&RQJUHVR'HUHFKR\6DOXG
6
Sistema Nacional de Salud y propuesta de reformas: más allá del ruido y la furia
HMHVUHGXFLUGHOGHVSLOIDUURLQIUDXWLOL]DFLyQVREUHXWLOL]DFLyQSUHYHQFLyQGHHIHFWRVDGYHUVRVDYDQ]DU
HQIyUPXODVTXHXQDQ¿QDQFLDFLyQ\XWLOL]DFLyQDOD
REWHQFLyQGHUHVXOWDGRVHQVDOXG¿QDQFLDFLyQVHOHFWLYDGHODVSUHVWDFLRQHVPpGLFDVORVPHGLFDPHQWRV\
ODVWHFQRORJtDVUHGLVHxRGHORVFRSDJRVHLQWHJUDFLyQ
GH SUHVXSXHVWRV KX\HQGR GH FRPSDUWLPHQWRV HQWUH
QLYHOHV DVLVWHQFLDOHV DYDQ]DU HQ OD FRRUGLQDFLyQ
HQWUH QLYHOHV \ VLVWHPDV DWHQFLyQ SULPDULD \ HVSHFLDOL]DGDVLVWHPDVVDQLWDULR\GHSURPRFLyQGHODDXWRQRPtDSHUVRQDO\DWHQFLyQDODGHSHQGHQFLDVDOXG
HQWRGDVODVSROtWLFDV\SURPRYHUHOEXHQJRELHUQR
GHODVDQLGDGEXVFDQGRSDUDHOORODSDUWLFLSDFLyQ\HO
DSR\RGHORVSULQFLSDOHVDFWRUHVGHOVLVWHPD
1. INTRODUCCIÓN
/DVDOXGHVXQRGHORVSLODUHVGRQGHVHDSR\DHO
ELHQHVWDUGHORVLQGLYLGXRV\ODVVRFLHGDGHV'HVGHOD
SHUVSHFWLYDLQGLYLGXDODXQTXHGLVIUXWDUGHXQDEXHQD VDOXG QR HV FRQGLFLyQ VX¿FLHQWH SDUD DOFDQ]DU R
PDQWHQHU XQ DOWR JUDGR GH ELHQHVWDU \ IHOLFLGDG HQ
WpUPLQRVJHQHUDOHVHVFRQGLFLyQQHFHVDULDFRPROR
PXHVWUDQGLVWLQWRVHVWXGLRVVREUHIHOLFLGDGUHDOL]DGRV
HQ ORV ~OWLPRV DxRV *UDKDP (O LPSRUWDQWH
YROXPHQGHUHFXUVRVLQYHUWLGRVHQODDWHQFLyQVDQLWDULDSRUSDUWHGHORVSDtVHVGHQXHVWURHQWRUQR\HO
QXHVWURSURSLRHVVLQGXGDUHÀHMRGHOJUDGRGHSULRULGDGTXHFRQFHGHPRVFRPRVRFLHGDGDODSURWHFFLyQ
GHODVDOXG¿QDQFLDQGRPHGLGDVGHFDUiFWHUSUHYHQWLYR\WUDWDPLHQWRVSDUDHYLWDURSDOLDUHQODPHGLGD
GHORSRVLEOHHOGRORU\HOVXIULPLHQWRTXHRFDVLRQDQ
ODVHQIHUPHGDGHV\ORVSUREOHPDVGHVDOXG
(VXQWySLFRUHLWHUDGRUHIHULUTXHHO6LVWHPD1DFLRQDOGH6DOXG616HVSDxROHVXQRGHORVVLVWHPDV
VDQLWDULRV GH PD\RU p[LWR HQ HO PXQGR 6ROR -DSyQ
\ )UDQFLD QRV VXSHUDQ HQ HO LQGLFDGRU ³PRUWDOLGDG
LQQHFHVDULDPHQWH SUHPDWXUD \ VDQLWDULDPHQWH HYLWDEOH´XQRGHORVPiVVHQVLEOHVDODDFWXDFLyQVDQLWDULD
1ROWH0F.HH/DVDQLGDGHVHOVHUYLFLRS~EOLFRPiVXWLOL]DGR\HOTXHPiVYDORUDQORVFLXGDGDQRVDVtFRPRHOTXHRSLQDQTXHPiVMXVWL¿FDORVLPSXHVWRVTXHSDJDQ$KRUDELHQDOPLVPRWLHPSRORV
FLXGDGDQRVRSLQDQWDPELpQTXHHVDTXHOGHOTXHVH
KDFHSHRUXVR&,6\HOTXHWLHQHPiVPDUJHQ
GH PHMRUD (OOR HV FRQJUXHQWH FRQ OD LGHQWL¿FDFLyQ
GHULJLGHFHV\SUREOHPDVGHDGDSWDFLyQDXQHQWRUQR
TXHKDFDPELDGRVXVWDQWLYDPHQWH\GRQGHODQHJDWLYDDDFRPHWHUUHIRUPDVFRPSURPHWHVHULDPHQWHVX
VROYHQFLDHQORVDxRVSUy[LPRV$(6D
2WURWySLFRHVWHQRWDQFRUUHFWRHVTXHQXHVWUR
VLVWHPDVDQLWDULRHVPX\EDUDWRFRPSDUDGRFRQRWURV
SDtVHVGHVXHQWRUQR3XHGHTXHORIXHUDHQHOSDVDGR
SHURHQGLH]DxRVHQWUH\HOJDVWRVDQLWDULRS~EOLFRSRUSHUVRQDKDFUHFLGRHQWpUPLQRVUHDOHV
DOJRPiVGHXQFXDWURYHFHVPiVGHSULVDTXHHO
3,%SDVDQGRGHODOHQ3XLJ-XQR\
3DVDQGR D ODV FLIUDV GHO JDVWR VDQLWDULR WRWDO
OD VXPD GHO S~EOLFR \ HO SULYDGR VHJ~Q ORV GDWRV
GH OD 2&'( HQ HO DxR HO SRUFHQWDMH GH 3,%
GHGLFDGRDVDQLGDGDVFHQGtDDO(QHODxR
DOFDQ]yHOGHQXHVWUR3,%FRQVHFXHQFLDGHOD
FDtGDH[SHULPHQWDGDSRUHO3,%\ODLQHODVWLFLGDGD
FRUWRSOD]RGHGLFKRJDVWR(QUHDOLGDGFXDQGRFRPSDUDPRVHOJDVWRVDQLWDULRSHUFiSLWDHVSDxROFRQHO
GHRWURVSDtVHVFRQIyUPXODVGHRUJDQL]DFLyQGHOVLVWHPDVLPLODUHVWLSR616FRPRVRQ,WDOLDHO5HLQR
8QLGRR6XHFLDFXDQGRHVWRVSDtVHVWHQtDQXQQLYHO
GH UHQWD SHU FiSLWD VLPLODU D OD HVSDxROD ODV FLIUDV
GHJDVWRVDQLWDULRSHUFiSLWDHUDQPX\SDUHMDV(VWR
~OWLPRSRGUtDKDFHUFUHHUTXHHOVLVWHPDVDQLWDULRQR
VHHQFXHQWUDH[SXHVWRDSUREOHPDVGHVRVWHQLELOLGDG
¿QDQFLHUD'HVDIRUWXQDGDPHQWHXQDVSHFWRGLIHUHQFLDOGHODFULVLVHQ(VSDxDUHVSHFWRDRWURVSDtVHVKD
VLGRODEUXWDOFDtGDGHORVLQJUHVRVWULEXWDULRVWRWDOHV
$VtVLREVHUYDPRVODHYROXFLyQGHOSURGXFWR,QWHULRU
%UXWR3,%HO*DVWR6DQLWDULR3~EOLFR*63\ORV
,QJUHVRV7ULEXWDULRV7RWDOHV,77GHVGHHODxR
KDVWDHODxR~OWLPRDxRGHOFXDOWHQHPRVFLIUDV
Tabla 1. Evolución del producto Interior Bruto, Gasto Sanitario Público e Ingresos Tributarios Totales
Año
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
PIB
GSP
ITT
)XHQWHHODERUDFLyQSURSLDDSDUWLUGHGDWRVGHO,QVWLWXWR1DFLRQDOGH(VWDGtVWLFD0LQLVWHULRGH6DQLGDG6HUYLFLRV6RFLDOHVH
,JXDOGDG\$JHQFLD7ULEXWDULD
7
Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
SDUDHO*63\HO,77REVHUYDPRVTXHHO*63FUHFtD
GXUDQWHODSULPHUDPLWDGGHOSHULRGROLJHUDPHQWHSRU
HQFLPDGHO3,%SHURGHPDQHUDVLPLODUDORV,776LQ
HPEDUJRDOHQWUDUHQODFULVLVHFRQyPLFDHQWUHORV
DxRV\ORVLQJUHVRVS~EOLFRVFD\HURQQDGD
PHQRVTXHXQHQWpUPLQRVQRPLQDOHVPLHQWUDV
HO JDVWR VDQLWDULR S~EOLFR FUHFtD XQ GXUDQWH HO
PLVPR SHULRGR 1R KD VLGR KDVWD ORV DxRV \
FXDQGRHOFUHFLPLHQWRGHO*63VHKDGHWHQLGR
SULPHUR\KDFDtGRHQWpUPLQRVQRPLQDOHVHO~OWLPR
DxRGHOSHULRGRFRQVLGHUDGR
$ODVLWXDFLyQGHVFULWDEUXWDOFDtGDHQORVLQJUHVRV S~EOLFRV KD\ TXH VXPDU LQFUHPHQWRV GH JDVWRV
HQSDUWLGDVS~EOLFDVVHQVLEOHVDORVPRPHQWRVGHFULVLVLQFUHPHQWRGHORVVXEVLGLRVSRUGHVHPSOHROR
FXDO KD HOHYDGR ODV FLIUDV GH Gp¿FLW S~EOLFR GXUDQWH ORV ~OWLPRV DxRV (VWH Gp¿FLW KD VLGR ¿QDQFLDGR
PHGLDQWHODHPLVLyQGHGHXGDS~EOLFD6LQHPEDUJR
ODIXHUWHSULPDGHPDQGDGDSRUORVPHUFDGRVSDUDOD
¿QDQFLDFLyQGHODPLVPDHVWiVXSRQLHQGRXQDFDUJD
DGLFLRQDOSDUDHOHUDULRS~EOLFR\PDQWLHQHHQHVWDGR
GH DOHUWD D WRGDV ODV SDUWLGDV SUHVXSXHVWDULDV S~EOLFDV(VQHFHVDULRGHVFULELUHVWHSDQRUDPDSDUDHQWHQGHUSRUTXpVHKDQWRPDGRUHFLHQWHPHQWHGXUDVPHGLGDVREHGHFLHQGRDODXUJHQFLDGHODVLWXDFLyQVLQ
HQWUDUDYDORUDUVXLGRQHLGDGTXHHQRWURPRPHQWR
QRVHKXELHUDQSODQWHDGRGHELGRDOFRVWHSROtWLFRTXH
SXHGHQVXSRQHU
6LQHPEDUJRPiVDOOiGHODDFWXDOVLWXDFLyQGH
DJRQtD¿QDQFLHUDODVROYHQFLDGHOVLVWHPDVDQLWDULR
HVWRHVVXFDSDFLGDGSDUDUHVSRQGHUDFDPELRVGHPRJUi¿FRV WHFQROyJLFRV \ VRFLDOHV VH YHUi IXHUWHPHQWHHURVLRQDGDVLQRVHDERUGDQXQDVHULHGHFDPELRVGHWLSRHVWUXFWXUDO(OREMHWLYRGHHVWHHVFULWRHV
FRPHQWDU EUHYHPHQWH DOJXQDV GH ODV UHIRUPDV TXH
HQ RSLQLyQ GH ORV DXWRUHV SUHFLVD HO 616 SDUD JDUDQWL]DUODVRVWHQLELOLGDG¿QDQFLHUD\ODVROYHQFLDGHO
VLVWHPDVDQLWDULRDPHGLRSOD]R
8Q SXQWR GH DUUDQTXH LGHDO SDUD SODQWHDU XQD
DJHQGDGHUHIRUPDVDQLWDULDRUGHQDGDVHUtDODSXHVWD
HQPDUFKDGHXQ3DFWRSRUOD6DOXGGHFDUiFWHUPiV
JHQHUDO TXH HO IDOOLGR 3DFWR SRU OD 6DQLGDG UHFLHQWHPHQWH SURSXHVWR TXH HQJOREDUD OD SURPRFLyQ GH
ODVDOXG\ODDXWRQRPtDSHUVRQDODVtFRPRODDWHQFLyQDODHQIHUPHGDGFUyQLFD\DODGHSHQGHQFLD\
TXHFRQWDUDFRQHOPD\RUQ~PHURSRVLEOHGHDSR\RV
WDQWRSDUODPHQWDULRVFRPRGHVRFLHGDGHVFLHQWt¿FDV
SURIHVLRQDOHV \ FLXGDGDQDV 1R REVWDQWH FRQ R VLQ
HVWHDFXHUGRODVUHIRUPDVDLPSOHPHQWDUHQHOVHQR
GHO616QRGHEHQUHWUDVDUVHPiVVRSHQDGHTXHGDU
GH¿QLWLYDPHQWH UHOHJDGDV DQWH HO DWLVER GH UHFXSH-
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS
UDFLyQHFRQyPLFDRSHRUD~QGHVHUVXVWLWXLGDVSRU
UHFRUWHV LQGLVFULPLQDGRV GH FDUiFWHU FRUWRSODFLVWD
/RV FXDWURV HMHV VREUH ORV TXH VH SURSRQH DYDQ]DU
VRQODUHGXFFLyQGHOGHVSLOIDUURODDSXHVWDGHXQLU¿QDQFLDFLyQ\XWLOL]DFLyQDODREWHQFLyQGHUHVXOWDGRV
HQVDOXGDYDQ]DUHQODFRRUGLQDFLyQHQWUHQLYHOHV\
VLVWHPDV\SURPRYHUHOEXHQJRELHUQRGHODVDQLGDG
EXVFDQGRSDUDHOORODFRPSOLFLGDGGHORVSULQFLSDOHV
DFWRUHVGHOVLVWHPD
2. LAS PROPUESTAS
2.1. Reducir el despilfarro
(O SULPHU SXQWR D DERUGDU SDUD OD PHMRUD GH OD
H¿FLHQFLDHQODDWHQFLyQVDQLWDULDHVUHGXFLUHOGHVSLOIDUUR%iVLFDPHQWHVHWUDWDGHOLPLWDUORVSURFHVRV
SURGXFWRV\VHUYLFLRVTXHQRDSRUWDQYDORUHQWpUPLQRVGHVDOXG\FDOLGDGGHYLGDDSDFLHQWHV\SREODFLRQHVDOWLHPSRTXHVHVDOYDJXDUGDQDTXHOORVTXHVL
ORRIUHFHQRFX\RYDORUUHODWLYRHVPD\RU
8QUHFLHQWHWUDEDMRDSUR[LPDEDODVFLIUDVGHGHVSLOIDUURHQHOVLVWHPDVDQLWDULRHVWDGRXQLGHQVHSUREOHPDV GH FDOLGDG FRRUGLQDFLyQ VREUHXWLOL]DFLyQ
FRPSOHMLGDG DGPLQLVWUDWLYD IUDXGH \ RWURV D HQWUH
HO\HOGHOJDVWRVXVDQLWDULR%HUZLFN'0
+DFNEDUWK(QHO616QRGLVSRQHPRVGHLQIRUPDFLyQ GH HVWH WLSR SHUR GLYHUVRV GDWRV DSXQWDQ
XQ LPSRUWDQWH GHUURFKH HQ PHGLFDPHQWRV DQWLELyWLFRV LQKLELGRUHV GH OD ERPED GH SURWRQHV HVWDWLQDVDQWLRVWHRSRUyWLFRVFR[LEVSVLFyWURSRVHWFQR
H[HQWRGHHIHFWRVDGYHUVRVHQSUXHEDVGLDJQyVWLFDV
GHVFRRUGLQDFLyQ GH OD DWHQFLyQ D FUyQLFRV \ RWURV
SUREOHPDVTXHVXJLHUHQTXHHVWDPRVFRPELQDQGRHO
VREUHWUDPLHQWR HQ SDFLHQWHV OHYHV JDVWR VLQ EHQH¿FLRV HQ VDOXG FRQ VXEWUDWDPLHQWR HQ SDFLHQWHV GH
DOWR ULHVJR SHRU VDOXG \ PD\RU JDVWR SRU GHVFRPSHQVDFLRQHV\FRPSOLFDFLRQHV
3RU XQD SDUWH H[LVWH XQ SUREOHPD GH subutilización GH VHUYLFLRV VDQLWDULRV HQ SDFLHQWHV TXH QR
UHFLEHQ SUXHEDV WUDWDPLHQWRV R LQWHUYHQFLRQHV TXH
HVWDUtDQ LQGLFDGRV GDGD VX VLWXDFLyQ FOtQLFD (Q HO
616 H[LVWHQ HYLGHQFLDV GLUHFWDV GH VXEXWLOL]DFLyQ
GHIiUPDFRVHQODSUHYHQFLyQGHOUHLQIDUWR6DQIpOL[
HW DO GH OD WURPERHPEROLD HQ OD ¿EULODFLyQ
DXULFXODU %DUULRV HW DO HQ OD LQVX¿FLHQFLD
FDUGLDFD 5RGUtJXH] 5RFD HW DO HQ HOGLDJQyVWLFR \ PDQHMR GH OD HQIHUPHGDG SXOPRQDU REVWUXFWLYD FUyQLFD 0LUDWYLOOHV HW DO DVt FRPR
HQODKLSHUWHQVLyQDUWHULDOHODVPD\HQHOPDQHMRGH
Sistema Nacional de Salud y propuesta de reformas: más allá del ruido y la furia
ORVOODPDGRV³VtQWRPDVPHQRUHV´/DVXEXWLOL]DFLyQ
WLHQHVXRULJHQHQGLIHUHQWHVSUREOHPDVHQHOPDQHMR
GHORVSDFLHQWHVLQFOX\HQGRODQRLQGLFDFLyQSULPDULDGHWUDWDPLHQWRVRSUXHEDVH¿FDFHVHOWHPRUDORV
HIHFWRVDGYHUVRVRDOPDQHMRGHIiUPDFRVFRQUDQJR
WHUDSpXWLFR HVWUHFKR OD OODPDGD LQHUFLD WHUDSpXWLFD
HOXVRGHGRVLVVXEySWLPDVODEDMDDGKHUHQFLDGHPXFKRV SDFLHQWHV FUyQLFRV \ RWURV /D VXEXWLOL]DFLyQ
LQFUHPHQWDHQRUPHPHQWHHOIUDFDVRWHUDSpXWLFRHQWHQGLGRFRPRORVLQFUHPHQWRVGHPRUELOLGDG\PRUWDOLGDGHYLWDEOHFRQHODGHFXDGRPDQHMRGLDJQyVWLFR
\WHUDSpXWLFRGHORVSDFLHQWHVORFXDOVHWUDGXFHHQ
GHVSLOIDUUR SRU HO JDVWR HQ KRVSLWDOL]DFLRQHV \ WUDWDPLHQWRV GH HQIHUPHGDGHV \ GHVFRPSHQVDFLRQHV
TXH VH SRGtDQ KDEHU HYLWDGR (Q HVWH VHQWLGR HQ HO
616 H[LVWHQ HYLGHQFLDV GH LPSRUWDQWHV GH¿FLHQFLDV
HQUHVXOWDGRVFOtQLFRVLQWHUPHGLRV\IDFWRUHVGHULHVJRQLYHOGHKLSHUWHQVLyQKHPRJORELQDJOXFRVLODGD
HWFTXHSXHGHQJXDUGDUUHODFLyQFRQODVDEXOWDGDV
±\PX\YDULDEOHVVHJ~QWHUULWRULRVFLIUDVGH³KRVSLWDOL]DFLRQHVSRWHQFLDOPHQWHHYLWDEOHV´$EDGtD7DLUD
HWDO
(Q HO H[WUHPR FRQWUDULR OD sobreutilización VH
UH¿HUH D OD LQGLFDFLyQ GH SUXHEDV WUDWDPLHQWRV LQWHUYHQFLRQHV YLVLWDV PpGLFDV \ RWUDV SUHVWDFLRQHV
VDQLWDULDVGHIRUPDLQQHFHVDULDVLQEHQH¿FLRVFOtQLFRVSDUDORVSDFLHQWHV(QHO616H[LVWHQHYLGHQFLDV
GLUHFWDVGHVREUHXWLOL]DFLyQGHDQWLELyWLFRVHQWUHHO
\ HO GH ORV TXH VH SUHVFULEHQ KLSROLSHPLDQWHVHQWUHHO\HODQWLXOFHURVRVHQWUH
HO\HODQWLRVWHRSRUyWLFRVHQWUHHO\
HO\SVLFyWURSRVGHSDFLHQWHVTXHUHFLEHQ
HVWRV IiUPDFRV VLQ SUHVHQWDU GHVRUGHQHV PHQWDOHV
$EDGtD7DLUD HW DO /D VREUHXWLOL]DFLyQ GH
SUXHEDVGLDJQyVWLFDVHVWiPHQRVHVWXGLDGDSHURDOJXQRVWUDEDMRVPXHVWUDQODVH[FHVLYDVVROLFLWXGHVGH
DOJXQDVSUXHEDVGHODERUDWRULR\XQDH[WUDRUGLQDULD
YDULDELOLGDGHQODVWDVDVSREODFLRQDOHVGHUHDOL]DFLyQ
GHODPD\RUSDUWHGHODVSUXHEDVGHODERUDWRULRTXH
VXJLHUHXQLPSRUWDQWHYROXPHQGHSHWLFLRQHVLQDGHFXDGDV 6DOLQDV HW DO 6REUH HO VREUHXVR GH
SUXHEDV GH LPDJHQ XQ HVWXGLR UHFLHQWH HQ DWHQFLyQ
SULPDULDORFLIUDEDHQWRUQRDODFXDUWDSDUWHGHODV
H[SORUDFLRQHV 3pUH] \ *XLOOpQ $VLPLVPR
KD\ TXH FRQVLGHUDU WDPELpQ ORV PiV KDELWXDOHV ODV
SURSLDVYLVLWDVDDWHQFLyQSULPDULDDFWXDFLRQHVSUHYHQWLYDVGHGLVFXWLEOHH¿FDFLDRODVGHULYDFLRQHVDOD
DWHQFLyQHVSHFLDOL]DGD*HUYiVHWDORODKXLGD
PDVLYDGHSDFLHQWHV³QRXUJHQWHV´KDFLDORVVHUYLFLRV
GHXUJHQFLDKRVSLWDODULRV3HLUyHWDO/DVREUHXWLOL]DFLyQ LPSOLFD XVR LQQHFHVDULR FRQVXPR GH
UHFXUVRVVLQEHQH¿FLRVHQWpUPLQRVGHVDOXG\SRU
WDQWRGHVSLOIDUURGLUHFWRGHUHFXUVRVTXHSRGUtDQVHU
HPSOHDGRV HQ RWURV SDFLHQWHV R HQ RWURV XVRV 3HUR
ODVREUHXWLOL]DFLyQWDPELpQLPSOLFDGDxRHLQGLUHFWDPHQWHPiVGHVSLOIDUUR(OGHULYDGRGHORVIDOVRVSRVLWLYRVGHODLUUDGLDFLyQGHODVSUXHEDVUDGLROyJLFDV
GHODVSUXHEDVSDUDGHVFDUWDUIDOVRVKDOOD]JRVWUDWDPLHQWRVLQQHFHVDULRVFRQVXVFRUUHVSRQGLHQWHVHIHFWRVDGYHUVRVHYLWDEOHVHWF<SRUGHVFRQWDGRPROHVWLDVJDVWRVGHVSOD]DPLHQWRVFRSDJRVSUHRFXSDFLyQ
SRUHOHWLTXHWDGRGLDJQyVWLFR\SpUGLGDVGHFDOLGDG
GH YLGD SDUD ORV SDFLHQWHV \ VXV IDPLOLDV \ SDUD OD
FRPXQLGDG
8QWHUFHUiUHDGRQGHFHQWUDUODDWHQFLyQVRQORV
SUREOHPDVGHseguridad y los efectos adversos. (Q
HVWH iPELWR FDEH GHVWDFDU ORV HVWXGLRV SURPRYLGRV
HQORV~OWLPRVDxRVHQHOiUHDGHKRVSLWDOL]DFLyQHVWXGLR (1($6 $UDQD]$QGUpV HQ DWHQFLyQ
SULPDULD HVWXGLR $3($6 $UDQD] $QGUpV UHVLGHQFLDVHVWXGLR($5&$6$LEDU5HPyQ
\HQDOJXQRVRWURVFDPSRVPiVHVSHFt¿FRV/RVUHVXOWDGRVFRPRUHVDOWDQORVGLYHUVRVLQIRUPHVQRVRQ
PX\GLIHUHQWHVDORVKDOODGRVHQRWURVSDtVHVGHVDUUROODGRVSHURSRUHVRPLVPRVRQPX\SUHRFXSDQWHV
6HJ~QHO(1($6HOGHORVSDFLHQWHVKRVSLWDOL]DGRV SUHVHQWDURQ DOJ~Q HIHFWR DGYHUVR ($ (O
GHHVWRV($HUDQJUDYHV\HOHYLWDEOHV
/D DSOLFDFLyQ GH HVWRV SRUFHQWDMHV D ORV PLOORQHV GH LQJUHVRV KRVSLWDODULRV TXH VH SURGXMHURQ HQ
(VSDxD HQ VXSRQGUtDQ HIHFWRV DGYHUVRV KRVSLWDODULRVDxR HYLWDEOHV GH HOORV
JUDYHVHYLWDEOHV/RVUHVXOWDGRVGHO
$3($6QRVRQPiVUHFRQIRUWDQWHVVHSURGXMRXQ($
SRUFDGDYLVLWDVPHGLFLQDJHQHUDOHQIHUPHUtDSHGLDWUtDFDVLODPLWDGUHODFLRQDGRVFRQPHGLFDPHQWRV8QGHORV($IXHURQ
OHYHV PRGHUDGRV \ JUDYHV \ XQ HUDQ HYLWDEOHV 6L VH DSOLFDQ HVWRV SRUFHQWDMHV D ORV
FDVL PLOORQHV GH FRQVXOWDV DQXDOHV HVWDUtDPRV
KDEODQGRGHPLOORQHVGHHIHFWRVDGYHUVRVSRUDxR
GHORVTXHXQRVVHUtDQJUDYHV\PLOORQHV
SRWHQFLDOPHQWHHYLWDEOHV(VWDVFLIUDVVLW~DQORVHIHFWRVDGYHUVRVFRPRXQRGHORVSULQFLSDOHVSUREOHPDV
HYLWDEOHVGHVDOXGGHODSREODFLyQHVSDxRODSUREDEOHPHQWHHOPiVLPSRUWDQWHMXQWRDODVHQIHUPHGDGHV
FDUGLRYDVFXODUHV\HOFiQFHU
2.2. Financiar y utilizar racionalmente basándonos en resultados
/DFUHGLELOLGDGGHODMXVWHSUHVXSXHVWDULRHQODVDQLGDGGHSHQGHVREUHWRGRGHODFDSDFLGDGSDUDHYROXFLRQDUHQXQSOD]RUD]RQDEOHKDFLDXQD¿QDQFLDFLyQ
selectiva de las prestaciones médicas, los medica-
Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
mentos y las tecnologíasEDVDGDHQHOPHMRUFRQRFLPLHQWRFLHQWt¿FRGLVSRQLEOH,QYHUWLUHQHYDOXDUOD
H¿FDFLD LQFUHPHQWDO FRPSDUDGD GH FXDOTXLHU QXHYR
WUDWDPLHQWR R GH ORV \D H[LVWHQWHV HQ HO PHUFDGR
HV OD IRUPD PiV HIHFWLYD GH JDUDQWL]DU OD VROYHQFLD
IXWXUDGHOVLVWHPDVDQLWDULRS~EOLFR8QDVSHFWRTXH
UHTXLHUH DERUGDMH XUJHQWH HV ¿QDQFLDU FRQ UHFXUVRV
S~EOLFRV VyOR DTXHOORV PHGLFDPHQWRV WHFQRORJtDV
SUHVWDFLRQHV \ VHUYLFLRV TXH ±DGHPiV GH H¿FDFHV \
VHJXUDV±VHDQH¿FLHQWHV6HWUDWDGHWRPDUHQFRQVLGHUDFLyQGHPDQHUDFODUD\H[SOtFLWDODGLPHQVLyQGH
ODH¿FLHQFLDHOEDODQFHHQWUHHOFRVWHDGLFLRQDO\HO
YDORUDGLFLRQDOHQWpUPLQRVUHODWLYRVHQODWRPDGH
GHFLVLRQHVUHODFLRQDGDVFRQOD¿QDQFLDFLyQS~EOLFD
HOSUHFLR\HOXVRDGHFXDGRGHXQDLQQRYDFLyQ$(6
E3XLJ-XQR\\3HLUy
$SHVDUGHODFULVLV\GHORVUHFRUWHVHQODVDQLGDGS~EOLFDVHJXLPRVDQFODGRVHQODVHQGDGHKDFHU
³PHQRV´GHORPLVPRDFDEDPRV¿QDQFLDQGRS~EOLFDPHQWHFDVLFXDOTXLHUQXHYRPHGLFDPHQWRRSUHVWDFLyQWDQWRVLHOFRVWHSRUUHVXOWDGRHQVDOXGHVUD]RQDEOHFRPRVLHVGHVRUELWDGR3DJDPRVSUHFLRVHOHYDGRVSRUWHUDSLDVTXHRWURVSDtVHVFRQPiVUHQWDQR
HVWiQGLVSXHVWRVDSDJDU$GLIHUHQFLDGHRWURVSDtVHV
HXURSHRVHQ(VSDxDHOYDORUWHUDSpXWLFRRJUDGRGH
LQQRYDFLyQQRSDUHFHVHUXQIDFWRUFODYHHQODGHWHUPLQDFLyQGHOSUHFLRGHHQWUDGDGHORVPHGLFDPHQWRV
QXHYRV(QUHDOLGDGQLVLTXLHUDVDEHPRVHOFRVWHSRU
DxRGHYLGDJDQDGRDMXVWDGRSRUFDOLGDG±$9$&GH
ORVPHGLFDPHQWRVTXHVHDXWRUL]DQFDGDPHVGHIRUPDFHQWUDOL]DGD
'DGRTXHODOLWHUDWXUDLQWHUQDFLRQDODSXQWDDTXH
ORV SULQFLSDOHV IDFWRUHV TXH LPSXOVDQ HO JDVWR VDQLWDULRVRQODDGRSFLyQGHLQQRYDFLRQHVVDQLWDULDV\HO
DXPHQWRGHOXVRSRUSHUVRQDHVFODYHSDUDODVRVWHQLELOLGDGGHODVDQLGDGGLVSRQHUGHXQSURFHGLPLHQWR
GH HYDOXDFLyQ LQGHSHQGLHQWH GH OD H¿FDFLDHIHFWLYLGDG LQFUHPHQWDO \ OD UHODFLyQ FRVWHHIHFWLYLGDG LQFUHPHQWDO TXH SHUPLWD DGRSWDU GHFLVLRQHV GH ¿QDQFLDFLyQVHOHFWLYD\GHSUHFLRVHJ~QYDORU1RSXHGH
UHVXOWDUH[WUDxRTXHGHVGH%UXVHODVVHOHUHFODPHD
(VSDxDTXHPHMRUHODUHODFLyQFRVWHH¿FDFLDGHOVHFWRUVDQLWDULR3XLJ-XQR\7UDSHUR%HUWUDQ
(VWR VXSRQH DxDGLU QXHYRV UHTXHULPLHQWRV DO
SURFHVR GH GHFLVLyQ \ H[LJH XQ PDUFR TXH OR KDJD
IDFWLEOHWDQWRHQORWRFDQWHDODQRUPDWLYDFRPRHQHO
iPELWRGHODJHVWLyQFOtQLFD,PSOLFDODQHFHVLGDGGH
GRWDUQRVGHLQVWLWXFLRQHVDGHFXDGDVSDUDLQIRUPDUODV
GHFLVLRQHVVREUHSULRUL]DFLyQGHUHFXUVRVTXHLQFRUSRUHQ OD GLPHQVLyQ GH OD H¿FLHQFLD /D H[SHULHQFLD
HXURSHDGHOD~OWLPDGpFDGDSXHGHVHUQRVGHH[WUDRU-
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS
GLQDULDD\XGD\DTXHXQQ~PHURFUHFLHQWHGHSDtVHV
,QJODWHUUD 6XHFLD +RODQGD $OHPDQLD 3RUWXJDO
KDQ DSRVWDGR SRU GLVWLQWRV PRGHORV GH ORV FXDOHV
SRGHPRVDSUHQGHUSDUDQRDGRSWDUDFUtWLFDPHQWHXQD
GHWHUPLQDGD IyUPXOD VLQR DTXHOOD FRPELQDFLyQ GH
HOHPHQWRVGHp[LWRLGHQWL¿FDGRVHQGLIHUHQWHVH[SHULHQFLDV\PiVIiFLOPHQWHDGDSWDEOHVDQXHVWURPHGLR
\HVWUXFWXUD2OLYDHWDO
$Vt OD LQWURGXFFLyQ GH OD HYDOXDFLyQ HFRQyPLFDGHPHGLFDPHQWRVHQODSUiFWLFDGHODVGHFLVLRQHV
HXURSHDV GH UHHPEROVR R ¿QDQFLDFLyQ KD VXSXHVWR
FDPELRV LPSRUWDQWHV TXH DIHFWDQ OD RUJDQL]DFLyQ
GHO VLVWHPD GH VDOXG HO SURSLR SURFHGLPLHQWR SDUD
FRQVHJXLU HO UHHPEROVR ODV GHFLVLRQHV GH UHHPEROVR \ OD DVLJQDFLyQ GH UHFXUVRV TXH UHVXOWD GH HVWDV
GHFLVLRQHV'HODREVHUYDFLyQGHORVXFHGLGRHQHVWDVGRV~OWLPDVGpFDGDVVHSXHGHQLGHQWL¿FDUYDULDV
GLPHQVLRQHVEiVLFDVVREUHODVTXHGH¿QLUODPDQHUD
FRPR FDGD VLVWHPD GH VDOXG TXLHUH DGRSWDU ODV LPSUHVFLQGLEOHVGHFLVLRQHVGH¿QDQFLDFLyQVHOHFWLYDGH
PHGLFDPHQWRV\SUHVWDFLRQHV
(QSULPHUOXJDUODorganización/DIXQFLyQGH
XQDDJHQFLDHYDOXDGRUDSXHGHVHUUHJXODGRUDDXWRULGDGGHFLVRUDROLPLWDUVHDXQDIXQFLyQDVHVRUDKDFHUUHFRPHQGDFLRQHV/DVGHFLVLRQHVDDGRSWDUVREUHODEDVHGHORVUHVXOWDGRVGHODHYDOXDFLyQSXHGHQ
VHU ODV GH FREHUWXUD R UHHPEROVR R WDPELpQ ODV GH
SUHFLRV(QJHQHUDOWLHQHQPiVLQÀXHQFLDHQODWRPD
GHGHFLVLRQHV\ODSUiFWLFDFOtQLFDVLODDJHQFLDWLHQHXQSDSHOUHJXODGRU(QVHJXQGROXJDUHOobjetivo
EXVFDGR/DPD\RUtDGHDJHQFLDVSHUVLJXHQODPHMRUD
GHODH¿FLHQFLDXVDQGRODUHODFLyQFRVWHHIHFWLYLGDG
GH IRUPD H[SOtFLWD 7DQWR ODV UHIRUPDV UHFLHQWHV HQ
)UDQFLDFRPRHQ$OHPDQLDWLHQGHQDLQWURGXFLUWDPELpQ OD UHODFLyQ FRVWHHIHFWLYLGDG HQ OD GHFLVLyQ R
QHJRFLDFLyQGHOSUHFLRGHORVQXHYRVPHGLFDPHQWRV
7HUFHUR VX ámbito de aplicación 6L ELHQ LQLFLDOPHQWHODVJUDQGHVDJHQFLDVHXURSHDVVHOLPLWDEDQD
HYDOXDU QXHYRV PHGLFDPHQWRV HQ ORV ~OWLPRV DxRV
HVFRP~QH[SDQGLUODHYDOXDFLyQDRWUDVWHFQRORJtDV
\DFDVLFXDOTXLHULQWHUYHQFLyQVDQLWDULD&XDUWRORV
procedimientosDDSOLFDU+D\YDULDVFDUDFWHUtVWLFDV
TXH GLVWLQJXHQ \ GLIHUHQFLDQ ORV SURFHGLPLHQWRV GH
HYDOXDFLyQTXHVHHPSOHDQHQFDGDSDtV\TXHFRQGLFLRQDQODDFHSWDELOLGDGWUDQVSDUHQFLD\OHJLWLPLGDG
GHODVGHFLVLRQHVEDVDGDVHQORVUHVXOWDGRVGHODHYDOXDFLyQ6LQH[WHQGHUQRVGHPDVLDGRHOJUDGRGHLQGHSHQGHQFLDGHODDJHQFLDHYDOXDGRUDVXSURWHFFLyQ
IUHQWHDORVFRQÀLFWRVGHLQWHUpVORVSOD]RVGHOSURFHGLPLHQWR GH HYDOXDFLyQ H[SOtFLWRV \ GH REOLJDGR
FXPSOLPLHQWR\ODSRVLELOLGDGGHTXHORVDIHFWDGRV
LQGXVWULDORVSURIHVLRQDOHV\ORVSDFLHQWHVSDUWLFL-
Sistema Nacional de Salud y propuesta de reformas: más allá del ruido y la furia
SHQ HQ HO SURFHVR DVt FRPR OD H[LVWHQFLD GH UHJODV
H[SOtFLWDVGHDSHODFLyQVRQDOJXQRVGHORVHOHPHQWRV
D FRQVLGHUDU 4XLQWR ORV métodos de evaluación D
DSOLFDU/DHYDOXDFLyQGHEHLQFOXLUVLHPSUHODHIHFWLYLGDGFOtQLFDLQFUHPHQWDORFRPSDUDGD\FRQPDWLFHVHODQiOLVLVFRVWHHIHFWLYLGDGLQFUHPHQWDO6H[WR
ORV criterios de decisión /DV SULQFLSDOHV DJHQFLDV
HXURSHDV SULRUL]DQ VHJ~Q EHQH¿FLR FOtQLFR SHUR QR
WRGDVFRQVLGHUDQODUHODFLyQFRVWHHIHFWLYLGDGGHPDQHUDH[SOtFLWD(QHVWHSXQWRVHVLW~DHOGHEDWHVREUH
HOXVRGHXPEUDOHVH[SOtFLWRVRLPSOtFLWRVGHGLVSRVLFLyQPi[LPDDSDJDUSRUXQ$xRGH9LGD$MXVWDGR
SRU&DOLGDG\VXDGDSWDFLyQSDUDFLHUWRVWUDWDPLHQWRV FRPR HV HO FDVR GH ODV WHUDSLDV RQFROyJLFDV<
VpSWLPR OD implementación $XQTXH LQLFLDOPHQWH
IXHUDGHOiPELWRGHLQWHUpVGHODVDJHQFLDVGHHYDOXDFLyQODIRUPDGHWUDVODGDUDODSUiFWLFDVXVGHFLVLRQHV
QRSXHGHTXHGDUDOPDUJHQGHODVDJHQFLDV(QYDULRV
SDtVHVVHDGRSWDQLQFHQWLYRV¿QDQFLHURV\QR¿QDQFLHURVSDUDIDYRUHFHUODDGRSFLyQGHODVGHFLVLRQHVHQ
ODSUiFWLFDFOtQLFD
6LUHDOPHQWHVHGHVHDHPSUHQGHUXQFDPLQRPiV
UDFLRQDOSDUDTXHOD¿QDQFLDFLyQVHEDVHHQODHIHFWLYLGDG FRPSDUDGD \ OD UHODFLyQ FRVWHHIHFWLYLGDG
FRQYLHQHDODOX]GHODH[SHULHQFLDHXURSHDQRHQFDOODUVHHQHO³TXLpQ´GHEHHYDOXDUVLQRFHQWUDUVHHQ
HO³TXp´³FXDQGR´³FyPR´\³SDUDTXp´HYDOXDU/R
TXHRFXUUDHQ(VSDxDHQHOIXWXURSUy[LPRPiVDOOi
GH ODV SDODEUDV \ GH OD QRUPDWLYD GHSHQGHUi GH OD
RSFLyQ TXH VH WRPH DQWH ODV DOWHUQDWLYDV FRQRFLGDV
SDUDFDGDXQDGHODVDQWHULRUHVGLPHQVLRQHV
3RU RWUD SDUWH ORV FULWHULRV GH H¿FLHQFLD GHEHQ
VHU XVDGRV QR VyOR SDUD YDORUDU TXp QXHYDV WHFQRORJtDVVHGHEHQLQFRUSRUDQDODFDUWHUDGHVHUYLFLRV
GHO 616 VLQR WDPELpQ SDUD YDORUDU ODV WHFQRORJtDV
D UHWLUDU &DPSLOOR$UWHUR \ %HUQDO'HOJDGR 5HSXOOR%HUQDO'HOJDGRHWDO/DVGHFLVLRQHVGHGHVLQYHUVLyQ\UHLQYHUVLyQGHEHUtDQHVWDU
JXLDGDVSRUODHYLGHQFLDFLHQWt¿FDVREUHODHIHFWLYLGDGFRPSDUDWLYD\ODH¿FLHQFLDUHODWLYDGHODVDFWXDFLRQHVSUHYHQWLYDVORVWUDWDPLHQWRV\ODVSUXHEDV(Q
VXPD GHFLVLRQHV GH LQYHUVLyQ \ GHVLQYHUVLyQ GHEHUtDQVHUORVX¿FLHQWHPHQWHWUDQVSDUHQWHVSDUDTXHODV
SDUWHV LPSOLFDGDV FRQR]FDQ \ FRPSUHQGDQ DXQTXH
QRODVFRPSDUWDQODVGHFLVLRQHVDGRSWDGDV\SXHGDQ
VHUYLUGHJXtDDODLQQRYDFLyQ
2WURDVSHFWRDFRQVLGHUDUHQHVWHHStJUDIHHVHO
SDSHOTXHGHEHQMXJDUODVDSRUWDFLRQHVGHORVXVXDULRVORV OODPDGRV copagosGHQWUR GHO iPELWR GHO
6166LQRVHGHVHDTXHVHFRQYLHUWDHQXQLPSXHVWR
VREUHODHQIHUPHGDGHOFRSDJRGHEHWHQHUXQSDSHO
UHFDXGDWRULROLPLWDGR6HUtDPiVGHVHDEOHXQFRSDJR
HYLWDEOH\EDVDGRHQFULWHULRVGHHIHFWLYLGDGDXQFRSDJROLQHDO\REOLJDWRULR6LHVREOLJDWRULRFRPRHVHO
FDVRDFWXDOORySWLPRHVTXHVHDGHLPSRUWHUHGXFLGR
SDUDWRGRVTXHVHDFXPXOHODFLIUDWRWDOTXHSDJDXQ
SDFLHQWHSRUFXDOTXLHUWLSRGHFRSDJRFRQXQOtPLWH
Pi[LPRGHDSRUWDFLyQ6XHFLDRXQSRUFHQWDMHGHOD
UHQWD$OHPDQLDGHMDQGRIXHUDGHOFRSDJRRVLHQGR
PX\UHGXFLGRSDUDSDFLHQWHVFRQHQIHUPHGDGHVFUyQLFDV(OFRVWHGHQRVHJXLUXQWUDWDPLHQWRHIHFWLYR
SRUHMHPSORGHVSXpVGHXQLQIDUWRHVGHPDVLDGRHOHYDGRFRPRSDUDGLVXDGLUDORVSDFLHQWHVLPSRQLHQGR
HOHYDGRVFRSDJRV
,GHDOPHQWHXQEXHQGLVHxRGHFRSDJRVGHEHUtD
KDFHU TXH pVWRV IXHUDQ HYLWDEOHV HQ DTXHOORV FDVRV
GRQGH HO WUDWDPLHQWR VHD PiV QHFHVDULR \ HIHFWLYR
\HOSDFLHQWHSDJDUDODGLIHUHQFLDKDVWDHOSUHFLRGH
RWURVWUDWDPLHQWRVPiVFDURVSHURTXHDSRUWDQHVFDVR
YDORUSDUDODVDOXG(OHOHPHQWRFODYHGHOGLVHxRGH
FRSDJRV D¿QDGRV HV TXH GHEHQ HVWDU EDVDGRV HQ HO
YDORU<HVWHYDORUGHEHVHUGHWHUPLQDGRSRUODHYLGHQFLD FLHQWt¿FRFOtQLFD 3XLJ-XQR\ $Vt VH
KDFH HQ PXFKRV SDtVHV HXURSHRV SRU HMHPSOR HQ
)UDQFLDGRQGHHOFRSDJRGHSHQGHGHOJUDGRGHQHFHVLGDG\GHODH¿FDFLDGHOWUDWDPLHQWRFXDQWRPiV
QHFHVDULR\H¿FD]PHQRUHVHOFRSDJRRHQ$OHPDQLD \ +RODQGD FRQ HVTXHPDV GH FRSDJRV HYLWDEOHV
3RURWUDSDUWHQRGHEHGHMDUGHVHUPHQFLRQDGRTXH
HOFRSDJRGLVFLSOLQDQRVyORDOSDFLHQWHVLQRWDPELpQ
DO PpGLFR D\XGDQGR D XQ XVR PiV UDFLRQDO GH ORV
UHFXUVRV
/D UHIRUPD GHO VLVWHPD GH FRSDJR IDUPDFpXWLFR LQLFLDGD FRQ ODV PHGLGDV DGRSWDGDV HQ MXOLR GH
D ODV TXH VH KD DxDGLGR OD GHV¿QDQFLDFLyQ GH
XQD OLVWD GH PHGLFDPHQWRV SDUD VtQWRPDV PHQRUHV
\ORVLQWHQWRVGHDSOLFDUWDVDVDXWRQyPLFDVVREUHOD
SUHVFULSFLyQ UHTXLHUH XQ UHGLVHxR LPSRUWDQWH DVt
FRPRXQDHYDOXDFLyQD¿QDGD\XUJHQWHGHVXVFRQVHFXHQFLDVDODYLVWDGHOQRWDEOHHIHFWRUHGXFWRUGHO
Q~PHURGHUHFHWDV(OQHFHVDULRUHGLVHxRGHEHWHQHU
HQ FXHQWD GLYHUVRV IDFWRUHV (Q SULPHU OXJDU TXH
FXDOTXLHUFRSDJRDSOLFDGRGHEHVHUDFXPXODWLYRVHD
IDUPDFpXWLFR R VREUH RWURV VHUYLFLRV FRQ XQ OtPLWH
Pi[LPR SDUD FXDOTXLHU SHUVRQD FRQ LQGHSHQGHQFLD
GHTXHVHDDFWLYRRSHQVLRQLVWD3XHGHWHQHUHIHFWRV
FRQWUDSURGXFHQWHV OD DSOLFDFLyQ GH FRSDJRV LPSRUWDQWHVVLQDSOLFDURVLQVDEHUJHVWLRQDUHVWHOtPLWH(Q
VHJXQGR OXJDU VHUtD EXHQR KXLU GH OD WUDPSD GH XQ
FRSDJR VXSXHVWDPHQWH UHODFLRQDGR FRQ OD UHQWD \D
TXH HO DFWXDO QR OR HVWi OR TXH VH UHODFLRQD FRQ OD
UHQWDHVHOSRUFHQWDMHGHOSUHFLRGHFDGDHQYDVHTXH
XQSDFLHQWHWLHQHTXHSDJDUSHURQRHOLPSRUWHWRWDO
11
Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
TXH GXUDQWH XQ SHUtRGR GH WLHPSR SDJD XQ SDFLHQWHWHQLHQGRHQFXHQWDTXHHOJDVWRVHDFXPXODHQXQ
Q~PHURUHGXFLGRGHSDFLHQWHV<HQWHUFHUOXJDUVH
GHEHUtDDSRVWDUPiVSRUXQFRSDJRGLVXDVRULRTXHQR
UHFDXGDWRULR HYLWDQGR HIHFWRV LQGHVHDGRV GH FRPSHQVDFLyQHQIRUPDGHPiVXWLOL]DFLyQGHRWURVVHUYLFLRVVDQLWDULRVXUJHQFLDV\KRVSLWDOL]DFLyQGHORV
SDFLHQWHV PiV JUDYHV PHGLDQWH HO GHVSOD]DPLHQWR
KDFLDFRSDJRVHYLWDEOHV\GLIHUHQFLDOHVTXHVHDQUHGXFLGRVRQXORVSDUDORVWUDWDPLHQWRVPiVQHFHVDULRV
\HIHFWLYRV\PiVHOHYDGRVSDUDORVGHSHRUUHODFLyQ
FRVWHHIHFWLYLGDG
(O WHUFHU JUDQ DVSHFWR D UHVHxDU GHQWUR GH HVWH
HStJUDIH HV OD QHFHVLGDG GH VXSHUDU OD JHVWLyQ VDQLWDULDEDVDGDHQFRPSDUWLPHQWRVHVWDQFRVFRQPHQWDOLGDG GH ³VLOR´ /RV UHFXUVRV GH TXH GLVSRQHPRV
VHUHSDUWHQHQSUHVXSXHVWRVFRPSDUWLPHQWDGRVHQWUH
QLYHOHV DVLVWHQFLDOHV ±DWHQFLyQ SULPDULD KRVSLWDOHV
VRFLRVDQLWDULRV\HQWUHWLSRVGHSURGXFWRV±UHFHWDV
PpGLFDVPHGLFDPHQWRVKRVSLWDODULRVSUyWHVLVFRPR
VLIXHUDQSDUWLGDVVLQUHODFLyQHQOXJDUGHUHSDUWLUORV
VHJ~QHOFRVWHMXVWL¿FDGRGHODDWHQFLyQLQWHJUDOTXH
UHTXLHUHXQSDFLHQWHDOPDUJHQGHGRQGHUHFLEDHVD
DWHQFLyQ'HEHPRVRULHQWDUORVSUHVXSXHVWRVSDUDSDJDUSRUDTXHOORTXHGHVHDPRVREWHQHU3RUWDQWROD
OtQHDGHFDPELRHVHPSH]DUDSDJDUHQHOPDUJHQSRU
UHVXOWDGRVHQVDOXGSDJDUPiVSRUWHQHUDORVSDFLHQWHV VDQRV TXH QR SRU WHQHU PiV GHVFRPSHQVDFLRQHV
GHSDFLHQWHVFUyQLFRVRPiVUHLQJUHVRVSRUFRPSOLFDFLRQHVGHVSXpVGHXQDLQWHUYHQFLyQTXLU~UJLFDRSRU
H[FHVRVHQODFLUXJtDHOHFWLYDSDJDUPiVSRUYLVLWDV
UHVROXWLYDV TXH SRU GHULYDFLRQHV GH SDFLHQWHV HQWUH
SURIHVLRQDOHV VLQ UHVROYHU VXV SUREOHPDV GH VDOXG
(OORUHTXLHUHintegrar los presupuestos compartimentados entre niveles asistencialesSULPDULDHVSHFLDOL]DGDVRFLRVDQLWDULDIDUPDFLDPHGLDQWHXQD
¿QDQFLDFLyQ¿MDSUHHVWDEOHFLGDSRUWRGDODDWHQFLyQ
GH XQD SHUVRQD VHJ~Q VXV FDUDFWHUtVWLFDV ULHVJRV
TXH D\XGH D YLVXDOL]DU HO FRVWH LQWHJUDO GH OD DWHQFLyQDXQSDFLHQWHOLPLWDQGRDVtODYLVLyQSDUFLDO\
IUDJPHQWDGDTXHKR\FHQWULIXJD\HQFXEUHODIDOWDGH
UHVROXFLyQFOtQLFD
)UHQWHDODDFWXDOFRPSDUWLPHQWDFLyQGHQLYHOHV
DVLVWHQFLDOHVODLQWHJUDFLyQGHSUHVXSXHVWRVDWUDYpV
GH XQD ¿QDQFLDFLyQ SURVSHFWLYD EDVDGD HQ XQD FiSLWD DMXVWDGD SRU ODV FDUDFWHUtVWLFDV GH OD SREODFLyQ
FXELHUWDFRQWULEXLUtDDIRPHQWDUODDWHQFLyQLQWHJUDO
GHODVDOXG\ODGHSHQGHQFLD\DYLVXDOL]DUORVFRVWHV
WRWDOHVGHULYDGRVGHVXDWHQFLyQ/DLQWHJUDFLyQDQLYHOPDFURGHEHUtDLQFOXLUHQWUHRWUDVFRVDVODREOLJDFLyQGHUHQGLUFXHQWDVVREUHHOGHVHPSHxRGHODV
RUJDQL]DFLRQHV HQ VX iPELWR JHRJUi¿FR FRUUHVSRQ-
12
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS
GLHQWH2EVHUYDWRULGHO6LVWHPDGH6DOXWGH&DWDOXQ\DORTXHDVXYH]IDYRUHFHUtDODLQWURGXFFLyQ
GH PHFDQLVPRV GH SDJR SRU UHVXOWDGRV UHIRU]DQGR
DVtORVLQFHQWLYRVDRIUHFHUXQDDVLVWHQFLDUHVROXWLYD
\RULHQWDGDDPDQWHQHUXQDSREODFLyQVDQD\FXLGDGD
8UEDQRVHWDO
2.3. Coordinación entre niveles y sistemas
/DV HQIHUPHGDGHV FUyQLFDV VRQ FRQ GLIHUHQFLD
ODSULPHUDFDXVDGHPRUELPRUWDOLGDGHQ(VSDxDFRQVXPLHQGR OD PD\RU SDUWH GHO SUHVXSXHVWR VDQLWDULR
DGHPiVGHWHQHUXQIXHUWHLPSDFWRHQRWUDVGLPHQVLRQHVHFRQyPLFDV2OLYD0RUHQR/DVHQIHUPHGDGHVFUyQLFDVWLHQHQFDUDFWHUtVWLFDVHVSHFt¿FDVTXH
GL¿FXOWDQVXJHVWLyQSRUORVHVTXHPDVWUDGLFLRQDOHV
GHODVRUJDQL]DFLRQHVVDQLWDULDVPiVGLVHxDGRVSDUD
HODERUGDMHGHODVHQIHUPHGDGHVDJXGDV\ODVLQIHFFLRVDV6XVFDXVDVVRQP~OWLSOHV\FRPSOHMDV(QVX
GHVDUUROORLQWHUYLHQHQQXPHURVRVIDFWRUHVGHULHVJR
HVWiQVXMHWDVDXQSDWUyQGHUHFXUUHQFLD\GHWHULRUR
SURJUHVLYR VX QDWXUDOH]D HV SHUPDQHQWH VH GHVDUUROODQDORODUJRGHODYLGDWLHQHQXQDSUHYDOHQFLD
PXFKRPiVHOHYDGDHQODYHMH]\WLHQGHQDSURGXFLU LQFDSDFLGDG IXQFLRQDO \ GHSHQGHQFLD 'HVGH OD
SHUVSHFWLYDGHORVVHUYLFLRVVDQLWDULRVSUHVHQWDQWUHV
FDUDFWHUtVWLFDVHVHQFLDOHVVRQHQEXHQDSDUWHSUHYHQLEOHVDWUDYpVGHFDPELRVHQORVHVWLORVGHYLGD\
FDPELRVVRFLDOHVXQDYH]VREUHYHQLGDVHVSRVLEOH SUHYHQLU VXV H[DFHUEDFLRQHV \ GHVFRPSHQVDFLRQHV \ PDQWHQHU OD FDOLGDG GH YLGD GH ORV SDFLHQWHV
UHGXFLHQGRHOFRQVXPRIXWXURGHVHUYLFLRVVDQLWDULRV
\VXDERUGDMHUHTXLHUHODSUHVWDFLyQGHVHUYLFLRV
FOtQLFRV FRPSOHMRV D ODUJR SOD]R \ D WUDYpV GH WRGR
HOFRQWLQXRDVLVWHQFLDOFRQDFFHVRFRRUGLQDGRDGLIHUHQWHVUHFXUVRVVDQLWDULRVIiUPDFRVSUXHEDVGLDJQyVWLFDV FLUXJtD UHKDELOLWDFLyQ SUyWHVLV FXLGDGRV
GHHQIHUPHUtDWUDQVSRUWH\HQPXFKRVFDVRVH[WHQGLGDDORVVHUYLFLRVVRFLDOHV
3HVH D DOJXQRV DYDQFHV UHFLHQWHV 2OOHUR %DWXURQH\2UR]FR%HOWUiQ*RELHUQR9DVFR
0LQLVWHULR GH 6DQLGDG 6HUYLFLRV 6RFLDOHV H ,JXDOGDG OD DWHQFLyQ D ODV HQIHUPHGDGHV FUyQLFDV
SHUPDQHFHFHQWUDGDHQWRUQRDOPDQHMRGHVXVH[DFHUEDFLRQHVDJXGDV7RGRVORVVLVWHPDVVDQLWDULRVGH
ORVSDtVHVGHVDUUROODGRVLQFOX\HQGRHO616EXVFDQ
IyUPXODVSDUDmejorar la atención a los pacientes
crónicos DOWLHPSRTXHUHGXFHQHOJDVWRGHULYDGRGH
VXVIUHFXHQWHVH[DFHUEDFLRQHV\GHVFRPSHQVDFLRQHV
(OOODPDGR&KURQLF&DUH0RGHO:DJQHUHWDO
EDVDGRHQODSURPRFLyQGHORVDXWRFXLGDGRVHOUHGLVHxRGHODRUJDQL]DFLyQORVVLVWHPDVGHLQIRUPDFLyQ
Sistema Nacional de Salud y propuesta de reformas: más allá del ruido y la furia
FOtQLFRV \ ORV UHFXUVRV FRPXQLWDULRV HVSHFLDOPHQWH
GHDWHQFLyQSULPDULDHVODDSUR[LPDFLyQPiVYLVLEOH
HQ QXHVWUR HQWRUQR SHUR HO FRQVHQVR JHQHUDO VREUH
VXVYHQWDMDVQRUHGXFHODLQFHUWLGXPEUHVREUHVXLPSOHPHQWDFLyQ\GHVDUUROORHQHOFRQWH[WRGHO616XQ
VLVWHPD H[WUHPDGDPHQWH MHUDUTXL]DGR \ FRQ IXHUWHV
EDUUHUDV HQWUH QLYHOHV DVLVWHQFLDOHV \ GHQWUR GH ORV
SURSLRV QLYHOHV 6H WUDWD GH XQ DVSHFWR HVHQFLDO GH
FX\DUHVROXFLyQGHSHQGHEXHQDSDUWHGHODHVWDELOLGDG¿QDQFLHUDGHO616SHURWDPELpQODHIHFWLYLGDG\
FDOLGDGGHORVFXLGDGRVTXHSUHVWDXQDVSHFWRHVHQFLDOGHVXVROYHQFLD
3DUDUHVSRQGHUDODQWHULRUUHWRVHSUHFLVDGHXQD
mayor coordinación intersistemas. (VGHFLUHQWUH
HOVLVWHPD VDQLWDULR\HOVLVWHPDGHVHUYLFLRVVRFLDOHV
(O DVSHFWR HVHQFLDO VREUH HO TXH DYDQ]DU HV WHQGHU
SXHQWHVTXHSHUPLWDQLUFRQVWUX\HQGRXQDFXOWXUDGH
ODFRRSHUDFLyQHQWUHDPERVVLVWHPDV3DUDHOORVHKD
GH VHU FRQVFLHQWH GH TXH OD YHUGDGHUD VROXFLyQ LQWHJUDODORVSUREOHPDVFUyQLFRVGHVDOXGGHODVSHUVRQDVVyORSRGUiDOFDQ]DUVHLQFOX\HQGRHQHOGLVHxR
GH VXV SURJUDPDV DVLVWHQFLDOHV OD H[SHULHQFLD \ FRQRFLPLHQWR GH DPERV VLVWHPDV 6LQ HPEDUJR HVWD
FRRUGLQDFLyQ VH GHEH DUPDU R SURSLFLDU 1R VXUJLUi
GHPDQHUDHVSRQWiQHD(QHVWHVHQWLGRORVDVSHFWRV
DUHIRU]DUVREUHPDQHUDHVFRQVLGHUDUTXHODVSROtWLFDV
GHVDOXGGHEHQLUPiVDOOiGHORVDVSHFWRVH[FOXVLYDPHQWHVDQLWDULRV\TXHODSURPRFLyQGHODDXWRQRPtD
SHUVRQDOQRHVPHUDPHQWHODDWHQFLyQDODVSHUVRQDV
HQVLWXDFLyQGHGHSHQGHQFLD6(63$62OLYD
HWDO3DUDYHUWHEUDUDPERVHOHPHQWRVHOSDSHO GH OD 6DOXG 3~EOLFD FRPR HOHPHQWR FRKHVLRQDGRU GH OD FRRUGLQDFLyQ HQWUH DWHQFLyQ VDQLWDULD \ D
OD DWHQFLyQ VRFLDO HV FODYH 6L HO REMHWLYR GH OD 6DOXG3~EOLFDHVJDUDQWL]DUTXHODVSHUVRQDVYLYDQHQ
FRQGLFLRQHVVDOXGDEOHVHQWRQFHVVXiPELWRGHDFWXDFLyQGHEHWUDVFHQGHUHOiPELWRVDQLWDULRHLGHQWL¿FDU
\DFWXDUVREUHORVGHWHUPLQDQWHVGHODVDOXGSUHVHQWHV
HQiPELWRVQRVDQLWDULRVFRPRODDWHQFLyQVRFLDOOD
HGXFDFLyQHOPHUFDGRODERUDOHOXUEDQLVPRRODVSROtWLFDVGH¿VFDOHVSRUFLWDUDOJXQDVHQORVTXHVHJHQHUDQRWUDQVPLWHQGHVLJXDOGDGHVVRFLDOHV\GHVDOXG
(Salud en todas las Políticas$UWDFR]HWDO
*RQ]iOH]/ySH]9DOFiUFHO\2UW~Q0LUDQGR
DGRVRWUHVGpFDGDVYLVWDXQHOHPHQWRFODYHSDUDOD
VRVWHQLELOLGDGGHO(VWDGRGH%LHQHVWDUVHUiHOHVWDGR
GHVDOXGGHODVSHUVRQDVGH\PiVDxRV3HURGLFKRHVWDGRQRGHSHQGHUiGHODVLQYHUVLRQHVVDQLWDULDV
UHDOL]DGDV HQ HVH PRPHQWR VLQR GH ODV LQYHUVLRQHV
UHDOL]DGDVDORODUJRGHODYLGDGHODVSHUVRQDVGHVGH
ODLQIDQFLDRLQFOXVRDQWHVFRQHOFXLGDGRSUHQDWDO
ODMXYHQWXG\ODPDGXUH]VLHQGRGLFKDVLQYHUVLRQHV
HQJUDQPHGLGDGHFDUiFWHUQRVDQLWDULR0XFKDVGH
HVWDVLQYHUVLRQHVWUDQVLWDQSRUDFXHUGRVHQWUHDJHQWHV
VRFLDOHVSLpQVHVHHQODUHGXFFLyQGHVDOHQODVFRPLGDVSUHSDUDGDVFRQWHQLGRVFXUULFXODUHVDLQFRUSRUDU
HQORVSODQHVHGXFDWLYRVGHSREODFLyQHQHGDGLQIDQWLO\MRYHQRGHOGHVDUUROORGHLQYHVWLJDFLyQDSOLFDGD
TXHLGHQWL¿TXHSROtWLFDVGHp[LWRHQRWURVSDtVHV¿VFDOHVGHFRRUGLQDFLyQHQWUHVLVWHPDV\SRUWDQWR
QR UHTXLHUHQ GH JUDQGHV GRWDFLRQHV SUHVXSXHVWDULDV
SDUDVXLPSOHPHQWDFLyQ6HKDGHVHUFRQVFLHQWHGH
TXH ODV LQYHUVLRQHV TXH WUDWDQ GH PRGL¿FDU KiELWRV
LQGLYLGXDOHV FRPSRUWDPLHQWRV VRFLDOHV R GH FUHDU
HQWRUQRVIDYRUDEOHVSDUDODVDOXGVyORWLHQHQUHWRUQRV
HQHOODUJRSOD]R6LQHPEDUJRQRSRUHOORVRQPHQRV
QHFHVDULDVGHDFRPHWHU
8Q~OWLPRDVSHFWRDFRQVLGHUDUGHQWURGHODSDUWDGRGHFRRUGLQDFLyQHVHOSODQWHDUQRVORVHVFHQDULRV
GH GHVDUUROOR GH OD colaboración público-privada
en sanidad \ HQ FRQFUHWR VREUH ODV fórmulas de
gestión de los servicios sanitarios. (QHVWHVHQWLGR
ODSURSXHVWDGHQXHYRVSODQWHDPLHQWRVRHODKRQGDU
HQHVWUDWHJLDV\DLPSOHPHQWDGDVGHEHUtDQHQWHRUtD
SDUWLUGHODFRPELQDFLyQGHORVSXQWRVIXHUWHVGHFDGD
VLVWHPDHQVXDSOLFDFLyQUHDOFRQHVSHFLDOpQIDVLVHQ
OD E~VTXHGD GH OD UHQWDELOLGDG VRFLDO SHUR VLQ GHMDU
GH GLVHxDU HVTXHPDV H¿FLHQWHV GH LQFHQWLYRV DSR\DGRVHQHOHPHQWRVGHFRPSDUDFLyQ\FRPSHWHQFLD
'XUDQWH ODV GRV ~OWLPDV GpFDGDV HQ (VSDxD KHPRV
H[SHULPHQWDGRFRQWRGRWLSRGHIyUPXODVGHJHVWLyQ
\FDPELRVGHIRUPDVRUJDQL]DWLYDVGHQWURGHODJHVWLyQVDQLWDULDWDQWRHQHOFDPSRGHODJHVWLyQGLUHFWD
S~EOLFD FRPR LQGLUHFWD SULYDGD DO OHFWRU LQWHUHVDGRHQORVGHWDOOHVGHODVIyUPXODVGHJHVWLyQVHOH
UHPLWH D$EHOOiQ HW DO (Q HVWRV DxRV GHEHUtDPRVKDEHUDFXPXODGRLQIRUPDFLyQUHOHYDQWHVREUH
ODIRUWDOH]DV\ODGHELOLGDGHVGHWHFWDGDVGHFDGDXQD
GHODVIyUPXODVHOHJLGDV6LQHPEDUJRUHVXOWDWULVWH
FRQVWDWDUTXHQRH[LVWHQHYDOXDFLRQHVLQGHSHQGLHQWHV
UHDOL]DGDVHQQXHVWURPHGLRVREUHHVWDFXHVWLyQ/D
RSDFLGDG HQ ORV UHVXOWDGRV GH ODV H[SHULHQFLDV LPSOHPHQWDGDVFRQOOHYDXQDIDOWDGHFRQRFLPLHQWRTXH
SURSLFLD UHFHOR \ GHVFRQ¿DQ]D VREUH ODV PLVPDV \
ODVWUDHOGHVDUUROORGHQXHYRVHVFHQDULRV
3DUDREWHQHUDOJ~QFRQRFLPLHQWRVREUHODFXHVWLyQ GHEHPRV UHFXUULU D OD OLWHUDWXUD LQWHUQDFLRQDO
+HOORZHOO\3ROORFN9HFFKLHWDO0DVRQ HW DO &RRSHU HW DO /D SULQFLSDO
FRQFOXVLyQGHODUHFLHQWHH[SHULHQFLDEULWiQLFDEDQGHUD HQ H[SHULPHQWRV GH FRODERUDFLyQ S~EOLFR SULYDGD HV TXH OD JHVWLyQ SULYDGD GH ORV VHUYLFLRV VDQLWDULRV QR HV QHFHVDULDPHQWH PHMRU TXH OD JHVWLyQ
S~EOLFD«QLDOFRQWUDULR)DFWRUHVWDOHVFRPRHOHQWRUQRDGPLQLVWUDWLYRHLQVWLWXFLRQDOODFXOWXUDGHORV
FHQWURVODVFRQGLFLRQHVGHORVFRQWUDWRV\ODDGHFXD-
Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS
GDVXSHUYLVLyQSRUSDUWHGHO¿QDQFLDGRUGHODFDOLGDG
GHO VHUYLFLR SUHVWDGR VRQ ORV HOHPHQWRV D WHQHU HQ
FXHQWDFXDQGRVHDQDOL]DQHVWRVFDVRV(QFDPELRVt
SDUHFHFODURTXHHOIRPHQWRGHODFRPSDUDFLyQ\OD
FRPSHWHQFLDHQWUHFHQWURVFRQLQGHSHQGHQFLDGHOD
IRUPDMXUtGLFDGHJHVWLyQVtSXHGHD\XGDUDPHMRUDU
VXVUHVXOWDGRVWDQWRHQWpUPLQRVGHH¿FLHQFLDFRPR
GHFDOLGDGFOtQLFD
SDFLGDGGHGLVFULPLQDUHOGHVHPSHxR\PD\RUJUDGR
GHDXWRQRPtDHQpVWHUHFRQRFLPLHQWRWLHPSRSDUDOD
IRUPDFLyQHLQYHVWLJDFLyQXQDPD\RUSDUWLFLSDFLyQ
HQODVGHFLVLRQHVGHVDUUROORGHODFDUUHUDSURIHVLRQDO
EDVDGDHQHOHPHQWRVGHPpULWR\GHVHPSHxRSURIHVLRQDOFODURV\H[SOtFLWRV$FDPELRGHHOORWDPELpQ
GHEHVHUH[LJLEOHODDSOLFDFLyQGHORVPLVPRVFULWHULRVJHQHUDOHVSURSXHVWRVWUDQVSDUHQFLD\UHQGLFLyQ
GHFXHQWDVHQHOGHVHPSHxR
2.4. Buen gobierno de la sanidad y complicidad de
los actores
$VLPLVPRODVROYHQFLDGHOVLVWHPDVDQLWDULRQR
VHUiYLDEOHVLQODFRUUHVSRQVDELOLGDGGHORVXVXDULRV
FRQHOVLVWHPDVDQLWDULR\FRQVXVDOXG3DUWLHQGRGHOD
YLVLyQGHODHFRQRPtDGHODVDOXGVREUHODSURGXFFLyQ
GHVDOXGTXLHQSURGXFHVDOXGQRVRQORVSURIHVLRQDOHVQRVRQODVWHFQRORJtDVHPSOHDGDVQRVRQORVJRELHUQRVVRQODVSHUVRQDVFLXGDGDQRVELHQLQIRUPDGRVFRPSHWHQWHV\FRPSURPHWLGRVHQODSURPRFLyQ
\FXLGDGRGHVXSURSLDVDOXG\ELHQIRUPDGRVHQODV
YHQWDMDV\ULHVJRVGHODXWLOL]DFLyQGHORVVHUYLFLRVVDQLWDULRV(OORVXSRQHLQFRUSRUDUDODFLXGDGDQtDFRPR
DJHQWHFODYHHQODSDUWLFLSDFLyQGHODSODQL¿FDFLyQGH
ODFRRUGLQDFLyQDVLVWHQFLDO\ODFRRUGLQDFLyQLQWHUVLVWHPDV(VWRLPSOLFDSRUXQDSDUWHUHWRVLPSRUWDQWHV
SDUDODFXOWXUDRUJDQL]DWLYD\SURIHVLRQDOSXHVWRTXH
VHGHEHIDFLOLWDUHODFFHVRDODLQIRUPDFLyQDVXFRPSUHQVLyQ\DVXYDORUDFLyQSRUSDUWHGHOFLXGDGDQR
FRPRSDUWHGHXQSURFHVRGRQGHVHLQFUHPHQWDVXOD
FDSDFLGDGGHHOHFFLyQ3RURWUDDXPHQWDQODVREOLJDFLRQHV\UHVSRQVDELOLGDGHVGHpVWHWRGDYH]TXHQRV
DOHMDPRVGHODLGHDGHOSDFLHQWHSDVLYRSDUDVXEUD\DU
ORVYDORUHVGHSDUWLFLSDFLyQ\UHVSRQVDELOLGDGGHQWUR
GHXQPDUFRUHVSRQVDEOHGHXVRGHORVVHUYLFLRVVDQLWDULRV\GHODSURPRFLyQ\FXLGDGRGHODSURSLDVDOXG
\DXWRQRPtDSHUVRQDO&XOOHQ
(OFXDUWRHMHHVHOPiVFRPSOHMRGHDERUGDU\D
TXHVXSRQHXQFDPELRFXOWXUDOSURIXQGRGHQWURGHO
616HLQFOXVRWUDVFLHQGHDHVWHiPELWR8QDEXHQD
JREHUQDQ]D LQÀX\H SRVLWLYDPHQWH HQ WRGDV ODV IXQFLRQHV GHO VLVWHPD VDQLWDULR PHMRUDQGR VX GHVHPSHxR \ HQ ~OWLPD HVWDQFLD ORV UHVXOWDGRV GH VDOXG
&RXQFLO RI (XURSH /D EXHQD JREHUQDQ]D
GH ORV VLVWHPDV VDQLWDULRV GHEH DSR\DUVH HQ YDORUHV
IXQGDPHQWDOHV FRPR VRQ ORV GHUHFKRV KXPDQRV HO
FXPSOLPLHQWRGHODVOH\HV\ODGHPRFUDFLD\HQSULQFLSLRVUHFWRUHVDORVTXHUHVSRQGHODVDQLGDGS~EOLFD
XQLYHUVDOLGDGHTXLGDG\VROLGDULGDG3HURODVDQWHULRUHV QRUPDV GHEHQ VHU FRPSOHPHQWDGDV SRU RWURV
SULQFLSLRVGHEXHQJRELHUQRFRPRVHUtDQFRQVWUXLUXQ
VLVWHPD PXFKR PiV WUDQVSDUHQWH HQ OD LQIRUPDFLyQ
SURSRUFLRQDGD D XVXDULRV SURIHVLRQDOHV \ FLXGDGDQRVEXVFDUIyUPXODVGHSDUWLFLSDFLyQHQODWRPDGH
GHFLVLRQHV FRQ ORV SURIHVLRQDOHV VDQLWDULRV \ FRQ OD
FLXGDGDQtDGHVDUUROODUQRUPDV\HVWUXFWXUDVFRQFUHWDVSDUDTXHODVSHUVRQDVUHVSRQVDEOHVGHODWRPDGH
GHFLVLRQHVULQGDQFXHQWDVGHODVPLVPDV\MXVWL¿FDU
ODV DQWHULRUHV EDViQGRVH HQ FULWHULRV H[SOtFLWRV GH
HIHFWLYLGDGH¿FLHQFLD\FDOLGDGHQWRGRVORVQLYHOHV
GHO VLVWHPD VDQLWDULR &RPSOHPHQWDULDPHQWH VH GHEHUtDSURPRYHUSULPHUR\GHIHQGHUDFRQWLQXDFLyQ
XQDFXOWXUDGHLQWHJULGDGEXHQDVSUiFWLFDV\GHpWLFD
SURIHVLRQDODWRGRVORVQLYHOHVFyGLJRVGHFRQGXFWD
DWHQFLyQ D ORV FRQÀLFWRV GH LQWHUpV \ SUHYHQFLyQ \
GHWHFFLyQGHOIUDXGH\ODFRUUXSFLyQ
/D FRPSOLFLGDG GH ORV SULQFLSDOHV DFWRUHV HQ HO
PDQWHQLPLHQWRGHODVROYHQFLDGHO616QRVHUiSRVLEOHVLQDYDQ]DUKDFLDQRUPDVGHEXHQJRELHUQR/RV
SURIHVLRQDOHVVDQLWDULRVSRVHHQPRWLYDFLyQLQWUtQVHFDDOWRQLYHOGHIRUPDFLyQHOHYDGRQLYHOLQWHOHFWXDO
ODUHOHYDQFLDVRFLDOGHVXGHVHPSHxRHVHQRUPH«\
VLQHPEDUJRXQRGHORVFROHFWLYRVSURIHVLRQDOHVFRQ
PD\RUHVtQGLFHVGH³EXUQRXW´(OORGHEHKDFHUSHQVDUHQHOUHGLVHxRGHORVDFWXDOHVVLVWHPDGHLQFHQWLYRV%HUGXGLQYHUWLUHQFDSLWDOPRWLYDFLRQDO
UHWULEXFLyQDGHFXDGDSURIHVLRQDOL]DUODJHVWLyQFD-
6LQ HPEDUJR SDUD SRGHU LQYROXFUDU DO UHVWR GH
SURIHVLRQDOHV\DJHQWHVVRFLDOHVGHEHH[LVWLUXQFRPSURPLVRTXHVHWUDGX]FDHQODGHFODUDFLyQGHUHJODV
FODUDV SRU SDUWH GH ORV GHFLVRUHV GH PiV DOWR QLYHO
UHSUHVHQWDQWHVGHODFLXGDGDQtD\HQXQDOWRJUDGR
GH H[LJHQFLD pWLFD EXHQ JRELHUQR$XQTXH HO GHVHPSHxRQRVHDVHQFLOORDIRUWXQDGDPHQWHFRQWDPRV
FRQDFHUWDGDVLQGLFDFLRQHVSDUDD\XGDUQRVHQHOPLVPR0HQHX52UW~Q*RELHUQR9DVFR
\ FRQ OD UHFLHQWH H[SHULHQFLD GH SDtVHV GH QXHVWUR
HQWRUQR TXH KDQ DSRVWDGR GHFLGLGDPHQWH SRU GRWDU
DVXVLVWHPDVDQLWDULRGHHVWHWLSRGHQRUPDVHQVXV
SURFHVRV'HSDUWPHQWRI+HDOWK
3. CONCLUSIONES
(O6LVWHPD1DFLRQDOGH6DOXGHVWiVLHQGRXQRGH
ORVHVWDELOL]DGRUHVVRFLDOHVFODYHHQ(VSDxDSDUDTXH
Sistema Nacional de Salud y propuesta de reformas: más allá del ruido y la furia
ODFULVLVHFRQyPLFDQRGHULYHHQXQDFULVLVVRFLDOGH
JUDQPDJQLWXG(OTXHORVFLXGDGDQRVWHQJDQDFFHVR
KDVWDKDFHSRFRWLHPSRSUiFWLFDPHQWHXQLYHUVDODOD
VDQLGDGS~EOLFDHVXQORJUR\XQGHUHFKRGHOTXHGLVIUXWDPRVSHURHVXQHOHPHQWRGHFRKHVLyQVRFLDO\
GHSURWHFFLyQGHODVDOXGTXHHVWiPRVWUDQGRWRGRVX
YDORUHQORVPiVGXURVPRPHQWRVGHHVWDFULVLV
(Q SRFR WLHPSR EXHQD SDUWH GH ORV PHQVDMHV
SROtWLFRV KDQ SDVDGR GH XQ GLVFXUVR DFUtWLFR KDFLD
QXHVWUR616DOXGLHQGR~QLFDPHQWHDVXVERQGDGHV
DPXWDUHQPHQVDMHVFDWDVWUR¿VWDVDYHFHVGLULJLGRV
SRUODVPLVPDVSHUVRQDVTXHDOXGHQDLPiJHQHVGH
GHVSLOIDUURJHQHUDOGHVPRWLYDGRVSURIHVLRQDOHVTXH
SHUVLJXHQPiVVXLQWHUpVSURSLRTXHHOELHQJHQHUDO
FLXGDGDQRVTXHKDFHQXQXVRLQDGHFXDGRGHORVUHFXUVRVVDQLWDULRV\XQVLVWHPDVDQLWDULRS~EOLFRTXH
HQ VXPD UHVXOWD ¿QDQFLHUDPHQWH LQVRVWHQLEOH 6LQ
HPEDUJRWDQ¿FWLFLRHUDHOSULPHUGLVFXUVRFXDOTXLHU
VLVWHPDSRUEULOODQWHTXHVHDVLHPSUHWLHQHPDUJHQ
GH PHMRUD \ KD GH UHVSRQGHU D QXHYRV UHWRVFRPR
HVWHVHJXQGRTXHRFXOWDGHOLEHUDGD\WRUWLFHUDPHQWH
ODVIRUWDOH]DVGHO616
6t SDUHFH FODUR \ QR KDEUtD TXH HQJDxDUVH HQ
HOORTXHHQXQFRQWH[WRGHLQJUHVRVS~EOLFRVUHGXFLGRV\FRQHVFDVRRQXORPDUJHQSDUDLQFUHPHQWDU
OD GHXGD SDUHFH XQ LPSHUDWLYR GHO TXH VHUi GLItFLO
HVFDSDU HO ORJUDU XQ PHMRU GHVHPSHxR FRQ PHQRV
UHFXUVRVGLVSRQLEOHV/RVFXDWURHMHVVHxDODGRVPDUFDQXQDDJHQGDDGHVDUUROODUHQHOHQWHQGLPLHQWRGH
TXHORVPLVPRVQRVyORVRQFRPSOHPHQWDULRVHQWUH
Vt VLQR TXH GLItFLOPHQWH SXHGHQ HQWHQGHUVH SRU VHSDUDGR \ TXH HO p[LWR GH DYDQ]DU HQ XQD SURSXHVWD
GH HVWDV FDUDFWHUtVWLFDV H[LJLUtD TXH VH DFRPHWLHUDQ
FRQMXQWDPHQWH
([SUHVDGRHQWpUPLQRVPiVFRQFUHWRVODVROYHQFLD GHO 6LVWHPD 1DFLRQDO GH 6DOXG \ OD SRVLELOLGDG
GHGHVDUUROODUSROtWLFDVGHVDOXGLQWHUVHFWRULDOHVTXH
DPRUWLJHQORVHIHFWRVGHODFULVLVHFRQyPLFDVREUH
OD VDOXG GH ORV FLXGDGDQRV SDVDUiQ QHFHVDULDPHQWH
SRUFRQMXJDUODJHVWLyQH¿FLHQWHGHORVUHFXUVRVFRQ
XQHVSHFLDOpQIDVLVHQODHTXLGDGGHODVSROtWLFDVLPSOHPHQWDGDV3DUDHOORFRQGLFLRQHVQHFHVDULDVDXQTXHQRVX¿FLHQWHVVHUiQDSR\DUQRVHQODVIRUWDOH]DV
GH QXHVWUR VLVWHPD SHUR WDPELpQ LGHQWL¿FDU EROVDV
GHLQH¿FLHQFLDDSUHQGHUGHH[SHULHQFLDVDMHQDVDSOLFiQGRODVFRQLQWHOLJHQFLDHQQXHVWURPHGLRDSHODUDO
OLGHUD]JR\FRPSURPLVRGHORVSURIHVLRQDOHVVDQLWDULRV\IDYRUHFHUODSDUWLFLSDFLyQFLXGDGDQDWRPDUGHFLVLRQHVLQIRUPDGDV\FXOWLYDUODHYDOXDFLyQGHQXHVWUDVSROtWLFDVQRFRPRXQDKHUUDPLHQWDUHODWLYDPHQWH
~WLO VLQR FRPR SDUWH GHO FDPELR FXOWXUDO QHFHVDULR
SDUD TXH QXHVWUR VLVWHPD VDQLWDULR FRQWLQ~H PDQWHQLHQGR\PHMRUDQGRHOELHQHVWDUVRFLDO
/DLPSDVLYLGDGODVPHGLGDVFHQWUDGDVH[FOXVLYDPHQWHHQHOFRUWRSOD]R\ODVGHFLVLRQHVDOHMDGDVGHO
FRQRFLPLHQWR FLHQWt¿FRWpFQLFR FRQOOHYDQ XQD HURVLyQGHODFDOLGDGGHOVLVWHPD\DUULHVJDQODGHVDIHFFLyQGHOFLXGDGDQRKDFLDHOVLVWHPDVDQLWDULRS~EOLFR
\KDFLDVXVUHSUHVHQWDQWHV 8QPDQWUDUHSHWLGRKDVWD
OD VDFLHGDG HQ ORV ~OWLPRV WLHPSRV HV TXH KD\ TXH
WRPDU GHFLVLRQHV YDOLHQWHV 6LQ GXGD 3HUR TXLHQHV
¿UPDPRV HVWDV OtQHDV RSLQDPRV TXH ODV GHFLVLRQHV
GHEHQ VHU VREUH WRGR LQWHOLJHQWHV ELHQ LQIRUPDGDV
SRUSUXHEDVFLHQWt¿FDVMXVWL¿FDGDVDQWHORVFLXGDGDQRVOHJLWLPDGDVSRUQRUPDVGHEXHQJRELHUQR\TXH
UHSDUWDQORVVDFUL¿FLRVHQWUHORVDJHQWHVLPSOLFDGRV
/RGHPiVQRVHUiQVLQRFXHQWRVOOHQRGHUXLGR\GH
IXULDVLQVLJQL¿FDGRDOJXQR
4. REFERENCIAS EMPLEADAS (POR ORDEN ALFABÉTICO):
‡ $EHOOiQ 3HUSLxiQ -0 0DUWtQH] 3pUH] -(
0pQGH]0DUWtQH],6iQFKH]0DUWtQH]),*DUULGR*DUFtD6)LQDQFLDFLyQ\H¿FLHQFLDGHO
VLVWHPD VDQLWDULR S~EOLFR GH OD 5HJLyQ GH 0XUFLD &RQVHMR (FRQyPLFR \ 6RFLDO GH OD 5HJLyQ
GH0XUFLD
‡ $EDGtD7DLUD 0% 0DUWtQH]/L]DJD 1 *DUFtD$UPHVWR65LGDR/ySH]0<DxH])6HUDO
5RGUtJXH] 0 HW DO 9DULDELOLGDG HQ ODV
KRVSLWDOL]DFLRQHV SRWHQFLDOPHQWH HYLWDEOHV UHODFLRQDGDVFRQODUHDJXGL]DFLyQGHHQIHUPHGDGHV
FUyQLFDV $WODV 9DU 3UDFW 0HG 6LVW 1DF 6DOXG
‡ $JHQFLD7ULEXWDULD,QIRUPHV$QXDOHVGH5HFDXGDFLyQ 7ULEXWDULD 9DULRV DxRV >FRQVXOWDGR
@ 'LVSRQLEOH HQ KWWSZZZDJHQFLDWULEXWDULDHV$($7LQWHUQHW,QLFLRBHVB(6
/DB$JHQFLDB7ULEXWDULD0HPRULDVB\BHVWDGLVWLFDVBWULEXWDULDVB(VWDGLVWLFDVBWULEXWDULDVBB(VWDGLVWLFDVBWULEXWDULDVBVKWPO
‡ $LEDU 5HPyQ & 'LU (VWXGLR ($5&$6 (YHQWRV $GYHUVRV HQ 5HVLGHQFLDV \ &HQWURV
$VLVWHQFLDOHV 6RFLRVDQLWDULRV 0DGULG
0LQLVWHULR GH 6DQLGDG \ &RQVXPR >FRQVXOWDGR
@ 'LVSRQLEOH HQ KWWSZZZPVVVL
JREHVRUJDQL]DFLRQVQVSODQ&DOLGDG616GRFV
($5&$6SGI
Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
‡ $UDQD]$QGUpV -0 'LU (VWXGLR 1DFLRQDO VREUH ORV (IHFWRV $GYHUVRV OLJDGRV D OD
+RVSLWDOL]DFLyQ (1($6 0DGULG 0LQLVWHULR GH 6DQLGDG \ &RQVXPR >FRQVXOWDGR
@ 'LVSRQLEOH HQ KWWSZZZPVVVL
JREHVRUJDQL]DFLRQVQVSODQ&DOLGDG616SGI
H[FHOHQFLDRSVFBVSSGI
‡ $UDQD]$QGUpV-0'LU(VWXGLRVREUH
ODVHJXULGDGGHORVSDFLHQWHVHQDWHQFLyQSULPDULD GH VDOXG $3($6 0DGULG 0LQLVWHULR GH
6DQLGDG \ &RQVXPR >FRQVXOWDGR @
'LVSRQLEOH HQ KWWSZZZPVFHVRUJDQL]DFLRQ
VQVSODQ&DOLGDG616GRFV/LEUR$3($6SGI
‡ $UWDFR] / 2OLYD - (VFULYi 9 =XUULDJD *
/D VDOXG HQ WRGDV ODV SROtWLFDV XQ UHWR
SDUD OD VDOXG S~EOLFD HQ (VSDxD ,QIRUPH 6(63$6*DFHWD6DQLWDULD6XSSO±
‡ $VRFLDFLyQ GH (FRQRPtD GH OD 6DOXG $(6
D $SRUWDFLRQHV DO GLDJQyVWLFR VREUH HO
616HVSDxROSDUDXQ3DFWRSRUOD6DQLGDG%DUFHORQD $VRFLDFLyQ GH (FRQRPtD GH OD 6DOXG
>FRQVXOWDGR @ 'LVSRQLEOH HQ
KWWSZZZDHVHV3XEOLFDFLRQHVVLQWHVLVSDFWR06&SGI
‡ $VRFLDFLyQGH(FRQRPtDGHOD6DOXGE
3RVLFLyQGHOD$VRFLDFLyQGH(FRQRPtDGHOD6DOXGHQUHODFLyQDODQHFHVLGDGGHXQPD\RUXVR
GHODHYDOXDFLyQHFRQyPLFDHQODVGHFLVLRQHVTXH
DIHFWDQ D OD ¿QDQFLDFLyQ S~EOLFD GH ODV SUHVWDFLRQHV \ WHFQRORJtDV HQ HO 6LVWHPD 1DFLRQDO GH
6DOXG >FRQVXOWDGR @ 'LVSRQLEOH HQ
KWWSZZZDHVHV3XEOLFDFLRQHV$(6((SGI
‡ %DUULRV9&DOGHUyQ$(VFREDU&GHOD)LJXHUD 0 3ULPDU\ &DUH *URXS LQ WKH &OLQL&OLQL
FDO&DUGLRORJ\6HFWLRQRIWKH6SDQLVK6RFLHW\RI
&DUGLRORJ\ 3DFLHQWHV FRQ ¿EULODFLyQ DXULFXODU
DVLVWLGRVHQFRQVXOWDVGHDWHQFLyQSULPDULD(VWXGLR9DO)$$35HY(VS&DUGLRO
‡ %HUGXG0&DEDVpV-01LHWR-0RWLYDWLRQDO&DSLWDODQG,QFHQWLYHVLQ+HDOWK&DUH
2UJDQLVDWLRQV'78QLYHUVLGDG3~EOLFDGH
1DYDUUD
‡ %HUQDO'HOJDGR ( *DUFtD$UPHVWR 6
&DPSLOOR$UWHUR & ¢6LUYHQ ORV HVWXGLRV
GHYDULDELOLGDGJHRJUi¿FDGHODSUiFWLFDSDUDLQIRUPDUGHODGHVLQYHUVLyQ"9DULDVFDXWHODV\DOJXQDVUHÀH[LRQHV*DF6DQLWKWWSG[GRL
16
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS
RUJMJDFHWD
‡ %HUZLFN'0+DFNEDUWK$'(OLPLQDWLQJZDVWHLQ86KHDOWKFDUH-$0$
‡ &DPSLOOR$UWHUR&%HUQDO'HOJDGR(
5HLQYHUVLyQHQVDQLGDGIXQGDPHQWRVDFODUDFLRQHVH[SHULHQFLDV\SHUVSHFWLYDV*DF6DQLW
KWWSG[GRLRUJMJDFHWD
‡ &HQWURGH,QYHVWLJDFLRQHV6RFLROyJLFDV&,6
&DOLGDG GH ORV VHUYLFLRV S~EOLFRV 9,
'LVWULEXFLRQHV PDUJLQDOHV (VWXGLR Qž -XQLR-XOLR
‡ &RRSHU = *LEERQV 6 -RQHV 6 0F*XLUH $
'RHV &RPSHWLWLRQ ,PSURYH 3XEOLF +RVSLWDOV¶ (I¿FLHQF\" (YLGHQFH IURP D 4XDVL([SHULPHQWLQWKH(QJOLVK1DWLRQDO+HDOWK6HUYLFH
&HQWUH IRU (FRQRPLF 3HUIRUPDQFH 'LVFXVVLRQ
3DSHU 1R /RQGRQ 6FKRRO RI (FRQRPLFV
DQG3ROLWLFDO6FLHQFH
‡ &RXQFLO RI (XURSH 5HFRPPHQGDWLRQ
&05HFRIWKH&RPPLWWHHRI0LQLVWHUV
WRPHPEHUVWDWHVRQJRRGJRYHUQDQFHLQKHDOWK
V\VWHPV
‡ &XOOHQ5(PSRZHULQJSDWLHQWVWURXJK
KHDOWK LQIRUPDWLRQ OLWHUDF\ WUDLQLQJ :RUOG /LEUDU\ DQG ,QIRUPDWLRQ &RQJUHVV ,)/$ JHQHUDO&RQIHUHQFHDQG&RXQFLO$XJXVW%XHQRV$LUHVKWWSZZZDUFKLYHLÀDRUJ
‡ 'HSDUWPHQWRI+HDOWK7KH0DQGDWH$
PDQGDWHIURPWKH*RYHUQPHQWWRWKH1+6&RPPLVVLRQLQJ %RDUG $SULO WR 0DUFK 3UHVHQWHG WR 3DUOLDPHQW SXUVXDQW WR 6HFWLRQ
$RIWKH1DWLRQDO+HDOWK6HUYLFH$FW
>FRQVXOWDGR @ 'LVSRQLEOH HQ KWWS
PDQGDWHGKJRYXN
‡ *pUYDV-*DUFtD2OPRV/06LPy-3HLUy6
>3DUDGR[HV LQ UHIHUUDO IURP SULPDU\ WR
VSHFLDOLVWFDUH@$WHQ3ULPDULD
‡ *RELHUQR 9DVFR 'HSDUWDPHQWR GH 6DQLGDG
\ &RQVXPR (VWUDWHJLD SDUD DIURQWDU HO
UHWR GH OD FURQLFLGDG HQ (XVNDGL >FRQVXOWDGR
@ 'LVSRQLEOH HQ KWWSFURQLFLGDG
EORJHXVNDGLQHWGHVFDUJDVSODQ(VWUDWHJLD&URQLFLGDGSGI
‡ *RELHUQR9DVFR&RQVHMHUtDGH6DOXG\&RQVXPR 5HFRPHQGDFLRQHV GHO &RQVHMR
Sistema Nacional de Salud y propuesta de reformas: más allá del ruido y la furia
$VHVRUVREUHHO&yGLJRGH%XHQ*RELHUQRGHOD
6DQLGDG 3~EOLFD 9DVFD FRQVXOWDGR 'LVSRQLEOH HQ KWWSZZZLUHNLDHXVNDGLQHW
HVQHZVEXHQJRELHUQRVDQLGDGSXEOLFD
YDVFD"W ‡ *RQ]iOH]/ySH]9DOFiUFHO%2UW~Q9
3XWWLQJ KHDOWK LQ DOO ZHOIDUH SROLFLHV LV LW ZDUUDQWHG"$6RXWKHUQ(XURSHDQSHUVSHFWLYH-(SLGHPLRO&RPPXQLW\+HDOWK
‡ *UDKDP & +DSSLQHVV $QG +HDOWK
/HVVRQVDQG4XHVWLRQV)RU3XEOLF3ROLF\+HDOWK
$IIDLUV
‡ +HOORZHOO03ROORFN$07KHSULYDWH
¿QDQFLQJRI1+6KRVSLWDOVSROLWLFVSROLF\DQG
SUDFWLFH(FRQRPLF$IIDLUV
‡ 0DVRQ$6WUHHW$9HU]XOOL53ULYDWH
VHFWRUWUHDWPHQWFHQWUHVDUHWUHDWLQJOHVVFRPSOH[
SDWLHQWVWKDQWKH1+6-56RF0HG$XJ
‡ 0HQHX 5 2UW~Q 9 7UDQVSDUHQFLD \
EXHQJRELHUQRHQVDQLGDG7DPELpQSDUDVDOLUGH
ODFULVLV*DF6DQLW
‡ 0LQLVWHULR GH 6DQLGDG 6HUYLFLRV 6RFLDOHV H
,JXDOGDG(VWUDWHJLDSDUDHO$ERUGDMHGH
OD &URQLFLGDG HQ HO 6LVWHPD 1DFLRQDO GH 6DOXG
>FRQVXOWDGR @ 'LVSRQLEOH HQ KWWS
ZZZPVVVLJREHVRUJDQL]DFLRQVQVSODQ&DOLGDG616SGI(675$7(*,$B$%25'$-(B
&521,&,'$'SGI
‡ 0LUDYLWOOHV0GHOD5R]D&1DEHUDQ./DPEDQ0*REDUWW(0DUWLQ$8VHRIVSLURPHWU\DQGSDWWHUQVRISUHVFULELQJLQ&23'LQ
SULPDU\FDUH5HVSLU0HG
‡ 1ROWH ( 0F.HH &0 0HDVXULQJ WKH
KHDOWK RI QDWLRQV XSGDWLQJ DQ HDUOLHU DQDO\VLV
+HDOWK$II0LOOZRRG
‡ 2EVHUYDWRULGHO6LVWHPDGH6DOXWGH&DWDOXQ\D &HQWUDO GH 5HVXOWDWV 4XDUW LQIRUPH ¬PELW
KRVSLWDODUL %DUFHORQD $JqQFLD G¶,QIRUPDFLy
$YDOXDFLyL4XDOLWDWHQ6DOXW6HUYHL&DWDOjGHOD
6DOXW'HSDUWDPHQWGH6DOXW*HQHUDOLWDWGH&DWDOXQ\D
‡ 2OLYD-$QWRxDQ]DV)5LYHUR$ULDV2
(YDOXDFLyQ HFRQyPLFD \ OD WRPD GH GHFLVLRQHV
HQ VDOXG (O SDSHO GH OD HYDOXDFLyQ HFRQyPLFD
HQODDGRSFLyQ\GLIXVLyQGHWHFQRORJtDVVDQLWDULDV,QIRUPH6(63$6*DF6DQLW
6XSSO
‡ 2OLYD0RUHQR-³/RVVRI/DERXU3URGXFWLYLW\&DXVHGE\'LVHDVHDQG+HDOWK3UREOHPV:KDW
LV WKH 0DJQLWXGH RI LWV (IIHFW RQ 6SDLQ¶V (FRQRP\"´(XU-+HDOWK(FRQ2FW
‡ 2OLYD-=XQ]XQHJXL9*DUFtD*yPH]3+HUUHUD(HGLWRUHV'HVDItRVHQODDXWRQRPtD\ODDWHQFLyQDODGHSHQGHQFLDGHODSREODFLyQPD\RU6tQWHVLV*DFHWD6DQLWDULD6XSSO
‡ 2OOHUR %DWXURQH 0 2UR]FR %HOWUiQ ' HGV
'RFXPHQWR GH FRQVHQVR &RQIHUHQFLD
1DFLRQDOSDUDODDWHQFLyQDOSDFLHQWHFRQHQIHUPHGDGHVFUyQLFDV6HYLOOD0HUJDEOXP>FRQVXOWDGR @ 'LVSRQLEOH HQ KWWSZZZ
RSLPHFRUJPHGLD¿OHV(QIHUPHGDGHVB&UQLFDVB
9SGI
‡ 3HLUy6/LEUHUR-5LGDR0%HUQDO'HOJDGR
( *UXSR GH 9DULDFLRQHV HQ OD 3UiFWLFD 0pGLFD
HQHO6LVWHPD1DFLRQDOGH6DOXG>9DULDELOLW\LQ6SDQLVK1DWLRQDO+HDOWK6\VWHPKRVSLWDO HPHUJHQF\ VHUYLFHV XWLOL]DWLRQ@ *DF 6DQLW
‡ 3pUH] , *XLOOpQ ) >8QQHFHVVDU\ UDGLRORJ\ LQ SULPDU\ FDUH@ $Q 6LVW 6DQLW 1DYDU
‡ 3XLJ-XQR\-3HLUy6>)URPWKHWKHUDSHXWLFXWLOLW\WRWKHDGGHGWKHUDSHXWLFYDOXHDQG
WKH LQFUHPHQWDO FRVWHIIHFWLYHQHVV UDWLR@ 5HY
(VS6DOXG3XEOLFD
‡ 3XLJ-XQR\-¢5HFRUWDURGHVLQYHUWLU"
(FRQRPtD\6DOXG1ž'LFLHPEUH
‡ 3XLJ-XQR\-¢4XLpQWHPHDOFRSDJR"
(OSDSHOGHORVSUHFLRVHQQXHVWUDVGHFLVLRQHVVDQLWDULDV%DUFHORQD/LEURVGHO/LQFH
‡ 3XLJ-XQR\ - 7UDSHUR%HUWUDQ 0 (O
IDFWRU GH VRVWHQLELOLGDG GH OD VDQLGDG S~EOLFD
XQDDJHQGD'LDULR(O3DtVGHPD\R
‡ 5HSXOOR-57D[RQRPtDSUiFWLFDGHOD
©GHVLQYHUVLyQVDQLWDULDªHQORTXHQRDxDGHYDORUSDUDKDFHUVRVWHQLEOHHO6LVWHPD1DFLRQDOGH
6DOXG5HY&DOLG$VLVW
17
Juan Oliva, Salvador Peiró, Jaume Puig-Junoy
‡ 5RGUtJXH]5RFD*&%DUULRV$ORQVR9$]QDU
&RVWD-/OLVWHUUL&DUR-/$ORQVR0RUHQR)-(VFREDU&HUYDQWHV&HWDO&DUDFWHUtVWLFDV
FOtQLFDVGHORVSDFLHQWHVGLDJQRVWLFDGRVGHLQVX¿FLHQFLD FDUGLDFD FUyQLFD DVLVWLGRV HQ$WHQFLyQ
3ULPDULD(VWXGLR&$5',235(65HY&OLQ(VS
‡ 6DOLQDV0/ySH]*DUULJyV0'tD]-2UWXxR
0<DJR0/Dt]%HWDO5HJLRQDOYDULDWLRQVLQWHVWUHTXLULQJSDWWHUQVRIJHQHUDOSUDFWLWLRQHUVLQ6SDLQ8SV-0HG6FL
‡ 6DQIpOL[*3HLUy6*RVDOEHV6ROHU9&HUYHUD
&DVLQR3/DSUHYHQFLyQVHFXQGDULDGHOD
FDUGLRSDWtD LVTXpPLFD HQ (VSDxD 8QD UHYLVLyQ
VLVWHPiWLFDGHORVHVWXGLRVREVHUYDFLRQDOHV$WHQ
3ULPDULD
‡ 6RFLHGDG (VSDxROD GH 6DOXG 3~EOLFD \ $GPLQLVWUDFLyQ 6DQLWDULD 6(63$6 'HFODUDFLyQ GH 7ROHGR &RQVXOWDGR 'LVSRQLEOHHQKWWSZZZVHVSDVHVDGPLQZHE
XSORDGVGRFVSGI
‡ 8UEDQRV 5 *RQ]iOH] % 3XLJ-XQR\
-/D FULVLV HFRQyPLFD OOHJD D OD VDQLGDG
S~EOLFD(FRQRPLVWDV
‡ 9HFFKL9+HOORZHOO0/RQJR)$UH
,WDOLDQKHDOWKFDUHRUJDQL]DWLRQVSD\LQJWRRPXFK
IRUWKHLUSXEOLFSULYDWHSDUWQHUVKLSV"3XEOLF0RQH\0DQDJHPHQW
‡ :DJQHU (+ $XVWLQ %7 'DYLV & HW DO
,PSURYLQJ FKURQLF LOOQHVV FDUH WUDQVODWLQJ HYLGHQFH LQWR DFWLRQ +HDOWK $II 0LOOZRRG
Vol. 23. Extraordinario XXII Congreso 2013 | PONENCIAS