Por Dr. Edgar Giménez Caballero edgica@gmail.com
Edición: Ilusión Quiñones lusionquionez@hotmail.com
La pandemia de COVID-19 ha provocado el colapso de sistemas sanitarios considerados robustos, sobrepasando su capacidad debido a la gran cantidad de pacientes ingresados en hospitales y unidades de cuidados intensivos en corto tiempo. Este fenómeno ha consumido de manera intensiva e inusitada recursos sanitarios y ha limitado la posibilidad de atención de otros enfermos, urgentes y crónicos. Además de los fallecidos, se ha producido una disrupción social y económica sin precedentes cuyo efecto sobre los determinantes sociales de la salud tendrá consecuencias desfavorables sobre el bienestar de la población en el mediano plazo.
En Paraguay, la pandemia exacerbó las precariedades del segmentado y desfinanciado sistema nacional de salud, sustentado predominantemente con el gasto de bolsillo de los enfermos y sus familiares.
Ciertamente hubo mejoras paramétricas antes de hacer frente al Covid-19, por ejemplo, según datos de la Comisión Bicameral de Presupuesto del Congreso Nacional, el presupuesto público ejecutado en 2019 fue cuatro veces superior al del 2009, cuando hubo que enfrentar la Influenza A H1N1. Pero, a pesar de este incremento, el financiamiento sanitario paraguayo mantuvo un bajo desempeño, en comparación con otros países del Cono Sur de las Américas.
En efecto, analizando los datos del Observatorio Global de Salud de la OMS, antes de la llegada del nuevo coronavirus, el gasto público en salud de Paraguay estaba entorno al 3,0% del PIB y la participación del gasto de bolsillo entorno al 45% del gasto sanitario total, mientras que el gasto público en relación al PIB de Argentina era 5,9%, el de Brasil 3,9%, el de Chile 4,6% y el de Uruguay 6,7%, en tanto que la participación del gasto de bolsillo de estos países era 28%, 28%, 33% y 17% respectivamente.
Además de este déficit en comparación con otros países, el financiamiento de salud ha sido desigual entre los subsistemas. En el Plan Estratégico Institucional 2019-2023 del MSPBS, se describe que en 2017 el gasto por persona para la población asignada al MSPBS era de 136 UDS por año, mientras que para los beneficiarios del IPS era de 340 USD por año y para los de medicina prepaga 649 USD.
Con estas brechas y asimetrías de financiamiento (que se traducen también en brechas y asimetrías de oferta de servicios) llegó el Covid-19 al Paraguay.
Para contrarrestar los déficits ante la crisis sanitaria se ha constituido un fondo de emergencia con empréstitos, mediante el cual el gobierno ha incrementado de forma acelerada la oferta pública de servicios, ha integrado (temporalmente) los servicios dependientes del Ministerio de Salud y del Instituto de Previsión Social, ha aumentado los contratos para el personal de salud y ha comprado servicios de cuidados críticos al sector privado. Pero todo esto, no ha sido suficiente.
El personal de salud ha tenido que enfrentar esta situación excepcional hasta el límite de sus fuerzas y capacidades, con notorias limitaciones de recursos y numerosos trabajadores de la salud han perdido la vida honrando su profesión.
La población, por su parte, ha soportado primero los efectos económicos y sociales de la crisis. Luego la angustia ante la hospitalización de sus familiares, la incertidumbre sobre su evolución al no poder acompañarlos, la desesperación ante la lista de espera para ingresar a cuidados intensivos y el dolor por el fallecimiento de miles de personas que son abuelos, abuelas, padres, madres, cónyuges, hijos, hijas, parientes y amigos. Y a todo esto se ha sumado las penurias económicas para pagar las cuentas.
De esta angustia social, ha surgido un anhelo colectivo de un nuevo sistema de salud que pueda incluir y proteger a todos. Por primera vez, la salud se ha posicionado como la prioridad en la agenda pública.
El desafío inmediato es mantener la capacidad instalada que se ha logrado durante la emergencia sanitaria. El financiamiento de los préstamos tendrá que sustituirse con recursos sostenibles.
Superada la crisis, habrá que emprender un proceso de transformación del Sistema Nacional de Salud basado en consensos sociales y políticos, legitimados mediante una amplia participación. ¿Es posible un sistema público de salud con cobertura y acceso universal a servicios integrales y de calidad? ¡Este es un derecho de todas las personas!
La OMS propone que es posible logarlo con al menos 6% de fondos públicos para salud y una reducción del gasto de bolsillo por debajo del 20% del financiamiento total.
Paraguay está a mitad de camino de estas metas porque ha postergado por tres décadas los mecanismos distributivos necesarios para darle contenido y significado real al Estado Social de Derecho y al Derecho a la Salud que proclama la Constitución Nacional.
Dr. Edgar Giménez Caballero: Asesor, docente e investigador de salud pública.
Investigación para el Desarrollo www.desarrollo.org.py
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