Recursos Humanos en Salud. Descentralización Pública y Multiempleo de Médicos en Argentina. Combinando acercamientos Econométricos y de Economía Política

DANIEL MACEIRA

Ciudad del Cabo

Conferencia; Taller sobre Gobernabilidad en Sistemas de Salud en Países en Desarrollo; 2016

Health care systems? operation critically relies on the characteristics of its human resources as well as in the way activities are coordinated along the chain of services. Beyond the incorporation of new technologies, the ?medical know-how? and the patient-doctor relation are key pillars of any sound health care strategy. Because of that, the study of those topics defining working conditions of physicians, nurses and other health care workers find a central role in the health systems research agenda. In many developing countries, where health systems? organization is signed by fragmentation, the authority of the Ministry of Health relies not only in his/her financial ability to provide monetary and non-monetary incentives to align the expectations and behaviors of patients and health care workers in the public sector. The public-private mix of services and the multiplicity of insurers, payers and health managers request a sound regulatory framework to provide governability to the whole system, where an array of stakeholders with different objectives interact. Market rules and public sector?s hierarchies therefore influence each other. However, the poorer the public resources available, and the weaker the institutional capacity of public managers, the higher are the chances for private health developments, the lower the resolution capacity of governmental services, and the stronger the probability of out-of-pocket payments, increasing inequity. Under these scenarios, physicians working at the public sector under relatively low-wages and weak-enforcement mechanisms complement activities in the private subsystem, with different rules and incentives. Dual or multiple job holding becomes an informal solution for physicians as well as creates a governance challenge to the overall sanitary authority, in a sector where the policy making process is particularly complex. Relative wages in public and private sectors heavily orient doctors? time allocation across subsystems, where not only traditional monetary drivers and payment mechanisms are relevant, but also other factors such as reputation, career opportunities, on-the-job-learning and social commitment. The goal of this article is to analyze how these characteristics affects doctors behavior in Argentina, a middle-high income country in Latin America, where decentralization allows provincial ministries of health to define wage levels, hierarchy structures, personnel rotation across public providers, weakening federal normative. As provinces are not equal in terms of economic development, private sector?s participation and supply of services also vary across them. Those differences trigger uneven opportunities to doctors in terms of alternative employments other than the public system, and the prices to be charged in the private sphere. This article claims that strategic governance needs to be considered by policymakers at the moment of identifying public labor conditions and incentives. In the following section the paper summarizes the antecedents on dual-job holding literature, providing next a theoretical discussion about incentives, stakeholders and labor markets, raising specific questions to be addressed. The methodological approach includes the use of administrative data at the provincial and hospital level, as well as in-depth interviews with hospital directors and multiple-choice questionnaires answered by a sample of doctors in those same institutions.