Alberto Vázquez is providing quality medical care to thousands in Argentina by putting local primary care centers, traditionally underused and undervalued, at the forefront of community health care and disease prevention efforts.
The New Idea
Alberto is correcting deep inefficiencies in Argentina’s current health care system. Patients overburden hospitals rather than seeking treatment at Primary Attention Centers, and spend disproportionate funds on treatment at the expense of prevention. Alberto’s model builds the Primary Attention Center’s role by training local people to serve as health promoters. He ensures that the community’s specific health concerns are addressed locally and motivates medical professionals at those centers long-considered to be outposts of health service. In the process, the role of the general practitioner is revived as patients get more personal attention and physicians refocus on preventative care. Alberto has forged institutional alliances to strengthen evaluation methods and management with the aim of replicating his model on a wide scale and influencing policy. Most importantly, since he is promoting a more efficient use of existing funds, Alberto’s far-reaching changes can be achieved without budgetary implications.
Only the wealthiest 10 percent of Argentina’s increasingly urbanized population has access to private health care through pre-paid medical insurance. The rest of the population relies on an overburdened and disorganized system of state health programs at public hospitals. The government spends 95 percent of its annual health budget on treatment and only a tiny fraction on preventive care. Though its health expenditures exceed those of Chile or Costa Rica, Argentina’s health care indices lag behind.The first port of call for a patient within the public system should be the local Primary Attention Center (CAP), where an estimated 90 percent of ailments can be treated. But CAPs—which are popularly called la salita or “the little room”—are widely considered to be second-rate. Patients frequently go straight to state hospitals, overburdening them and decreasing efficiency.A 1998 opinion poll of 3,000 outpatients and families of patients admitted to 20 hospitals found that 87 percent went directly to a hospital rather than a CAP either because of a lack of information about CAPs or previous poor-quality care received at a CAP. Two out of three patients visiting CAPs were referred to hospitals and respondents complained bitterly at the amount of time spent waiting to be seen by a hospital doctor. This misuse of the system has been accentuated by the country’s 2001 economic crisis, which pushed the middle class into poverty. This population was already less likely to use the CAPs, and by seeking treatment at public hospitals has further displaced the poorest within the health care system. CAPs funded by municipalities often lack resources and their few doctors feel undervalued and have less job stability. In turn, CAPs tend to offer specialty care, such as maternal health, Aids, or reproductive health programs, so the concept of a single family doctor who understands a patient’s life history and appreciates his or her specific risk factors does not exist within the public health service.
Alberto, a cardiologist, realized that the shortcomings of the current system could only be tackled by remaking the CAPs as the heart of community health care efforts. This meant raising awareness about their role among the population they should be serving and giving people the ability to be proactive about their own health. He saw that neighborhoods needed better primary care from their existing health centers. There was no need for massive new spending. He began a pilot of his PRO-SAL (pro-health) program in 2002 in Pilar in Greater Buenos Aires—he was then a regional manager of a major drugs company. Since then, and even without being able to devote all his time to the project, he has improved health care facilities in an area covering 95,000 of the total 220,000 inhabitants of Pilar. A key element of Alberto’s strategy is to train local residents as health promoters who draw up action plans based on the particular concerns of the neighborhood—for example, access to clean drinking water after a hepatitis outbreak. In one district where teenage pregnancy was identified as a major concern, he convened a workshop involving doctors from the local CAP and other specialists. Health promoters then conducted a census of 6,000 local residents, informing them of the CAP and its services to monitor pregnancies and dispensing family planning information. As a result, up to 60 pregnant women sought medical attention, half of whom had not seen a doctor at all during their pregnancy. Members of the health promoter network are volunteers, though some receive government subsidies as part of a state-sponsored work program. The PRO-SAL project itself has six staff members, including Alberto.Alberto has swiftly spread his approach. In 2002, he was working in one district of Pilar. By 2003, he had expanded to 10 districts and trained more than 100 neighborhood health promoters. He has begun a pilot effort in the neighboring community of Derqui and is evaluating whether to move to nearby Quilmes. He aims to cover all of Pilar within three years, and establish a health information free phone line and an Internet link between neighborhoods, linking health promoters and enabling communication and information exchange. In order to lay solid foundations and influence federal policy, Alberto has forged links with the University of Western Ontario to study the effectiveness of strategies for managing human resources in primary care. He is also working with the graduate research institute at the Austral University, based in Pilar, to improve the administrative management of each CAP.Alberto has persuaded the municipal health authorities to allow him to work in each CAP and establish local health action plans. He is leveraging these relationships to secure municipality-backed training for professionals working in CAPs, including drawing up career plans to re-engage them in their current work. Alberto has raised funds from corporate sponsors and intends to hold seminars for local factory workers to highlight the benefits of preventive health care and services offered at the CAPs. Ultimately, Alberto’s approach will be self-financing: the funds are already assigned from municipal coffers and Alberto is demonstrating that they can be put to better use through his approach.
Alberto grew up in a humble and enterprising family. His mother did not finish grade school, and his father was an immigrant who worked from the age of eight delivering bread and eventually saving enough to buy the bakery. Alberto helped his parents in the bakery, which was situated in a tough neighborhood in Buenos Aires.Alberto’s mother was determined that her son should receive the best education possible and sent him to a prestigious high school where Alberto became head of a student center. He was the first in his family to attend university and believed from an early age that medicine would be his life’s work. He worked at the Posadas Hospital at the height of Argentina’s military dictatorship when many of his colleagues were “disappeared” and he went to work every day wondering if he would share their fate. The hospital had been taken over by the military and its director carried a machine gun. While at the Posadas Hospital, Alberto worked out what was at the time a highly innovative approach to preventing and treating cardiovascular patients. Social workers and occupational therapists worked on his team, involving patients in gymnastics and other activities. That experience convinced Alberto of the need for a holistic approach to health care. He subsequently raised funds and convinced hospital directors to establish a new cardiology rehabilitation department at the Antartida Hospital. There, he also set up a patients’ committee to deal directly with hospital management.Alberto was profoundly affected by the social ramifications of the country’s 2001 crisis, which fueled his resolve to reform the delivery of health care in Argentina and bring care the country’s poorest families.