Salud

Evaluando los programas de salud

Gustavo Leal F.*

De acuerdo con María José Montiel del Instituto Mexicano de la Competitividad, la suerte de las evaluaciones a los programas de salud es singular. La tarea para establecer resultados y medir el desempeño de la costosa capa alta de la administración pública federal ha realizado un sinfín de calificaciones al sector, pero ellas casi no se usan para corregir y ajustar los programas multievaluados.

A pesar de las buenas intenciones de la Ley Federal de Presupuesto y Responsabilidad Hacendaria para que ellas pesen en las decisiones presupuestarias, fue preciso idear el Premio a los programas federales comprometidos con el proceso de evaluación para estimular su uso correctivo entre los tecnócratas que operan los programas.

¿De cuántas hablamos? Montiel extrae la siguiente cuenta: entre 1994 y 2010 se han realizado casi 600 en programas relacionados con la salud y la formación de capital humano (¿Qué pasa con las evaluaciones a los programas de salud en México?).

Cerca de 50 por ciento de ellas se refiere a ejercicios de revisión de indicadores (evaluaciones específicas de desempeño) y sólo una quinta parte son de consistencia y resultados. Además de que las de impacto representan 9.1 por ciento, mientras que las de diseño suman 6.8 por ciento del total. Su costo entre 2008 y 2011, documenta Montiel, alcanzó 14.5 millones de pesos.

Como correctamente concluye Montiel: La verdadera meta de la evaluación se alcanzaría si sus resultados se utilizaran, más que como logros en sí mismos, como insumos para mejorar la operación de los programas. Cuando esto sea posible, habría que agregar.

No sorprende que las evaluaciones sobre el diseño de los programas de salud sean las que alcancen el porcentaje más pequeño. Porque ¿qué hacer con el Seguro Popular y el (apenas rebautizado por los peñistas) Seguro Médico Siglo XXI que afilian, no curan, incentivan la informalidad y constituyen bolsas opacas al servicio de los gobernadores que enmarcan la corrupción? ¿Cómo reformular a partir de esas evaluaciones sus proyectos, programas y políticas? ¿Es eso posible?

Lamentablemente las evaluaciones consignadas por Montiel poco se ajustan a las severas fallas de diseño de los programas (responsabilidad de Frenk-Gil Díaz para el Seguro Popular y Calderón para el Seguro Médico Siglo XXI) y se refieren básicamente a su cuestionable operación. Esas evaluaciones y sus respectivos evaluadores aún no acaban de ocuparse del tronco programático mal diseñado y priorizan el examen de sus follajes.

Algo similar –aunque aún más grave– ocurrió con la evaluación de la crecientemente criticada OCDE al IMSS: Estudios sobre la contratación pública. Aumentar la eficiencia e integridad para una mejor asistencia médica. IMSS. En ella se consignó que: no se reconoce a lo largo de la institución que la función de adquisiciones es un instrumento estratégico que contribuye a alcanzar los principales objetivos del IMSS. Esto impide que las oficinas de compras, muy descentralizadas geográficamente, trabajen de manera consistente y coherente, lo que da lugar a prioridades contradictorias, reduce la eficiencia y da lugar a niveles de desempeño de proveedores muy deficiente, (pp.25-26)

Esta situación deriva del modelo de centralización impuesto por las administraciones de Fox y Calderón en el IMSS-PAN (35 delegaciones institucionales a nivel nacional), y la conversión (por Santiago Levy) del tercer nivel de atención (centros médicos nacionales) en 25 Unidades Médicas de Alta Especialidad (UMAES) que responden exclusivamente al director general del IMSS.

El propio Sindicato Nacional de Trabajadores del Seguro Social exigió que se modificara la forma en que se administra ese servicio de alta especialidad porque es ineficiente y caro. Quieren que desaparezcan y vuelvan a ser como antes, parte del tercer nivel del atención. Según ellos las UMAES cuestan mil millones de pesos anuales cada una. Además de que no dan información sobre en qué se gasta el presupuesto. En ellas laboran casi 2 mil trabajadores de confianza. Es una estructura muy obesa. Hay que se restructurar al personal de confianza, liquidarlo y regresarlo a sus bases, para que sea personal sindicalizado. También exigimos que se informe en qué se gastan esos recursos (Reforma, 18.9.2011).

¿Cómo emplear la evaluación de la controversial OCDE para corregir el monumental despropósito sanitario que resumen las UMAES panistas? ¿Se trata sólo de un fenómeno de incoherencia administrativa o la opaca y sospechosa manera de gastar que acontece en ellas estaría directamente relacionada con la corrupción endémica que caracterizó la administración panista del IMSS?

Es claro que las evaluaciones no son capaces de corregir el status quo del régimen impuesto por los panistas y que se sirven de la política de salud y seguridad social con fines de legitimación electoral (afiliaciones automáticas al Seguro Popular y al Seguro Médico Siglo XXI) que fomentan procesos opacos y poco transparentes. Es el caso del escandaloso episodio del fraude con los medicamentos del Seguro Popular en Guanajuato (Proceso, 1839) o la reciente crisis sanitaria tabasqueña que ya ocupa a la secretaria Mercedes Juan.

Esas evaluaciones tampoco entran a la raíz de los intereses económicos y corrupción endémica que pesan secularmente sobre las bolsas sectoriales (como en las UMAES de Levy) o el contrato multianual con la empresa Tata Consultancy firmado por el IMSS-Molinar Horcasitas, documentado profusamente por la ASF.

Como en el caso específico del Coneval, otro gran asunto pendiente es el de la urgente evaluación de los evaluadores.

*Universidad Autónoma Metropolitana-Xochimilco

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