Tendências e contratendências de mercantilização: as reformas dos sistemas de saúde alemão, francês e britânico

Ao longo dos últimos trinta anos, entre meados das décadas de 1980 e 2010, os sistemas de saúde da Alemanha, França e Reino Unido foram reformados, gerando uma crescente mercantilização no financiamento e na prestação de serviços. O trabalho analisa as raízes dessas mudanças, assim como identifica que a mercantilização não ocorreu nem mediante os mesmos mecanismos e nem com a mesma profundidade, havendo importante inércia institucional. As diferenças observadas atestam as especificidades de cada país, em termos de seu contexto econômico, de seus arranjos políticos, das características institucionais de cada sistema e das formas que assumiram os conflitos sociais (extra e intra sistema de saúde). Os sistemas de saúde alemão, francês e britânico, enquanto sistemas públicos de ampla cobertura e integralidade, são frutos do período após a Segunda Guerra Mundial. Um conjunto de fatores contribuiu para aquele momento histórico: os próprios impactos do conflito, que forjaram a ampliação na solidariedade nacional e a maior pressão por parte dos trabalhadores; a ascensão socialista na União Soviética; o maior apoio à ação e ao planejamento estatal; o forte crescimento econômico, fruto da emersão de um regime de acumulação fordista, pautado na expansão da produtividade. A acomodação do conflito capital-trabalho, neste contexto, ocorreu mediante a expansão dos salários reais e ao desenvolvimento do Estado de bem-estar social, ou seja, de políticas públicas voltadas à criação e/ou ampliação de uma rede de proteção social. No entanto, a crise econômica da década de 1970 corroeu a base de financiamento e gerou questionamentos sobre sua eficiência, em meio à transformação do regime de acumulação de fordista para financeirizado, levando à adoção de reformas constantes ao longo das décadas seguintes. Além disso, as transformações específicas do setor saúde complexificaram a situação, tendo em vista o crescente envelhecimento populacional, a demanda por cuidados mais amplos e complexos e, principalmente, os custos derivados da incorporação tecnológica. Este cenário impulsionou a implementação de uma série de alterações nesses sistemas de saúde, com destaque para a incorporação de mecanismos de mercado (como a precificação dos serviços prestados, a indução à concorrência entre prestadores de serviços), o crescimento da responsabilidade dos usuários pelo financiamento do sistema (como o aumento nos co-pagamentos e a redução na cobertura pública) e a ampliação da participação direta do setor privado na prestação dos serviços de saúde (realizando os serviços auxiliares, a gestão de hospitais públicos, comprando instituições estatais). No entanto, de forma simultânea, as reformas ampliaram o acesso e a regulamentação estatal, além da modificação na base de financiamento, principalmente na França. Isto significa que a mercantilização não foi o único direcionamento das reformas, em decorrência de dois fatores principais: a própria crise econômica expulsou parcela da população dos mecanismos pós-guerra de proteção à saúde, demandando reação estatal, e diferentes agentes sociais influenciaram nas mudanças, bloqueando ou ao menos limitando um direcionamento mercantil único.

El liberalismo social del Presidente Clinton. La cooperación como política pública

Bill Clinton recuperó la tradición de liberalismo social que, desde una perspectiva de transversalidad, conformaba su diseño de una Presidencia donde confluían la acción y la respuesta, en forma de política pública, de las demandas sociales. La Administración Clinton hizo de la democracia como un activo social de necesaria incorporación a la idea compartida de Buen Gobierno y servicio público. En este artículo se estudian diversos ámbitos de aplicación del liberalismo social implementado por el Presidente Clinton. Las políticas públicas constituyeron el centro de su acción de Gobierno, mediante la implementación de una elasticidad que abarcaba la atención al ciudadano y la defensa de su dignidad como miembro activo del demos. El despliegue de lo social como parte del patrimonio moral de la democracia.

Nuevas perspectivas y paradigmas de las políticas públicas sociales en tiempos de crisis

El artículo analiza el impacto de la crisis múltiple actual del Estado de Bienestar en las políticas públicas sociales, en un contexto de sociedades plurales y complejas, haciendo hincapié en las diversas clases y características de las mismas, así como en una serie de propuestas y soluciones alternativas.

El incierto sentido del trabajo en la sociedad de riesgo global

Partiendo de los objetivos propuestos, el artículo pone de manifiesto la profunda crisis estructural en la que ha entrado el trabajo en la Posmodernidad. Esto ha supuesto, la pérdida de su seguridad en el contexto del cuestionamiento de la prosperidad de la economía, del Estado de Bienestar, del propio Estado y de la democracia. Cierto, el trabajo se presenta hoy con riesgo, precario, inseguro, incierto, desespacializado, fragmentado, acelerado, flexible, desregulado, informalizado, impactado por las nuevas tecnologías, “brasileñizado”, jerarquizado, desigual, individualizado y con el carácter corroído del trabajador. De esta forma, el trabajo se desvaloriza, se convierte en ilegible y pierde su sentido. Además, si se tiene en cuenta que los remedios puestos encima de la mesa en Occidente son claramente insuficientes y poco creativos, parece que nos encontremos ante el colapso o el final de una etapa, del trabajo, del propio capitalismo y del Estado social-liberal-democrático.

Sexual health and socioeconomic-related factors in Spain

Purpose: The aim of the present study was to describe sexual health in Spain according to three important indicators of the World Health Organization definition and explore the influence of socioeconomic factors. Methods: We performed a population-based cross-sectional study of sexually active people aged 16-44 years residing in Spain in 2009 (2365 women and 2532 men). Three main aspects of sexual health were explored: sexual satisfaction, safe sex, and sexual abuse. The independent variables explored were age, age at first intercourse, reason for first intercourse, type of partner, level of education, country of origin, religiousness, parity, and social class. Bivariate and multivariate logistic regression models were fitted. Results: Both men and women were quite satisfied with their sexual life, their first sexual intercourse, and their sexual relationships during the previous year. Most participants had practiced safe sex both at first intercourse and during the previous year. Levels of sexual abuse were similar to those in other developed countries. People of disadvantaged socioeconomic position have less satisfying, more unsafe, and more abusive sexual relationships. Women experienced more sexual abuse and had less satisfaction at their first intercourse. Conclusions: The state of sexual health in Spain is relatively good. However, we observed inequalities according to gender and socioeconomic position.

Social determinants of sexual satisfaction in Spain considered from the gender perspective

Aims: To describe gender- and social class-related inequalities in sexual satisfaction and analyze their relationship with self-perceived health status. Methods: This population-based, cross-sectional study included 7384 sexually active people aged 16 years and over residing in Spain in 2009 (3951 men and 3433 women). The explanatory variables were gender, age, social class, share in performing domestic tasks, spend time looking after oneself, collaborate economically in supporting the family, caring for children, self-perceived health status, and the desire to increase or decrease frequency of having sexual relations. Bivariate and multivariate logistic regression models were fitted. Results: Among women, sexual satisfaction declines progressively after age 45. Sexual satisfaction is 1.7 times higher among women who look after themselves and who feel good compared with those who do not. The odds of wanting to increase sex is 3.3 times higher for women who are satisfied compared with women who desire a lower frequency of sexual intercourses; and good perceived health was associated with sexual satisfaction. In satisfied men, the corresponding odds is 1.9 times that of men desiring to reduce their frequency of sex. Conclusions: Gender and social class inequalities are found in sexual satisfaction. This is associated with perceived health status, adding evidence in support of the World Health Organization definition of sexual health.

Incidencia e influencia de las políticas en el cambio social: responsabilidad de las trabajadoras sociales e implicaciones para su educación teórica y práctica

La incidencia en las políticas sociales es una importante función profesional de las trabajadoras sociales que precisa ser integrada en la educación teórica y práctica en Trabajo Social. Este artículo indaga sobre los fundamentos de esta función de incidencia en los cambios sociales promoviendo políticas sociales que reconozcan los derechos humanos. Partiendo de los referentes internacionales del trabajo social, se analiza el caso de España teniendo en cuenta los códigos deontológicos, los planes de estudio en Trabajo Social, la práctica profesional y los nuevos Grados en Trabajo Social. Se concluye planteando interrogantes sobre el grado de responsabilidad y de implicación de las universidades y Colegios profesionales en coherencia con los principios y valores del Trabajo Social.

La opinión pública internacional y el Estado del Bienestar

Esta investigación efectúa una revisión de los proyectos internacionales de opinión pública que estudian, de forma comparada, las opiniones y valores relacionados con la provisión del bienestar social. Las dificultades metodológicas que plantea la comparación entre diferentes países es elevada. No obstante, de dicho estudio exploratorio se pueden extraer varias conclusiones relevantes. Así, la opinión pública entiende que la obligación de proveer de bienestar social es del gobierno y de la administración pública. No es una responsabilidad de la sociedad civil o de las organizaciones que la vertebran. El papel que se atribuye a las instituciones de caridad o del sector privado es mínimo. La reducción de la intervención del estado en el bienestar, es valorada de forma negativa en todos los países considerados. En la atención a la pobreza y la reducción de desigualdades también se atribuye el papel central al gobierno y el estado. En general, tanto los planteamientos individualistas, donde cada individuo debe resolver sus problemas por sí solo, como el planteamiento que traslada a las organizaciones de la sociedad civil la responsabilidad de la protección social, no tienen acogida en la opinión pública de los países considerados. La opinión sobre la necesidad de que el gobierno intervenga para reducir las diferencias en los ingresos, debe interpretarse en un contexto general donde la impresión más extendida afirma que la desigualdad se acentúa e incrementa en los últimos años. Una desigualdad considerada como un problema grave, e importante para la democracia en el país. En cierto sentido la desigualdad, la pobreza y la responsabilidad del gobierno para atenuar una y evitar la otra, son más que evidentes, así como su lectura desde la óptica de la legitimación democrática del sistema. Nos encontramos en una situación paradójica donde, si bien queda perfectamente claro que la responsabilidad de la lucha contra la pobreza es de los gobiernos, como veremos, en general la confianza en que estos gobiernos van a actuar e intervenir correctamente es bastante baja. La crisis iniciada en 2007 y el desmantelamiento del estado de bienestar que se efectúa en varias sociedades del sur de Europa se producen en este contexto.

The relevance of harmonising the technical level of social housing with the urban level of the neighbourhood through the example of the 500 dwellings in Albacete

The Architecture and Household Trade Union built nearly 2,000 subsidized dwellings in Albacete from 1941 to 1971. It was the responsible entity from the end of the Civil War until the beginning of Democracy of the social policy programs in Spain. Later on, and together with the National Housing Institute, were responsible for the construction activity. Its limited budget, scarcity of technical and human resources and an urgent need for new housing developments, constituted the basis for producing a vast housing market of low construction qualities. However, thanks to the true architectonic expertise of some of the professionals, some of the developments were designed with a clear urban strategy and in direct relation with the city, which characterizes them to be studied and conserved. This is the case for the selected development for the analysis, the urban complex of the 500 dwellings in Albacete, the Hermanos Falcó Neighborhood. Designed and built between 1963, Alfonso Crespo and Adolfo Gil architects, and 1977 second reformed project by the architect Fernando Rodríguez. It is characterized by its layout on the territory, its controlled relation with the city and its different types of open blocks. Above all, its spatial and human scale strengths, directly related to the European post-war proposals, have to be emphasized; although its technical deficiencies affect the interior quality of the houses. This paper examines its virtues and failures and proposes, using current tools, its renovation. This proposal main aims are to extend its lifetime and develop the particular and urban sustainability levels.

Constituição e modelo de mercado : uso liberal e desuso neoliberal

Tese de doutoramento, Direito (Ciências Jurídico-Políticas), Universidade de Lisboa, Faculdade de Direito, 2016

A realistic bridge towards European banking union. Bruegel Policy Contribution 2013/09, June 2013

New obstacles to the European banking union have emerged over the last year, but a successful transition remains both necessary and possible. The key next step will be in the second half of 2014, when the European Central Bank (ECB) will gain supervisory authority over most of Europe’s banking system. This needs to be preceded by a rigorous balance sheet assessment that is likely to trigger significant bank restructuring, for which preparation has barely started. It will be much more significant than current discussions about a bank resolution directive and bank recapitalisation by the European Stability Mechanism (ESM). The 2014 handover, and a subsequent change in the European treaties that will establish the robust legal basis needed for a sustainable banking union, together define the policy sequence as a bridge that can allow Europe to cross the choppy waters that separate it from a steady-state banking policy framework.

Saving for Retirement and Investing for Growth. Report of the CEPS-RCMI Task Force on Long-term Investing and Retirement Savings. CEPS Task Force Report, September 2013

Europe is facing a double challenge: a significant need for long-term investments – crucial levers for economic growth – and a growing pension gap, both of which call for resolute action. Crucially, at a time when low interest rates and revised prudential standards strain the ability of life insurers and pension funds to offer guaranteed returns, Europe lacks a framework ensuring the quality and accessibility of long-term investment solutions for small retail investors and defined contribution pension plans. This report considers the potential to steer household financial wealth – accounting for over 60% of total financial wealth in Europe – towards long-term investing, which would achieve two goals at once: higher growth and higher pensions. It follows a holistic approach that considers both solution design – how to gear product structuring towards long-term investing – and market structure – how to engineer a competitive market setting that is able to deliver high-quality and cost-efficient solutions. The report also considers prudential rules for insurers and pension funds and the potential to build a single market for less-liquid funds, occupational and personal pensions, with improved investor protection. It urges policy-makers to act aggressively to deliver more inclusive, efficient and resilient retail investment markets that are better equipped and more committed to deliver value over the long-term for beneficiaries.

Performance of Long-Term Care Systems in Europe. ENEPRI Research Report No. 117, 21 December 2012

This report evaluates the performance of long-term care (LTC) systems in Europe, with a special emphasis on four countries that were selected in Work Package 1 of the ANCIEN project as representative of different LTC systems: Germany, the Netherlands, Spain and Poland. Based on a performance framework, we use the following four core criteria for the evaluation: the quality of life of LTC users, the quality of care, equity of LTC systems and the total burden of LTC (consisting of the financial burden and the burden of informal caregiving). The quality of life is analysed by studying the experience of LTC users in 13 European countries, using data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Older persons with limitations living at home have the highest probability of receiving help (formal or informal) in Germany and the lowest in Poland. Given that help is available, the sufficiency of the help is best ensured in Switzerland, Italy and the Netherlands. The indirectly observed properties of the LTC system are most favourable in France. An older person who considers all three aspects important might be best off living in Belgium or Switzerland. The horizontal and vertical equity of LTC systems are analysed for the four representative countries. The Dutch system scores highest on overall equity, followed by the German system. The Spanish and Polish systems are both less equitable than the Dutch and German systems. To show how ageing may affect the financial burden of LTC, projections until 2060 are given for LTC expenditures for the four representative countries. Under the base scenario, for all four countries the proportions of GDP spent on public and private LTC are projected to more than double between 2010 and 2060, and even treble in some cases. The projections also highlight the large differences in LTC expenditures between the four countries. The Netherlands spends by far the most on LTC. Furthermore, the report presents information for a number of European countries on quality of care, the burden of informal caregiving and other aspects of performance. The LTC systems for the four representative countries are evaluated using the four core criteria. The Dutch system has the highest scores on all four dimensions except the total burden of care, where it has the second-best score after Poland. The German system has somewhat lower scores than the Dutch on all four dimensions. The relatively large role for informal care lowers the equity of the German system. The Polish system excels in having a low total burden of care, but it scores lowest on quality of care and equity. The Spanish system has few extreme scores. Policy implications are discussed in the last chapter of this report and in the Policy Brief based on this report.

Current Problems of Social Europe. Research Papers in Law, 7/2007

From the Introduction. The main difficulty of Theology lies in the fact that the very existence of its subject-matter, God, may be put into question. Talking about Social Europe has something of a theological dimension. The aim of this article is to contribute into the debate, by putting into perspective some of the latest manifestations of social Europe. The need for the pursuance of social policies at the European level is now more pressing than ever (para 2). The EU, however, as it now stands, is the direct evolutionary result of the predominantly economic entity created back in 1957. This explains that the social policies pursued at the European level are piecemeal and often impregnated with market concerns (para. 3). From an instrumental point of view, EU social policy is being pursued concomitantly by secondary legislation (hard law) in the fields where the EU does have the relevant competences and by softer means of cooperation (soft law) in several other fields. Hard law has given the occasion to the European Court of Justice (ECJ), in a series of recent judgments, of putting to the fore the concept of a ‘social market’ (para. 4). Soft cooperation has been formalised into the infamous Lisbon Strategy and has been the main object of experimentation with the open method of coordination (OMC) (para. 5). The advances achieved in the above ways, however, do not offer firm answers to basic questions concerning the future development of the European social identity (para. 6)

Public Procurement Law and Health care: From Theory to Practice. Research Paper in Law, 2/2010

From the Introduction. This contribution will focus on the core question if, how and to what extent the EU procurement rules and principles (may) affect the national health care systems. We start our analysis by summarizing the applicable EU public procurement legislation, principles and soft law and its exact scope in relation to health care. (section 2). Subsequently, we turn to the parties in a contract, subject to procurement rules in the field of health care, addressing both the definition of contracting authorities and relevant case law (section 3). This will then lead to an analysis of possible justifications for not holding a tender procedure in the field of health care (section 4). Finally, we illustrate the impact of EU public procurement rules on health care by analysing a Dutch case study, in which the question whether public hospitals in the Netherlands qualify as contracting authorities in terms of the Public Sector Directive stood central (section 5). Our conclusions will follow in section 6.