Marcelo Viale (Argentina, 1995) is introducing long overdue reforms of hospital management and health care delivery that are revolutionary in the Argentine setting. He is wresting hospital budgetary and administrative decision making from outmoded, highly centralized administrative structures and assigning that responsibility to democratically created community boards and implementing a series of organizationa and technological changes that are dramatically improving the quality and cost-effectiveness of hospital care.
The New Idea
Marcelo Viale's new model of hospital organization and management is based on principles of decentralization, self-governance and community control. Although those principles have been effectively employed in other settings, they are dramatic departures from prevailing norms in Argentina and elsewhere in Latin America. Key elements of Marcelo's model include a shared management structure that teams doctors with enlightened community leaders; a redesigned management and service delivery system that includes modern technology and computer-based controls; and a compensation structure that allows hospital employees to benefit from savings generated by cost-cutting measures. In the hospital that he directs in Tigre, he is pioneering a new structure in which a volunteer community board, rather than a centralized government agency, is responsible for the institution's governance. Thus "liberated" from obsolete rules imposed by long-entrenched political interests, he is demonstrating that public institutions can provide health care in a humane, cost-effective and efficient manner. With the endorsement of the hospital's community board, a portion of the savings achieved from cost-cutting measures and administrative reforms is earmarked for bonuses for hospital professionals and staff members. This scheme, which is a major departure from the usual compensation practices in public institutions, is providing a much-needed and quick-acting stimulus for improved performance. Marcelo is taking special care to ensure that the principle of universal accessibility to high-quality and humanely provided care is uniformly reflected in the hospital's practices. Indeed, Marcelo views community-based governance and up-to-date and efficient management practices not as ends, in and of themselves, but as vehicles for achieving his true goal-a new ethic in providing sensitive, efficient and high-quality health care to all citizens of Argentina.
Argentina's public health system is riddled with problems, and powerful and deeply entrenched political forces have prevented much-needed reforms in hospital care and management for decades. In Argentina, as in other Latin American settings, rigid and outmoded policies imposed by over-centralized bureaucracies have resulted in poor planning and organization, programs that are both inefficient and unresponsive to community needs, inadequate budgetary controls and an attendant misuse of scarce resources. According to well-placed experts, needless outlays and waste claim more than ten percent of hospital budgets that are already far short of sufficient to meet even the most pressing of their needs. Unfortunately, moreover, problems of mismanagement and inefficiency are compounded by antiquated systems of health care delivery that have failed to keep pace with rapidly changing technologies and evolving health needs. As a result, the average person of limited economic means in Argentina receives treatment that is poor, at best, in an unsanitary, undignified and ill-equipped facility.
The "Tigre model," as it has come to be known, is identified first by the concepts of decentralization and community participation in hospital governance. Control of the Tigre hospital's budget and administration now lies squarely in the hands of a volunteer community board, comprised of elected representatives of various constituencies-including local business, community groups, doctors, nurses and nonprofessional hospital staff. The community board is responsible for final decision making on hospital salaries, capital expenditures (including equipment purchases) and other major resource allocation and administrative matters. In addition to replacing central bureaucratic government control with community oversight and governance, Marcelo has assembled a diverse group of experts to implement the specialized elements of his model, including computer-based control systems. Rational management and a reordering of priorities has enabled the Tigre hospital to make substantial investments in modern technology, and with the advice of the appropriate experts, it has substantially expanded the array of services that it provides. It now offers laparoscopic and arthroscopic surgery, for example. The reforms have already produced dramatic results. In a four-year period, Marcelo has transformed the Tigre hospital from a malfunctioning, loss-incurring institution into a model of effective and cost-efficient management. In a facility that attends some 800 to 1,000 patients per day and has 750 beds, savings totaling more than $7,000,000 have been achieved. Those savings, plus social insurance payments and "voluntary contributions" from patients (who are asked to pay according to their ability and never denied services for inability to pay), have enabled the hospital to make enormous strides in meeting its goals for addressing the health needs of Tigre's 275,000 inhabitants. In seeking to introduce his reforms, Marcelo had to obtain the necessary authorizations and waivers from the provincial health ministry (under the provisions of a recently enacted law). And in a campaign to replicate the Tigre model, Marcelo and others are lobbying other local governments to adopt the required enabling statutes. As a member of an official consulting group for the Province of Buenos Aires, Marcelo is also lobbying for modifications of the enabling legislation that will simplify the reform process. When that has been achieved (and the proposed law already enjoys the support of key legislators), Marcelo will lay the groundwork for a national campaign for the introduction of the Tigre reforms. Since the provincial health ministry is now eager to decentralize hospital governance and control, many hospitals outside Buenos Aires are taking steps to implement critical aspects of the Tigre reforms, and a number of them have requested Marcelo's services as a consultant. Following a radio station interview aired in July 1995, Marcelo received scores of invitations to visit municipal hospitals in other provinces and to serve in a consulting capacity to several of them that were ready to take the plunge into community management and decentralization. Also in that year, the Inter-American Development Bank provided funds for the construction of five public hospitals in various Argentine provinces, with the understanding that those institutions would adopt the Tigre model. To further speed the replication process, Marcelo has formed a working group to produce technical materials that explain in detail the steps required for creation of an effective community-managed hospital. He has received in-kind support for this undertaking from a foundation in Buenos Aires and from other nongovernmental organizations promoting community engagement in the provision of health services. As he switches hats, from innovative hospital administrator to national health care changemaker, Marcelo recognizes that his model of a community-managed hospital must be adapted and reconfigured to fit the varying local needs and realities of different parts of the country. Since community decision making is a key component of his model, he expects each hospital adopting the Tigre reforms to wind up with a slightly different structure. What matters to Marcelo is that the core principles-local decision making freed from political influence, rational budget controls, efficient management and distribution systems, and equitable health care delivery-remain intact.
Marcelo has long been preoccupied by the question of how to improve medical attention for all segments of Argentine society. He comes from a long line of family doctors, who passed down not only their professional interest in medicine but also their concerns for the underprivileged. His father's untimely and accidental death also affected Marcelo's professional development by pushing his medical practice in the direction of emergency services. As a young medical student, Marcelo took time from his studies to intern at a public hospital that served a poor fishing population in Rosario, Argentina. In that assignment, he gained exposure to the urgent need for traumatic and emergency care for underserved populations. Thus, upon completing his undergraduate studies, Marcelo chose the specialty of orthopedics and traumatology for his postgraduate work. When his residency ended, Marcelo opted to work in the public hospital of Tigre, where he believed that his skills would be particularly effectively utilized. In 1987, when he was already serving as chief of orthopedics and traumatology, Marcelo was asked by his colleagues to serve as the hospital's director. And in that capacity, he became more fully aware of the deficiencies of the country's health care system and the severity of the management problems and financial waste caused by excessive centralization of decision making and inadequate budgetary controls. After convincing his colleagues, community leaders and municipal authorities that a radical change was in order, Marcelo began to implement the series of reforms that he is now working to introduce on a province and nationwide basis.