Some of the recurring themes seen on health-sector reform agendas of Western countries (those at the center as well as those on the periphery) over the last decade have been: the debate over new ways of organizing health systems, with sights set on achieving greater efficiency and quality; redefining health care benefit packages and services to better distribute health resources; and incorporating market mechanisms into the health care environment to better respond to expectations of health care consumers. The fundamental purpose of this article is to analyze certain concepts that define and explain the origin of the 1990s health care reforms in Latin America and to refute some of the more important principles, such as: the belief that improving the functional efficiency of the health care system alone would improve the health of the population; the excessive concern with the administrative and structural aspects of health systems without a discussion of the underlying theoretical models; the idea that access, in and of itself, can guarantee "equity in health"; and lastly, the undo emphasis that was placed on individual "risk factors" as the cause of all illness.

El denominador común en la mayoría de las reformas sanitarias llevadas a cabo desde los años noventa es la búsqueda de mecanismos para hacer frente a la escasez de recursos, el logro de una financiación equitativa y sostenible, la meta de una producción sanitaria más eficiente y la distribución de recursos de manera efectiva en los sistemas sanitarios, aspectos que constituyen nuevos desafíos de las políticas sanitarias actuales. En este artículo se analizarán los fundamentos teóricos de dichos mecanismos y los dilemas éticos que la racionalización genera en el sector de la salud, especialmente en lo relacionado con los costos compartidos, los criterios para establecer a qué y a quiénes darle prioridad, la definición del papel de los expertos y de la comunidad en este proceso de determinación de prioridades y las tensiones que se pueden presentar cuando se intenta balancear las metas de equidad, eficiencia y financiación sostenible de los servicios de salud.

The common factors in most of the health care reforms held from the nineties are the searching of mechanisms to face the scare of resources, the achievement of an equitable and sustainable financing, the goal of a more efficient sanitary production and an effective way for distribution of resources in the sanitary systems. All those factors constitute news challenges for the actual sanitary policies. Theoretical foundations of the main sanitary resources rationalization strategies and the ethical dilemmas that they cause in health sector will be analyzed here, especially the establishment of share costs, definition of what to give priority in the selection for clinical or public health interventions, the role of experts and community in the process of priority definitions and the tensions when trying to balance the targets to equity, efficiency and economical sustainability of the health services.