Resumen Las empresas farmacéuticas influyen sobre la conducta para formular los medicamentos de diversas formas, incluyendo a los vendedores de las empresas farmacéuticas (representantes de medicamentos), las muestras de medicamentos, pares influyentes y eventos educativos. La información sobre los medicamentos suministrada por los representantes de la industria ha demostrado ser inexacta. Las muestras de medicamentos son una de las herramientas de mercadeo más efectivas con que cuentan las empresas. Se recurre a "Los líderes de pensamiento" o a los "principales líderes de opinión" (KOLs por sus siglas en inglés) para convencer a sus pares de que utilicen medicamentos para usos no aprobados, sensibilizar sobre patologías objetivo, y conformar percepciones sobre los beneficios y perjuicios de un medicamento, además de crear impresiones sobre medicamentos en competencia. A pesar de que se dice que las asignaciones monetarias para dictar charlas, celebrar seminarios y reuniones no deben tener restricciones, es claro que la empresa selecciona determinados conferencistas y que aquellos cuyas opiniones socaven los mensajes de mercadeo no serán invitados. Se ha demostrado que la promoción aumenta la prescripción de medicamentos específicos y aumenta los costos de esta.

Abstract Pharmaceutical companies affect prescribing behavior through various means, including pharmaceutical salespeople (drug reps), drug samples, influential peers, and educational events. Information on drugs provided by industry representatives has been shown to be inaccurate. Drug samples are among the most effective marketing tools that companies have. "Thought leaders" or "key opinion leaders" are used to persuade peers to use drugs for unapproved uses, raise awareness of targeted diseases, and to shape perceptions of a drug's benefits and harms, as well as perceptions about competing drugs. Although grants provided for talks, seminars, and meetings are described as "unrestricted," it is understood that the company gets to select some speakers, and that speakers with views that undermine marketing messages will not be invited. Promotion has been shown to increase physicians' prescription of targeted drugs, and increases prescription costs.

OBJECTIVE: This article discusses the effects of the second decentralization of the Mexican Ministry of Health (1994-2000). MATERIAL AND METHODS: It is based on a review of official and archival documents, health and productivity statistics, observations in clinics and hospitals, and 232 in-depth interviews in the states of Baja California Sur, Colima, Guanajuato, Nuevo León, Sonora and Tamaulipas. The interviewees included high-level administrators of state and district health systems, leaders of workers unions, health providers and representatives of civil society. RESULTS: The article identifies the problems that offices of health at state level had to overcome to implement the decentralization. CONCLUSIONS: Descentralizacion failed to achieve the objectives stated by its promoters.

OBJETIVO: Este artículo presenta los resultados de la segunda descentralización de la Secretaría de Salud de México (1994-2000). MATERIAL Y MÉTODOS: Además de revisar documentos oficiales y de archivo, estadísticas de salud y de productividad, se realizaron observaciones en los centros asistenciales y 232 entrevistas de profundidad en los estados de Baja California Sur, Colima, Guanajuato, Nuevo León, Sonora y Tamaulipas con directivos de las secretarías de salud estatales y jurisdiccionales, dirigentes de sindicatos, prestadores de servicios y representantes de la sociedad civil. RESULTADOS: Se identifican los problemas que los estados tuvieron que enfrentar para implementar la descentralización. CONCLUSIONES: No se alcanzaron los objetivos trazados por los promotores de la descentralización.

OBJECTIVE: This article discusses the effects of the second decentralization of the Mexican Ministry of Health (1994-2000). MATERIAL AND METHODS: It is based on a review of official and archival documents, health and productivity statistics, observations in clinics and hospitals, and 232 in-depth interviews in the states of Baja California Sur, Colima, Guanajuato, Nuevo León, Sonora and Tamaulipas. The interviewees included high-level administrators of state and district health systems, leaders of workers unions, health providers and representatives of civil society. RESULTS: The article identifies the problems that offices of health at state level had to overcome to implement the decentralization. CONCLUSIONS: Descentralizacion failed to achieve the objectives stated by its promoters.

OBJETIVO: Este artículo presenta los resultados de la segunda descentralización de la Secretaría de Salud de México (1994-2000). MATERIAL Y MÉTODOS: Además de revisar documentos oficiales y de archivo, estadísticas de salud y de productividad, se realizaron observaciones en los centros asistenciales y 232 entrevistas de profundidad en los estados de Baja California Sur, Colima, Guanajuato, Nuevo León, Sonora y Tamaulipas con directivos de las secretarías de salud estatales y jurisdiccionales, dirigentes de sindicatos, prestadores de servicios y representantes de la sociedad civil. RESULTADOS: Se identifican los problemas que los estados tuvieron que enfrentar para implementar la descentralización. CONCLUSIONES: No se alcanzaron los objetivos trazados por los promotores de la descentralización.

This work analyzes the neoliberal health sector reforms that have taken place in Latin America, the preparation of health care workers for the reforms, the reforms' impacts on the workers, and the consequences that the reforms have had on efficiency and quality in the health sector. The piece also looks at the process of formulating and implementing the reforms. The piece utilizes secondary sources and in-depth interviews with health sector managers in Bolivia, Colombia, Costa Rica, the Dominican Republic, Ecuador, El Salvador, and Mexico. Neoliberal reforms have not solved the human resources problems that health sector evaluations and academic studies had identified as the leading causes of health system inefficiency and low-quality services that existed before the reforms. The reforms worsened the situation by putting new pressures on health personnel, in terms of both the lack of necessary training to face the challenges that came with the reforms and efforts to take away from workers the rights and benefits that they had gained during years of struggles by unions, and to replace them with temporary contracts, reduced job security, and lower benefits. The secrecy with which the reforms were developed and applied made workers even more unified. In response, unions opposed the reforms, and in some countries they were able to delay the reforms. The neoliberal reforms have not improved the efficiency or quality of health systems in Latin America despite the resources that have been invested. Nor have the neoliberal reforms supported specific changes that have been applied in the public sector and that have demonstrated their ability to solve important health problems. These specific changes have produced better results than the neoliberal reforms, and at a lower cost.

Neoliberal reforms have promoted privatization and decentralization as strategies to improve equity, efficiency, and the quality of health services. In this piece the impact of these reforms in Latin America is critically analyzed, and the impacts of privatization in Colombia and of decentralization in Mexico are detailed. These two cases show that after 10 years of privatization in Colombia and 20 years of decentralization in Mexico the reforms have had the opposite of the desired effect: They have not improved equity, have increased health expenditures, have not increased efficiency, and have not shown a positive impact on quality. Public health programs in Colombia have deteriorated, while decentralization in Mexico has had a very high cost, without achieving the proposed objectives. It is officially accepted that decentralization in Mexico has increased inequity, and that new reforms implemented in 2003 promote vertical programs. Health systems based on regulated competition are not the most suitable ones for Latin America. Latin American countries should improve their health systems in line with the principles stated in the Declaration of Alma Ata and according to their own national experiences.