unserved communities just by improving the efficiency and rationalizing the allocation of resources for health programs. The political and technical feasibility Ot osigning and Implementing these reforms is difficuit to assess, but given the major macro-reforms already implemented in Mexico and Brazil, this policy seems to be feasible.

Fifth, reduce dffferences In quality of care between health agencies. Again, this policy Is already necessary regardless of the Implications of the epidemiological transition, due to the low standards of care prevailing In many health institutions In these countries (Gish, 1988). The equity objective reinforces the need for quaiity, overcoming the uneven distribution that exists between institutions that serve different socioeconomic groups. A lEarge study of quaiity of perinatal health services In Mexico City demonstrated that neonatal mortality rates (standardized for obstetric risk) were higher In Ministry of Health hospitals, which mainly serves the poor, when compared with social security hospitals (Bobadilla, et al. 1991).

# _2. Reform of the Health Care Model_

The current health c.re model of the three countries is inadequate to deal with the increasing complexity of the epidemiological profile. As in many other countries, in these three, the first level of care Is weak and under-utilized, and most of the public hospitals are overcrowded and used for conditions that could be treated in lower levels of care. Three interrelated changes In the current health care model are proposed to correct these problems.

First, to increase the technological com2lexity of the first level of care. The Increasing demand for health services that derives from the rise of the absolute number of noncommunicable disease cases will not be met adequately with the limited health personnel and restricted technology available at the first level of care. Common conditions, such as hyperten.;ion, ischemic heart disease, menopause. cervical dysplasia, cataract, varicose veins, etc., can be controlled with current inexpensive treatments. Early detection of many chronic conditions can save resources by reducing the number of cases that advance to nore severe stages and require hospitalization. Diagnostic and screening procedures and cost-effective ambulatory therapies should be selected and made available at the primary level of care. This policy should not be Implemented, however, If resources are going to be taken from services for matemal and child health, which are still the priority in poor areas.

Second, to restrict hosDitai care for the most severe conditions and to give priority to conditions amenable to treatment with cost-effective interventions. Low risk deliveries, sterilizations, and minor surgery are examples of services that can be provided at a lower level health facility. The next policy proposal defines such a facility.

Third, to create or strengthen the Advanced Primary Health Care Centers. Wth different names and slight changes in the content, the three countries analyzed here have already recognized the need for a new level of care. This would deal with the health problems mentioned previously: low risk delivery, ambulatory surgery, common diseases and conditions that require an specialist, and others. This proposal for a more complex intermiediate ievel of care is only feasible for urban areas, having a largs enough population base to support such an institution. For this reason, it is important to note that this policy without the preceding one, could aggravate the current inequalities between the urban and the rural populations. This is an extremely important strategy to face the fast growing health problems of urban areas, and defining mechanisms of cooperation between public and private sectors can be very effective, since both are already providing care for these hear'th conditions. The most successful experience that has applied these reforms to the health care model comes from Call. Colombia. Several reports have shown that with limited investment, these policies led to

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