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date: 15 October 2018

Health Policies and Systems in Latin America

Summary and Keywords

Since the early 1990s, health policy in Latin America has focused on reform in most countries with the explicit purpose to increase access, decrease inequity, and provide financial protection. Basically, two different and opposed models of reform have been implemented: the Universal Health Coverage (UHC) model and the Single Universal Health System model. The essential characteristics of Latin American UHC are that health care is commodified by the introduction of competition that depends, in turn, on the payer/provider split, free choice, and pre-priced health service plans. In this framework, insurance, be it public or private, is crucial to assuring market solvency, because health needs not backed by purchasing power do not constitute a market that is particularly important in the Latin American region, the most unequal in the world. The Single Universal Health System (in Spanish, Sistema Universal de Salud, SUS) model is a model inspired by the principles of social justice and egalitarian, universal social rights. Characteristically funded by tax revenues, it makes provision of health services to the whole population a responsibility of the State and a universal citizens’ entitlement, independent of individual ability to pay or prior contributions. It considers health to be a public good that, for reasons of efficiency and equity, the market cannot provide. Everyone is entitled, as a right, to free care financed by the State.

Given that health system reform occurs in specific historical contexts, these models have had different results in each country. In order to highlight the concrete reform outcomes, the following issues need be addressed: the political scenario and the stakeholders involved; the previous health system and the relative strength of the public and private sectors; coverage achieved by public institutions or insurance, public or private; the different health packages existing within each country; the institutional (re)organization; and the relative importance of public health actions. An analysis is needed of the UHC reforms in Chile, Colombia, and Mexico, on the one hand; and the Single Universal Health System in Brazil, Venezuela, and Cuba on the other.

The UHC model in practice tends to increase inequity in access, create new bureaucratic barriers to timely care, fail to provide financial protection, and leads to deteriorated public health measures. It has also created new powerful private sector stakeholders, particularly in Chile and Colombia, while in Mexico the predominance of a strong public sector has “crowed-out” the private one. The Single Universal Health System has significantly increased access for millions that before reform had almost no access and has also strengthened public health actions. However, the strong preexisting private sector providers have profited from the public-sector purchases of complex medical services. Private health insurance has also increased among the upper middle class and workers belonging to strong labor unions.

Keywords: Health policy, Latin America, Universal Health Coverage, Single Universal Health System

In the past three to four decades, health reforms have brought far-reaching changes to Latin American health systems. Previous systems were based mainly on the so-called Bismarckian model, forming part of a corporate pact between employers, trade unions, and the State in connection with the economic policy of import substitution that started during World War II. Under this deal, organized workers in formal employment were covered by social security comprising health insurance financed—as it still is—by employer-employee-State contributions. The rest of the population received limited medical assistance provided by the Ministries of Health or, in some countries, by the church, other philanthropic organizations, or universities. The role of the private sector varied from country to country depending on how social insurance was organized. In Mexico, for instance, the public social security institutes have their own health services with salaried personnel, while in Brazil many social insurance institutes assured health care at private hospitals under contract. The percentage of the population covered by social insurance also varied from country to country depending on the size of the formal sector and on whether or not coverage extended to workers’ families. Social health insurance differed between countries, ranging from less than 15% (Bolivia) to around 60% (Uruguay) (Giovanella, Feo, Faria, & Tobar, 2012).

The role of the Ministries of Health was generally threefold. They were—and still are—legally the Health Authority that regulates the whole health system, both public and private. They were also responsible for public health actions and provided limited free or low-cost medical assistance to those excluded from social security. In many cases, however, ministries developed highly specialized hospitals that both provided care for the uninsured and engaged in research and training. The public services provided by the Ministries of Health have steadily diversified, and their territorial and population coverage has expanded.

The importance of private service providers in each country depended on the social insurance arrangement, but doctors with private practices were—and are—quite common in most countries. Private medical insurance and large private hospitals developed later on, particularly where population coverage by public social security was low and where stable, lucrative markets had developed.

This three-tier system tends to persist, with national specificities, despite the fact that its multiple problems were precisely the strongest arguments for reform. However, there are considerable differences from one country to another, depending on what reform model has been implemented. Segmentation of coverage and organizational fragmentation are still important. Inequality in service coverage and access to required services persist and is strongly determined by socioeconomic characteristics and geographical barriers. Although Primary Health Care (PHC) is strongly promoted all over the region, segmentation (whatever its causes) poses problems for efforts to establish integrated health service nets. Most Latin American health systems are still underfunded, although this is sometimes difficult to perceive, because the methodology used to report funding has changed and differs among countries (Cetrángolo, 2009). For instance, norms for what is public and private vary. Not unexpectedly, inequality in health status is still a major concern.

The purpose here is to discuss the main characteristics, achievements, and problems of the two health system models present today in Latin America: the Universal Health Coverage (UHC) model, centered on insurance; and the Single Universal Health System (in Spanish, Sistema Universal de Salud, SUS) model, in which care is tax funded and legally a responsibility of the State, that is, a universal citizens’ entitlement.1 This may seem a simplification, since it is evident that health reforms have structured very diverse systems in terms of coverage, access to services, institutional organization, and financing (Cetrángolo, 2009), but they can be ascribed to one of the basic models. Although at present these are the two basic models, it is important to note that almost all Latin American countries, even Costa Rica whose health system functions well, have undergone a period of neoclassic/neoliberal health reform as a result of the adjustment programs instrumented by the World Bank under guidelines of the Washington Consensus.

The UHC model as applied in Latin America can be considered to inform the second-generation neoclassic health reforms in the context of the so-called modernization of the State (Ozslak, 1999).2 The essential characteristics of UHC are that health care is marketized and commodified by the introduction of competition that depends, in turn, on the payer/provider split, free choice, and pre-priced health service plans or packages. In this framework, insurance, be it public or private, is crucial to assuring market solvency, because health needs not backed by purchasing power do not constitute a market. This question is particularly important, given that the Latin American region is the most unequal in the world. UHC is an ambiguous term and after a long debate, the regional office of the WHO, the Pan American Health Organization (2014), defined universal health coverage more comprehensively, but the terms of the debate remained the same. However, UHC is not implemented in the same manner everywhere. There are significant differences between countries, as will be exemplified with the reforms in Chile, Colombia, and Mexico, which belong to the UHC model, but have diverse characteristics mainly due to their historical and political settings.

The Single Universal Health System (SUS) is a model inspired by principles of social justice and egalitarian, universal social rights. Characteristically funded by tax revenues, it makes provision of health services to the whole population a responsibility of the State and a universal citizens’ entitlement, independently of individual ability to pay or prior contributions. It considers health to be a public good that, for reasons of efficiency and equity, the market cannot provide. Everyone is entitled, as a right, to free care financed by the State.

The idea that health and health services are a responsibility of the State and a universal social right can be traced historically to the British National Health Service (NHS), the Beveridge model of health system. The NHS was founded on the shared value that good health care should be available to all, regardless of wealth. The NHS is a tax-funded service that provides comprehensive, universal health care to all, free at point of delivery and based on clinical needs, not ability to pay.

In the SUS model of health system, the State generally provides health services directly. The hospital and outpatient service network, or the larger part of it, is State owned, and its health personnel are largely civil servants. As the main provider, the State is better able to regulate services, define procedures, and control costs. In the SUS, uniform rules are established for most health actions and services in order to guarantee similar services and more equitable conditions of access countrywide. Guaranteeing comprehensive care means offering integrated promotion, prevention, cure, and rehabilitation. Personal care and public health measures are integrated into a single system organized to meet the health needs of both individuals and populations. For these characteristics, Single Universal Health Systems are regarded as more efficient (they do more with fewer resources), more equitable, and as having greater impact on health conditions.

The SUS model has inspired health sector reforms in Latin America. Nonetheless, the nature and reach of the reform processes undertaken to build these systems have differed greatly between countries, as will be exemplified here by the cases of Brazil, Venezuela, and Cuba.

The underlying issues that will be addressed here in order to highlight differences and similarities among the selected cases are the following: the political scenario and the stakeholders involved; the previous health system and the relative strength of the public and private sectors; coverage achieved by public and private insurance; the different health packages existing within each country; the institutional (re)organization; and the relative importance of public health actions.

Universal Health Coverage Through Insurance: Trajectory and Complications

Universal Health Coverage (UHC) based on health insurance and a payer/provider split is at present the dominant model in Latin America. UHC is frequently presented as a financing reform (Giedion, Alfonso, & Díaz, 2013) that, however, implies a thorough reorganization of the whole health system. The basic assumption of insurance-based UHC is that health is just another economic sector and would benefit from competition to increase quality and contain costs (Londoño & Frenk, 1997).3 In order to make competition work, it is necessary to constitute one or several health funds; several fund managers that buy services for their enrollees; several service providers; and free choice of fund manager but not always of provider.

This scheme tends to obey the logic of private health insurance. In order for it to operate, priced health benefit packages have to be established and provision must be centered on the individual. This implies that health education, promotion, and prevention are focused, at best, on the person. Accordingly, population-wide or public health actions must be carried out by a separate agency, usually the State, which also has the very complicated task of regulating the health system and occasionally subsidizing the market to ensure its solvency, while fund administration/purchasing services and providers could be private or public.

The reason for examining Chile, Colombia, and Mexico is that these countries have implemented this model differently, and it has been in place for long enough to allow us to analyze changes, vicissitudes in its application, and results. In Chile the 1980–81 reform was part of the sweeping social security reform devised by pupils of Milton Friedman. The 1993 Colombian reform was also part of a broader social security reform strongly influenced by the World Bank. The Mexican reform was similar to Colombia’s, but was implemented stepwise in 1995, 2003, and 2007 and explicitly maintained existing public social security institutes even though a single system was envisioned for the future.

Chile, the World Pioneer of Reform to Commodify Health

The Chilean case is interesting for several reasons. One is that Chile carried out the world’s first neoclassical/neoliberal health reform, which subsequently became the model for other countries. A second is that political ideology and values were much more important than evidence-based or technical concerns. A third is that the reform interrupted a sustained effort to bring the right to health and access to all through a public health system. Fourthly, it radically changed the whole health system and gave rise to powerful new stakeholders.

In 1952 Chile started to build Latin America’s first National Health System (NHS) covering formally employed workers and the uninsured population (Labra, 2002). The rest of the population received services either through the social security institute for public employees, which used primarily private providers, or by paying directly for private services. When Salvador Allende, a doctor, became president in 1970, he set out to turn the NHS into a single unified public system financed by taxes. The NHS thus became a symbol of his government. By 1973 the public system provided about 90% of hospital care and 70% of outpatient care, but there were still geographic and social inequalities.

The 1973 military coup was designed primarily to destroy any possibility of democratic socialism in Chile, but the military junta had no plan for change countrywide and even less so for the health sector (Garretón, 1983). Lacking a national project, Pinochet set up a group of neoclassic/neoliberal economists, led by Milton Friedman, which launched the “Seven Great Transformations” (Piñera, 1991). These became the basis for a new constitution in 1980 that included health and social security. The NHS was formally ended in 1978, but the most important reform was put in place in 1981. The new model called for compulsory health insurance, for which workers alone would pay a contribution corresponding to 7% of their wages, while employer and State contributions were eliminated. Significantly, however, the armed forces maintained their own social security institutes.

At the same time, the ISAPREs (Social Security Health Institutions) were created to manage health funds and procure services on behalf of their clients. Several private ISAPREs were set up, but there was a single public fund manager, FONASA (National Health Fund), which covered (and covers) most of the population, but with diverse benefit packages and copayment schemes.4 The ISAPREs mainly engaged private providers under contract, while the FONASA channelled its enrollees, except those with free-choice schemes, to public facilities. These latter were reorganized in the National Health System with 28 Territorial Health Services, which were responsible for hospital care at autonomous hospitals, while oversight of primary health care facilities was transferred to municipalities (Missoni & Solimano, 2010).

The for-profit ISAPREs were allowed to accept or reject any person or family and could refuse to renew insurance when a client’s health conditions changed. Those refused by ISAPREs could always turn to the FONASA: The scene was set for skimming (Tetelboin, 2003). ISAPREs collected the compulsory 7% plus voluntary fees to increase service coverage and received a 2% public subsidy. Initially they were able to adjust their health plans freely to the amount paid by the client, to age, and to health conditions, which resulted in thousands of different plans (Missoni & Solimano, 2010). The distribution of financial resources became very favorable to the ISAPREs, which soon controlled 60% of the national health budget, while providing care to around 20% of the population (Labra, 2002). The ISAPREs can be seen to have profited legally from all the advantages, while public services shouldered the burden of caring for the poor, the ill, and the elderly.

Reorganization of the health sector gave birth to two parallel systems, one private and the other public. It also introduced financial capital, in the form of the ISAPREs, as a new and dominant stakeholder in the health sector. Large private hospitals grew rapidly and so did their power. The Medical Association, which had played an active role in support of the military coup, initially had more power, but lost its place to the new ISAPREs and private hospitals. The previously strong public system was systematically weakened by State measures, but it continued to offer services to the vast majority of the population. This explains why it retained strong public acceptance despite its increasing operating difficulties (Tetelboin, 2003).

This two-tier system remained after the end of the dictatorship, but several reforms have been implemented under Socialist Party presidencies to restrict the worst abuses of the ISAPREs and to grant more equal access to services. The best-known reform (Missoni & Solimano, 2010) is the AUGE (Regime of Explicit Health Guarantees) introduced in 2004 to guarantee timely access to a selected range of care, presently comprising 80 interventions, which is compulsory for both the private and the public sectors. However, it is recognized to have favored the private sector indirectly and increased private provision (Tetelboin, 2015).

The public sector has also been strengthened by investment in infrastructure, a substantial increase in personnel, and a higher budget. Also, it has been reorganized to perform its multiple functions better (Missoni & Solimano, 2010). The Ministry of Health was restructured and now has two under-secretariats: one for public health and another for health services. This enables the ministry to fulfill its tasks as health authority and as service provider. The FONASA was reinforced as the main health fund and the State’s function as regulator of private and public sectors has been concentrated in the Superintendence Office. This reorganization has established the public sector as the main or principal health system in Chile, while the ISAPRE system is considered supplementary (Comisión Asesora Presidencial, 2014). This view is coherent, because the public sector regulates the health system and is responsible for population health, while the FONASA covers 74% of the population, as compared to the ISAPRE’s 17% and the armed forces’ 2%. Universal insurance coverage has not been attained and 7% are uninsured (Giovanella et al., 2012). The public provider system also has the largest infrastructure, including 91% of health facilities and 90% of hospital beds, according to government figures.

A major effort has thus been made to restore the historical tradition and grant the right to health for all. However, the two-tier structure remains, as do copayments and unequal access. The reason is that the private system—particularly the for-profit ISAPREs—has become a powerful stakeholder and is backed by the political right. This became evident during the government of Sebastián Piñera (2010–2014), who envisioned a reform similar to Colombia’s, which included the concession of management of public autonomous hospitals and Private-Public Partnerships for new hospitals (Informe Comisión Presidencial, 2010). However, this reform was never carried out because Piñera lost the presidential election in 2014.

Colombia, Failed Showcase for Latin American Reforms

Chile’s was the first neoclassical health reform, but its implementation depended on a totalitarian regime, and it did not provide a credible health discourse to justify the commodification of health. Meanwhile, the World Bank designed a reform model published in 1993 with the title “Investing in Health.” Along these lines, Londoño, a Colombian economist; and Frenk, a Mexican public health expert, developed a “structured pluralism” reform model for Latin America (Londoño & Frenk, 1997) based on Enthoven’s managed competition. This has become Latin America’s blueprint for UHC.

The new Columbian constitution of 1991 apparently established a Social State based on human rights principles and intended to pacify the country after decades of violence. At the same time, however, the government introduced a structural adjustment plan that contradicted the new constitution (Franco, 2015). Enacted in 1993, Law 100 ushered in a comprehensive social security reform that included a health system reform modeled on structured pluralism (Restrepo-Zea, 2002), that is, a market-based reform whose method was to commodify health care and subsidize markets.

The new health system, the General Social Security Health System (Sistema General de Seguridad Social en Salud—SGSSS), was organized as a health insurance system with competing public and private sectors. It comprised a Unified Health Fund (FOSYGA); private or public fund managers or insurers (Health Promotion Enterprise/EPSs), which register users, issue identity cards, collect contributions, and purchase services for their clients; and private providers (Health Provider Institutions/IPSs) or public providers (State Social Enterprises/ESEs). Contributions to the system are mandatory.5 Two regimes were established, one contributory and the other subsidized for the poor, with different benefit packages, respectively, POS-C and POS-S. Regulatory functions and public health activities are the responsibility of both the national and local governments.

Despite being a market arrangement, this reform proffered a social health discourse (Hernández & Vega, 2001) of universality, redistribution, and equality. It promised to attain universal coverage by 2000 and redistribution was to be accomplished by the FOSYGA’s transferring 1% from the contributory regime, plus public funds, to the subsidized regime. Equality was understood as health insurance for all. None of these promises was fulfilled, however, and the new system suffered from mounting tensions.

Universal insurance coverage was not achieved as planned, mainly because an important part of the population is occupied in informal activities and insufficiently poor to classify for the subsidized regime, entry to which depends on a poverty census conducted by the municipalities. This led to a new stratification between those included and excluded. Furthermore, the discourse made no clear distinction between insurance coverage and access to needed services. Differences in access are inherent to the model and depend on the benefit package, POS-C or POS-S, but also on other barriers, such as place of residence. The scheme soon got into financial trouble and showed a rising deficit. Last, but not least, there was little room for public health activities in a scheme oriented to providing medical care for individuals or families. As a result, tuberculosis and malaria, for instance, increased rapidly (Arbelaez et al., 2004).

These results led to a series of adjustments. A drive to increase insurance coverage was begun in 2002, when Londoño became Minister of Health and Social Protection. The largest increase in insurance coverage was in the subsidized scheme, which now accounts for 55% of all insured. However, by 2010 about 8% of the population was still uninsured (Giovanella et al., 2012) and depended on care from the local health systems.

The legal framework was also changed and new legislation was put in place (Giovanella et al., 2012). In 2001 a new law defined the functions of the central, provincial, and municipal levels of government, which added to the complexity of the system. In 2007 a National Public Health Plan was introduced to counter the effects of Law 100 on public health activities and, in 2011, Primary Health Care (PHC) was stipulated as the basic care model. Basically the new legislation organized a system of public health to address what Law 100 had disregarded. Although it has some important differences, the model is like that of the United States, with two parallel structures, one for public health and another, predominantly private one, for medical care.

However the financial uncertainties were not settled; rather they worsened with the rapid growth of the subsidized insurance financed from multiple sources in addition to the solidarity transfers from the FOSYGA (Guerrero, Prada, Pérez, Duarte, & Aguirre, 2015). About 7% of Colombia’s GDP is presently devoted to health (an increase of almost 2% since 1994). Of this total, 52% is spent on social health insurance (with the contributory scheme accounting for two-thirds and the subsidized schemes for one-third), while direct private spending represents close to 20%, because of different kinds of copayments (Giovanella et al., 2012).

In late 2007 President Uribe declared a “social emergency” and issued 10 executive orders with force of law to reform the SGSSS. The underlying causes of this action (Franco, 2010) were its difficulties and the financial risks caused by widespread corruption and abuses, mainly in the private system, plus a real danger of the system’s bankruptcy. The aim of the executive orders (Hernández, 2010) was to extend and strictly regulate the market system; restrict benefit packages; limit professional autonomy; and require everybody to pay, by selling assets or borrowing, for instance. Furthermore, public funding for the SGSSS was to be subordinated to the government’s priority decision to protect State finances. This proposal caused widespread social mobilization and debate, which also revealed very serious corruption (Morelli, 2012) and arbitrary refusals to treat patients, particularly by IPSs. The Constitutional Court later overruled the executive orders, declaring them unconstitutional.

Public debate over the SGSSS and its objectives has continued, and two different alliances have formed: one comprising those who consider health a human right and an obligation of the State, health professionals, health service users, academics, and the political left; and the other, the new stakeholders of the marketized system, the techno-bureaucracy, and the political right. The former alliance won an important legislative victory when health was recognized to be a right and an obligation of the State (Franco, 2015). However, the two-tier market system remains and the National Development Plan 2014–18 underlines neoclassical/neoliberal principles and states: “As much market as possible and as much State as necessary.”

Although some authors still extol the merits of the Colombian health system, it has become difficult to present it as a showpiece, given the problems that have brought it almost to the point of bankruptcy. It has also become evident that it has managed, at best, to provide universal insurance coverage, but that vast inequality in access persists. The question remains: When a health system is paid for mainly with public funds and incurs major transaction costs, is in whose interest is it preserved?

Mexico, an Emerging Showcase in Trouble

After the failings of the Colombian reform, Mexico’s—and particularly its Popular Health Insurance (Seguro Popular de Salud—SPS) scheme—has often been presented as the new success story by supranational organizations. However, its promises of achieving universal health coverage in 10 years, increasing public health funds by 1% of GDP (up from about 3%), substantially diminishing out-of-pocket payments, and establishing a single universal health system in the future have not been fulfilled. To understand the Mexican reform process, it has to be remembered that the country’s public health system is historically very strong. Its two main pillars are the public social security institutes, one (IMSS) for private sector workers and another (ISSSTE) for State employees; and the federal Health Secretariat and decentralized State health services, which all have their own infrastructure and salaried personnel. At present these public institutions provide services close to 90% of the population (INEGI, 2016).

Although some authors argue that several reforms have taken place over the last two decades, it is more accurate to consider these a single reform process with stepwise implementation (Laurell, 2013)—the reason being that the basic reform model is the same, that is, managed competition or structured pluralism. The first phase involved the IMSS and was legislated in 1995 as a conditionality for the bailout provided to Mexico by the IMF and the Treasury of the United States to avoid a massive banking crash that could have destabilized global financial markets (Huerta, 1997). The reform changed the entire IMSS social security legislation, and two important modifications were made to the health insurance provisions.6 One, in financing, reduced employer contributions and increased the State contribution from 5% to 30%; the other made it possible, as required by the World Bank (1998), to set up private fund managers and providers (Laurell, 2001). In 2007 an almost identical reform was approved for the ISSSTE health insurance (Ulloa & Alonso-Raya, 2008), in disregard of the fact that the IMSS reform was in serious trouble.

In 2003 the second phase of reform (Laurell, 2015) established the Seguro Popular de Salud-SPS scheme. Led by Frenk, the health minister of the new neoliberal right-wing government, it was similar to the Colombian reform, but attempted to solve some of its problems (public health issues, for instance) and to adapt the model to conditions in Mexico. One important difference was that it contemplated only the uninsured population and not the public social security institutes, despite claiming to be the social health insurance of the uninsured. The modifications to the health legislation set up a National Commission, which receives health funding, most of which it transfers to state governments, which are then to purchase services for the enrollees from public or private providers. Except where child care is concerned, the SPS covers only a limited package of procedures, including only a small number of high-cost interventions.7 Funding comes formally from three sources: federal taxes, state taxes, and a premium from families in the 5th to 10th income deciles. In fact, almost all funding comes from the federal government, which collects nearly all taxes, while family contributions are negligible.

After almost 15 years, the promises for the SPS (Secretaría de Salud, 2005) have not been fulfilled. The most recent data on insurance coverage show that about 17% or 21 million Mexicans are still uninsured, and there are considerable regional differences, from 23% to 10% coverage. SPS and public social security insurance have achieved almost the same coverage, while private insurance represents only 2.7%, according to the 2015 midterm census (INEGI, 2016). The SPS National Commission reports about 8 million more individuals covered than the data collected directly in the population survey (CNPSS, 2016). This discrepancy could be explained by the fact that federal and state governments have a shared interest in inflating SPS membership, the former to show success in coverage and the states to receive more funding, which is proportional to membership. The classification of SPS members by decile is absurd, with the Commission reporting 2.7 times more members in decile I than the total population in this decile (CNPSS, 2016).

Although most official publications equate “access” with “insurance coverage”, access defined as receiving needed services differs considerably between SPS and public social security beneficiaries. This is so because the SPS benefit package comprises about 15–20% of social security health benefits (CONEVAL, 2013), plus SPS enrollees have to pay for excluded services, which raises substantial economic barriers. Furthermore, growth in the SPS has not been accompanied by expansion in physical and human resources, meaning that even if SPS beneficiaries require authorized services, nobody is offering them. In addition, drug shortages are much more common in SPS providers (Laurell, 2013). SPS service provision is almost exclusively public and offered by federal and state health institutions, so rather than being a health insurance, SPS is a publicly financed health system (Lakin, 2010).8

All public health institutions continue to face funding shortfalls (Laurell, 2017), and total public health expenditure is about 3% of GNP and private expenditure another 3%. The overall out-of-pocket, that is, private spending has decreased slowly and was 48% of total health expenditure in 2013 (Secretaría de Salud, 2013). The law stipulates the amount of SPS funding, but the budget approved by Congress is systematically lower than stipulated and is not fully executed. Also the Federal Congress Auditing Office has discovered multiple cases of fraud and corruption (Auditoría Superior de la Federación, 2017) on such a large scale that legislation has recently been passed to curb the abuses, but has yet to prove effective. Furthermore the financial reform deprived the IMSS of about 5% of its revenue, despite the increase in government subsidies.

There is now a consensus that, overall, the UHC reform of the Mexican health system has failed. Despite insistent efforts to establish a payer/provider split and competition between public and private fund managers and providers, these things have not happened. The public health sector undeniably continues to be the main provider, particularly for hospital care, and further privatization could lead to a service collapse. A single unified public system will not materialize in the near future, because very critical economic and political issues are involved (Laurell, 2017). Public institutions have instead chosen to exchange surplus service capacity, which, however, is very scarce in an overloaded system.

This does not mean that things will remain as they are. Even though private stakeholders, health professionals, users, supranational organizations, and most politicians agree that Mexican health services are in lingering crisis, the proposed solutions diverge (Laurell, 2017). The private sector, particularly private think-tanks and insurers, recommends introducing complementary payments or insurance in order for SPS to pay private providers. The public health institutions recommend expanding and formalizing the exchange of services with preset tariffs for payments between institutions. Academics, health workers’ and users’ organizations, and part of the political left uphold the constitutional right to health protection and have presented proposals for the gradual introduction of a single, public, universal health system financed by taxes. As things stand now, however, Mexico has a health system with dominantly public service provision financed mainly with public funds. It is certainly underfunded, which explains considerable out-of-pocket expenditure, but there is little evidence that the structured pluralism model would resolve the problems, particularly those of access and equity.

The History of Unified, Public, Universal Health Systems

In recent decades, the SUS model has influenced health sector reforms in Latin America during democratization processes following periods of dictatorship, especially in the political changes of the 2000s, when left-wing and center-left democratic governments led endeavors to move toward universal health systems. Over the past 10 years, many Latin American countries have recognized health as a constitutional right that it is the State’s duty to guarantee. Following Brazil, which passed the “Citizens’ Constitution” in 1988, other countries, such as Venezuela (1999), Ecuador (2008), and Bolivia (2009), promulgated constitutions that both defined health as a fundamental social right and the responsibility of the State and proposed construction of an SUS (Giovanella et al., 2012). The reforms to build unified, public, and universal health systems in Latin America will be exemplified by the cases of Brazil, Venezuela, and Cuba. Cuba’s pioneering universal health system has influenced reforms to set up SUSs in other countries in the region. Of these, Brazil, a country of continental dimensions, with a population of more than 200 million and considerable geographical and social heterogeneity, in the context of a re-democratization process ongoing since 1988, has unified its health social security and Ministry of Health institutions and facilities to create the Unified Health System (Sistema Único de Saúde, SUS). Venezuela has expanded its public health system with strong community-oriented primary health care.

Brazil, the Unified Health System (SUS)

Framed in the context of Brazil’s re-democratization after more than 20 years of military dictatorship, the 1988 Federal Constitution instituted a universal health system based on the principles that health is a citizen’s right and the duty of the State. Offering tax-funded universal access at no charge, the SUS aims, at all levels of government, both to provide universal comprehensive care through decentralized health service management and provision and afford social participation (Paim, Travassos, Almeida, Bahia, & Macinko, 2011).

Support for universalizing the right to health grew out of the political process and strong social mobilization. “The singularity was a social protection system designed by civil society movements and its strong association with the transformation of State and society into a democracy” (Fleury et al., 2013).

In the context of Brazil’s democratization process following the overthrow of the military regime, a powerful health policy movement—the Brazilian health movement—emerged in favor of the universal right to health, bringing together civil society organizations such as the Centro Brasileiro de Estudos de Saúde (Cebes), collective health scientific societies such as the Associação Brasileira de Pós-graduação em Saúde Coletiva (Abrasco), representative associations of doctors and other health professionals, the student movement, and grassroots movements. Espousing and spreading the notion of the social determination of health, the Brazilian health movement contributed decisively to shaping consensus around a critical diagnosis of the existing health system and an agenda of change toward building a SUS. Its proposal that health is a citizens’ right, summed up in 1986 at the 8th National Health Conference, guided the discussions of the Constituent Assembly. Strong pressure from civil society and left-wing and center-left democratic movements fostered a robust political coalition, which managed to influence the drafting process to frame health as a universal right and the State’s duty, as well as to provide for creation of a SUS, both of which were written into the 1988 Constitution.

In the previous health system, comprising social health insurance funded by compulsory employer-employee contributions, access had been restricted to the portion of the population in formal employment; population coverage was less than 50%. The Ministry of Health was responsible for public health measures to prevent and control disease and provided limited medical assistance for groups excluded from social insurance. The social security system provided outpatient medical care, generally at its own facilities, and engaged private providers under contract for hospital care, with a purchaser-provider split. In 1988, 74% of beds in Brazil were private. The prevalence and strength of private health providers hampered introduction of the new system.

Implementation of the SUS began in 1990 when the Social Security National Institute of Medical Care (Inamps) and the Ministry of Health were unified under Ministry of Health control. The Inamps health facilities were decentralized and transferred to state (most hospitals) and municipal governments (most outpatient care clinics). The new health system design meant considerable changes in the distribution of political power and accountabilities among the national, state, and municipal levels of government and between State and civil society by way of new mechanisms for social participation and a substantial process of decentralization, which transferred decision making power and competences from the national to subnational levels.

The SUS acknowledges universal entitlement and, accordingly, formally covers 100% of the population with comprehensive care, including health promotion and preventive actions, through an extensive network of primary health care facilities, specialized and hospital care, through to high-complexity procedures, such as oncological treatment and organ transplants. Nonetheless, 25% of the population is also covered by voluntary, supplementary private health insurance.

The institutional reorganization involved combining a decentralized health care system with a decision making process resting on cooperation among federative intergovernmental bodies and organized society in participatory arenas. The three levels of government share responsibility for individual and collective care. “The existence of political spheres for negotiation and instruments for consensus-building were important innovations in the intergovernmental relationships and in the relationship between the State and social actors” (Fleury et al., 2013, p. 19).

The SUS operates under national guidelines to guarantee the right to health, although responsibility for health care provision is decentralized. Each level of government has health competences and sets up an authority (a health department) responsible for managing the health system in its territory, a health policy council with social participation and a health fund. Provision of primary care by multi-professional teams is the responsibility of municipal governments, while the state and federal governments provide specialized care. Ambulatory care is provided at public health center, and hospital care at public hospitals and private hospitals under contract (a legacy from the previous model). In the SUS, the health departments at each level of government form part of, and are responsible for, public health and personal care actions. Organization of health regions in each state is ongoing as a means to extend coordination and reduce the system fragmentation that resulted from the choice to decentralize to the municipal level.

Since its founding nearly 30 years ago, the SUS has been implemented gradually with advances and setbacks depending on the political coalitions in power. It has enormously expanded the population’s access to health and has reduced inequalities in access, even though considerable regional and social inequalities persist. Its expenditures correspond to about 4% of GDP, although it is underfunded and about half of total health spending in Brazil remains private. Since 2015, economic recession, political crisis, and austerity policies have imposed further economic and political constraints, holding back full institutionalization of the legally assured universal right to health.

Cuba, Latin America’s Unique Universal National Health Service

In Cuba, support for universalizing the right to health grew out of a vigorous political process, the 1959 Cuban revolution. From the outset, the revolutionary socialist regime made health a priority. The revolutionary government of Fidel Castro began to organize a single national public health system (SUS) on the principle that health is an inalienable right and health care is the responsibility of the State. In the Cuban SUS, health care is available to all equally and free of charge. Preventive, public health, and curative services are integrated. Social participation is a key characteristic of the health system, and health care activities are integrated with economic and social development (Keck & Reed, 2012).

In the previous system, health care services had been predominantly private and concentrated in the cities, with wide disparities between rural and urban areas (Keck & Reed, 2012). Construction of the SUS started in 1960, marking the beginning of efforts to distribute services according to people’s health needs. A Rural Medical Service was introduced, and hundreds of newly graduated doctors were posted to remote areas. From being based on hospitals and specialist physicians, the model of care underwent changes from the 1970s onward. Community-based polyclinics were set up and staffed in basic specialities in order that comprehensive care could be provided to people where they lived. Medical school curricula and residency training were redesigned and polyclinics were included among teaching settings (Keck & Reed, 2012).

In the mid-1980s, a new model of primary care introduced training for doctors to specialize in Comprehensive General Medicine. Teams consisting of a family doctor and a nurse began to provide coordinated medical care and led health promotion efforts in communities of specified geographical catchment areas (Domínguez-Alonso & Zaca, 2011). This community-based PHC model, combining public health actions and personal care, inspired PHC reforms in several other Latin American countries.

In Cuba, the State regulates, funds, and provides health services. The SUS is organized on three administrative levels: national, provincial, and municipal. As the governing body of the National Health System, the Ministry of Public Health has normative, coordination, and oversight functions. It is responsible for integrated public health and personal care services. In addition to implementing health policies, the Ministry of Public Health is responsible for conducting research and developing the medical sciences and the medical pharmaceutical industrial complex (Domínguez-Alonso & Zacca, 2011; De los Santos-Briones, Garrido-Solano, & Chávez-Chan, 2004).

The SUS guarantees universal coverage free of charge to the whole population. Health spending is almost exclusively public: Public spending accounts for 96% of total health spending. Health facilities are public and staffed by civil servants. The SUS guarantees care at all levels, from primary to tertiary care, in an integrated, territorially organized system. The SUS is publicly funded by the national government, which redistributes funding among the various levels and care facilities through the provincial and municipal assemblies (Domínguez-Alonso & Zacca, 2011).

Not only public health and personal care actions are integrated. Health care activities are integrated with economic and social development. The government’s emphasis on inter-sector collaboration in extended social policies with social participation enables it to address the social determinants and achieve favorable health outcomes. The social participation involves a system of political and social organizations, such as the Committees in Defence of the Revolution (CDRs) and the Federation of Cuban Women (FMC), which work in coordination with health services on community health promotion and prevention actions.

In the mid-1990s, with the overthrow of the Soviet Union, Cuba went through a severe economic crisis, which had secondary effects on the health system. With infrastructure deteriorating and materials, medicines, and medical equipment in short supply, waiting times increased; and, as a result, dissatisfaction grew among both users and health personnel. In subsequent years, restructuring programs were undertaken to strengthen primary care and reform hospital care by concentrating in polyclinics the services previously provided in hospitals, closing hospitals and raising the number of users allocated to each primary care facility (Rojas, 2012). Despite the reforms, difficulties persisted, and it was not until the mid-2000s that services recovered. In that process, the polyclinics became training centers for health personnel and hubs for health system integration, coordinating all care and offering extended primary care, including imaging services, and some medical specialities. Some 500 polyclinics now coordinate more than 14,000 doctors’ surgeries and 30,000 family doctors across the country (Morales, Pérez, & Salabarría, 2009). At present, under recent budget pressures, new reorganization proposals are being implemented to redistribute and concentrate services regionally, so as to guarantee timely access and, at the same time, make the system more efficient (Rojas, 2012).

Another unique feature of the Cuban health system is its role in global health cooperation. Under cooperation agreements, thousands of Cuban doctors provide care for vulnerable communities in a number of countries worldwide. Cuban health internationalism is recognized as having profound humanitarian impact around the world (Huish, 2014). In Latin America, the main cooperation agreements for provision of doctors are with Venezuela, where some 20,000 Cubans doctors are posted, and Brazil, where 11,000 are working in community-based PHC.

Health care has been a priority and a political commitment continuously over more than 50 years in Cuba, with inter-sector action and community participation and, as a result, health has improved steadily. Cuba is among the countries with the world’s best health indicators, particularly infant mortality of fewer than five deaths per thousand live births.

Despite the United States embargo and the economic crisis that affected Cuba so strongly in the 1990s following the collapse of the Soviet Union, powerful political support from government and the population has enabled Cuba to achieve exceptional outcomes in health indicators, as well as high standards in health science and technology and human resources in health (Fleury et al., 2013). Nonetheless, the present context of economic austerity imposes severe constraints on investment and may undermine these advances.

Venezuela—Misión Barrio Adentro, Unfinished Universalization

Health sector reform processes in Venezuela during the 1990s accompanied the macroeconomic structural adjustment programs guided by the Washington Consensus. Provision and funding competences in health were progressively decentralized to 17 of 23 states; “cost recovery” user charges were introduced at public health facilities; tax incentives were offered for the construction of private health centers; and private health service provision increased, while public health spending declined considerably. These reforms produced further health system fragmentation, selectivity in public provision and more serious barriers and inequity in access.

The neoliberal adjustment policies substantially raised poverty levels, concentrated income, and worsened conditions of life and health. By the mid-1990s that context had given rise to a robust grassroots and left-wing movement opposed to the neoliberal policies, which culminated in 1998 in the electoral victory of the Bolivarian movement led by Hugo Chávez. The new government, which identified itself as ideologically socialist, broke with the previous policies and proposed the creation of an SUS.

In December 1999 a referendum approved the new Constitution of the Bolivarian Republic of Venezuela. This declared that health is a fundamental social right and the State’s duty to guarantee and institute a Public National Health System (Sistema Público Nacional de Salud, SPNS) (Feo & Curcio, 2004). Article 83 of the Constitution stipulates:

“Health is a fundamental social right, the obligation of the State, which will guarantee it as part of the right to life. The State will promote and apply policies directed to raising quality of life, collective wellbeing and access to services. All persons have the right to health protection and a duty to participate actively in promoting and defending it” …

(Venezuela, 2000).

In order to guarantee the right to health, the State is required to set up, exercise stewardship over, and manage a public national health system (Sistema Público Nacional de Salud, SPNS) which is to be inter-sector; decentralized and participatory; integrated with the social security system; and governed by the principles of solidarity, gratuity, unicity, universality, comprehensiveness, equity, social integration, and multiculturality (Venezuela, 2000).

Universality entails affording all persons the right to health, to which end access to health services will be guaranteed without discrimination and in effective conditions of equality. Equity acknowledges and addresses the differing needs of population groups, so as to reduce health inequalities resulting from geographical location, social class, gender, and ethnicity. Solidarity requires that all persons and sectors contribute to directing the health system toward meeting needs and achieving well-being and collective health for the whole population. Gratuity in all health services provided by a public national health system prohibits direct charges and abolishes previous copayment arrangements (Giovanella et al., 2012).

Beginning in 1999, after enactment of the new constitution, the government of President Hugo Chávez embarked on a process of change and redefinition away from the previous health system and toward establishing a public national health system, which is still incomplete.

In Venezuela, as in most Latin American countries, the previous health system comprised the Ministry of Health, which was responsible for public health actions and for partial coverage of the population, and a mandatory membership social security system for those in formal employment. Set up in 1944, the Venezuelan Social Security Institute (Instituto Venezolano de los Seguros Sociales), an autonomous organization attached to the Ministry of Labour, is the main social security institution. It provides health services to workers in formal employment in the public and private sectors nationwide and to their families, and, as a result, covers less than 20% of Venezuela’s population.” Other social security institutions cover specific sectors—public education, the armed forces, the national oil enterprise (Petróleos de Venezuela, PDVSA) and universities—insuring and providing health services to their employees. The private sector is funded out of pocket, as well as by private insurance that covers around 10% of the population. Generally speaking, each of these coverage segments retains its own clientele and care structure, forming a segmented, fragmented system (Bonvecchio, Becerril-Montekio, Carriedo-Lutzenkirchen, & Landaeta-Jiménez, 2011; Giovanella et al., 2012).

Implementation of the Public National Health System has been slow. In 2000, one of the Chávez government’s early measures toward universalizing health care was to afford access to IVSS health services for the whole population. At present, IVSS hospitals and ambulatory services provide care to the general public on demand, with no need for referral. However, major corporative and trade union resistance prevented the subsequent unification of the social security organizations.

From the outset, health management under the Bolivarian government has been directed to introducing a model of comprehensive care and to developing social participation in health. The changing model of care is framed by a program—the Misión Barrio Adentro (MBA) (Inside the Neighbourhood Mission)—set up in 2003 in a context of severe social and political crisis after a failed coup attempt by conservative forces in 2002.

The 2014–2019 National Health Plan took up Barrio Adentro as a strategy for new institution building in health, as a model for continuous, comprehensive care oriented to the family and community with universal coverage. MBA is the organizing principle of the Public National Health System (SPNS) (Venezuela, 2014).

Implemented under an agreement with Cuba, with the participation of some 20,000 Cuban doctors (Armada, Muntaner, Chung, Williams-Brennan & Benach, 2009) trained in family and community medicine, the MBA embodied a wide-ranging policy of comprehensive, territorially based, community-oriented primary health care, which guarantees accessibility by siting clinics and popular surgeries in communities. By setting up more than 6,000 popular surgeries in peripheral neighborhoods of Caracas and in communities in the country’s poorest municipalities, it is estimated to have expanded access for between 15 and 17 million people (53% to 57% of the population) previously without access to health services (Armada, Muntaner, Chung, Williams-Brennan, & Benach, 2009; Curcio, 2012).

The MBA guarantees comprehensive care. It combines collective health promotion and disease prevention measures with individual care provided by teams comprising a general practitioner and specialist in comprehensive medicine, a nurse, and a community health worker (health promotor).

Barrio Adentro has strong inter-sector, participatory, and territorial components, with an emphasis on health promotion and on addressing the social determinants of health. It interconnects locally with the set of social missions that promote comprehensive improvement in quality of life for impoverished populations in areas such as access to food (through Casas de Alimentación) to reduce malnutrition, education to address illiteracy, productive employment, social integration, preservation of culture, and development of values of solidarity and social co-responsibility (Curcio, 2012; OPS/OMS, 2006; Venezuela, 2014). This interaction was implemented through social networks of community participatory organizations through nearly 9,000 Health Committees with members elected in assemblies and the Community Councils in place in many of the municipalities (Curcio, 2012).

As the MBA developed, timely access to specialized and hospital services was gradually organized in two stages. Misión Barrio Adentro II, which offers specialized diagnostic and treatment services, provided free of charge at Comprehensive Diagnostic Centres (Centros de Diagnóstico Integral), Advanced Technology Centres (Centros de Tecnología Avanzada), and Comprehensive Rehabilitation Rooms (Salas de Rehabilitación Integral). Misión Barrio Adentro III and IV modernized the technology and improved infrastructure in the national hospital sector, in order to consolidate the referral and counter-referral system, and developed new highly specialized hospital centers to provide care, training, and research (Giovanella et al., 2012).

In order to gradually replace the Cuban doctors, since 2008 an extensive training program in Comprehensive Community Medicine has been operated by six Venezuelan universities as part of the MBA. By 2014 16,000 doctors had graduated from it and more than 20,000 students of comprehensive community medicine had been trained at academically certified MBA clinics, with substantial participation by Cuban professors specializing in comprehensive general medicine (Venezuela, MPPS, & OPS, 2013). The students are residents of the communities and, on starting the course, commit to providing services in the public system. All graduates are guaranteed employment in the Public National Health System.

Implementation of the Barrio Adentro network afforded access to public health actions and health services for an enormous contingent of the population that had previously been deprived of them. Studies show the MBA’s positive impacts on the population’s health, including effects in reduced infant mortality, particularly its postnatal component (deaths from infectious intestinal diseases and malnutrition), as well as in the death rate among one- to four-year olds (Curcio, 2012).

The Public National Health System has not been set up completely. The system was never fully unified and the social security institutes remain. Unicity, one of the core principles of the public national health system, has not been attained and institutional fragmentation has increased. The Barrio Adentro service network was implemented as a structure parallel to the existing public health establishment network of the Ministry of Health and state governments. The MBA is funded and managed from the Presidency of the Republic, which has contributed to fragmenting funding and service provision and poses new challenges for coordination of care and efficiency in the public health system (Bonvecchio et al., 2011; Tejerina-Silva, 2015). Segmentation has not been addressed. In parallel with efforts to implement the public national health system, private insurance coverage has also expanded. As in Brazil, many civil servants take out private insurance subsidized by the government department that employs them.

Even though health system unification has not occurred, the whole population does have access to health services free of charge, through either the MBA, the conventional system, or the social security system. That is, everyone has access to and can receive identical services at facilities of the public system and the social security system.

Hugo Chávez won four presidential elections and Bolivarian policies have undoubtedly brought about substantial reductions in social inequalities, poverty, and illiteracy, expanding education for young people and strengthening social participation, among other gains. However, since Chávez’s death in 2013, Venezuela has been dogged by severe political, economic, and social crises, while clashes between conservative and Bolivarian forces have steadily intensified and the Bolivarian government’s support base has been eroded, placing the gains in jeopardy.

In the health sector, the economic crisis has led to greater difficulties in funding the public system and thus substantial shortages in health supplies and medicines, administrative discontinuity (seven health ministers in the four years, 2014–17), lack of infrastructure maintenance, wage freezes, and mounting dissatisfaction among health personnel and the user public.9 The social and economic crisis is threatening the MBA’s health outcome gains, and some health indicators, such as maternal and infant mortality, are visibly deteriorating.

The MBA experiment is unfinished. Full implementation of the Public National Health System will depend on rebuilding alliances in defense of the universal right to health.

Conclusions and Further Research

Traditionally, the key features of Latin America health policies and health systems have been their segmentation of coverage, organizational fragmentation, and privatization of funding and health service provision. Segmentation means a diversity of subsystems tasked with providing health care to different population groups under heterogeneous rules of funding, membership, and access to procedures and service networks, all determined by social position, income level, or participation in the labor market. Organizational fragmentation undermines health system efficiency and precludes the coordination necessary to guarantee quality, comprehensive care. Segmentation, fragmentation, and privatization challenge the guaranteed universal right to access health services according to need and regardless of ability to pay.

In order to attain universal access to health care, Latin American countries have to address not only the challenges common to all health systems (shifts in demand resulting from demographic and epidemiologic dynamics, from population aging and rising prevalence of chronic non-communicable diseases and multimorbidity, introduction of new technologies, financial constraints, and increased health care spending), but also their historical social shortfalls. The countries of Latin America have to address their high levels of poverty, gaping social inequalities, and social exclusion in health, in addition to the specific characteristics of their health systems and the epidemiological profiles of their populations. The latter are conspicuous for high levels of violence and the world’s highest homicide rates, which in 2012 stood at 53.7 per 100,000 population in Venezuela, 43.9 in Colombia, and 32.4 in Brazil, contrasting starkly with western European countries, where homicide rates are fewer than 2 per 100,000 population (WHO, 2016).

Rates of poverty and inequality remain high in the region, even though most countries have seen the proportion of poor decline and income distribution improve, mainly between 2008 and 2012 under social protection policies prioritized by left-wing and center-left governments (ECLAC, 2016). In 2014, 28% of the population (about 168 million people) lived in situations of poverty, in contrast with 1990, when the proportion was 48% (204 million below the poverty line). The Gini coefficient, which ranges from 0 (complete equality) to 1 (complete inequality), is 0.469 for Latin America, according to available data for 2015. Income distribution can also be expressed as the ratio between the average per capita incomes of households in the highest and lowest income quintiles. ECLAC (2016) estimated that, in 2015, the average ratio was 12.2. In other words, for every 100 monetary units received by members of households in the lower quintile, members of households in the upper quintile received, on average, 1,220 monetary units (ECLAC, 2016).

In that context, strategies to expand coverage by means of focalized private or public insurance will intensify the segmentation and the social inequalities in health service access, as was so well demonstrated by the international financial agencies’ efforts to impose focalized insurance plans with limited coverage as loan conditionalities in the 1990s. Neoliberal adjustment programs have intensified the historical legacy of social protection in health care segmented by institution and population group. These arrangements reduced the provider role of the State, which became the insurer of a minimum package of fewer health procedures, while social health protection became more segmented, with coverage differing widely among population groups and crystallizing existing social inequalities in health service access.

The Single Universal Health System (SUS), with tax funding and universal access to a single network of services and procedures independently of ability to pay, expands access with less inequality and greater efficiency and effectiveness. By integrating personal care and public health action, it is better able to address the social determinants of health and potentially to produce better health outcomes, as so clearly exemplified by Cuba. In the other countries, however, despite its legal status, the universal right to health has not been fully implemented. After health sector reform is enacted, effectively assuring that right depends on reducing stakeholders’ veto power and maintaining public support for, and governments’ commitment to, the SUS. In fact, with extremely rare exceptions, universal access to health has not been attained in Latin America, because of the institutional legacy, economic, political, and social constraints.

The huge social inequality also speaks to immense unsatisfied social needs, which pose strategic problems to governments even if there is a clear coincidence between political ideology and values and the proposals for health system financing and organization. This implies that progressive governments have to prioritize the satisfaction of these needs, which involves health policy. For instance, massive job creation and a general increase in the minimum salary or cash transfers tend to have a higher impact on inequality than to grant the right to health or even to education. The distribution of financial resources between different social programs is thus a key strategic issue and depends on the concrete context of each country. However, the previous structure and historical tradition of the health system plays an important role that could facilitate or obstruct reforms whatever their orientation.

In Chile, Pinochet´s dictatorship aimed at destroying the public system but with the return of elected center-left governments the public system was again strengthened and the private further regulated. In Colombia the instability of the State, contradictory reforms, and the privilege of private management led to a segmented and inefficient system that suffered a technical bankruptcy. The Mexican reform has had serious problems to advance to a competitive and mercantile given its strong public system and a weak private health sector.

The main obstacles to the full implementation of the SUS model again have their roots in the historical characteristics of the health systems. The lack of public health resources, a strong medical-industrial complex, and special interest groups with political influence have impeded the achievement of the strong political commitment to the right to health and equality on part of the left or center-left governments.

This article gives a broad overview of the problems that Latin American health systems face. However, like in other (sub-)continents, there are vast differences between countries that need to be explored and specific problems to be resolved. Given the sweeping cuts in social expenditure and social services imposed during the “Great Recession” starting in 2008, the Latin American experience might provide some valuable indications concerning how to analyze health system reforms.

Suggested Reading

ECLAC—Economic Commission for Latin America and the Caribbean. (2016). Social panorama of Latin America 2016. Santiago, Chile: Social Development Division and the Statistics Division, ECLAC.Find this resource:

Fleury, S., Faria, M., Durán, J., Sandoval, H., Yanes, P., Penchaszadeh, V., & Abramovich, V. (2013). Right to health in Latin America: Beyond universalization. Series ECLAC Financing for Development Series. No. 249. Santiago de Chile: Economic Commission for Latin America and the Caribbean.Find this resource:

Giedion, U., Alfonso, E. A., & Díaz, Y. (2013). The impact of universal coverage schemes in the developing world: A review of the existing evidence. Washington, DC: The World Bank.Find this resource:

Giovanella, L., Feo, O., Faria, M., & Tobar, S. (Orgs.). (2012). Sistemas de salud en Suramérica: Desafíos para la universalidad la integralidad y la equidad. Rio de Janeiro: Instituto Suramericano de Gobierno en Salud.Find this resource:

Hernández, M., & Torres-Tovar, M. (2010). Colombia’s new health reform: Helping keep the financial sector healthy. Social Medicine/Medicina Social, 5(4), 177–181.Find this resource:

Laurell, A. C. (2015). The Mexican popular health insurance. Myths and realities. International Journal of Health Services, 45(1), 105–125.Find this resource:

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.Find this resource:

Pan American Health Organization. (2017). Health in the Americas 2017 edition. Summary: Regional outlook and country profiles. Washington, DC: PAHO.Find this resource:

Santos, L. M. P., Oliveira, A., Trindade, J. S., Barreto, I. C. H. C., Palmeira, P. A., Comes, Y., & Shimizu, H. E. (2017). Implementation research: Towards universal health coverage with more doctors in Brazil. Bulletin of the World Health Organization, 95, 103–112.Find this resource:

WHO—World Health Organization, (2010). Health systems financing: The path to universal coverage. World health report 2010. Geneva, Switzerland: WHO.Find this resource:

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Notes:

(1.) This system is similar to, and modeled on, the British National Health Service.

(2.) This view could be challenged by arguing that UHC could be achieved by different means, but a closer analysis of, for instance, the WHO scheme for expanding universal coverage reveals that it presupposes insurance coverage (WHO, 2008; World Health Report, 2008, ch. 2), Technical Briefs for Policy Makers (WHO, 2005), and Health Systems Financing. The path to universal coverage (WHO, 2010).

(3.) This supposition has never been empirically substantiated, but it is an underlying assumption of neoclassical economic reasoning.

(4.) There are two types of ISAPRE: “open” for profit and “closed.” The latter correspond to large companies and are kinds of mutualities.

(5.) The amount and origins of contributions have varied over time. Presently employees pay 4% of their wages, employers 8.5% of their profits, and independent workers 12.5% of their income (Guerrero, Prada, Pérez, Duarte, & Aguirre, 2015).

(6.) The most important modification changed the basis for pensions from pay-as-you-go to individual capitalization.

(7.) It includes 8 cancers, drugs, and outpatient care for HIV/AIDS, myocardial infarction under 60 years of age, and Hepatitis C for patients aged between 20 and 50 years.

(8.) Family contributions correspond to 0.007% of total funding.

(9.) Severe supply shortages, especially in medicines, have ensued nationwide.