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Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce Published Online
socioeconomic inequalities, improve health outcomes, and provide nancial risk protection. In particular, starting in October 16, 2014
http://dx.doi.org/10.1016/
the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused S0140-6736(14)61646-9
on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have
This is the rst in a Series of four
produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and papers about universal health
collective action to overcome social inequalities. In most of the countries studied, government nancing enabled the coverage in Latin America
introduction of supply-side interventions to expand insurance coverage for uninsured citizenswith dened and Harvard School of Public Health
enlarged benets packagesand to scale up delivery of health services. Countries such as Brazil and Cuba introduced (Prof R Atun FRCP) and Harvard
Global Equity Initiative
tax-nanced universal health systems. These changes were combined with demand-side interventions aimed at
(F M Knaul PhD), Harvard
alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged University, Boston, MA, USA;
populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and Oswaldo Cruz Foundation,
lessons from the Latin American experience are relevant for countries advancing universal health coverage. Rio de Janeiro, Brazil
(Prof L O Monteiro de Andrade PhD);
School of Medicine,
Introduction impetus for these countries to strengthen their health Federal University of Cear,
Well-functioning health systems improve population systems and progress towards universal health coverage. Fortaleza, Brazil
health, provide social protection, respond to legitimate We selected these countries because they have introduced (Prof L O Monteiro de Andrade);
Pan American Health
expectations of citizens, contribute to economic growth,16 health-system reforms to achieve universal health
Organization, Washington, DC,
and underpin universal health coverage.7 Political stability, coverage and because relevant data are available. As with USA (G Almeida PhD); The World
committed leadership, sustained economic growth, and the other reports in the Lancet Latin America Series, we Bank, Washington, DC, USA
strong health systems are crucial for achieving universal have not analysed the English-speaking countries of the (D Cotlear DPhil,
health coverage, which is hindered by income inequalities.8
Starting in the late 1980s, many countries in Latin
America began social sector reforms to alleviate poverty Key messages
and reduce socioeconomic inequalities, including reforms Latin American countries are characterised by sociocultural, economic, and political
in the 1990s to strengthen health systems and introduce diversity, with wide socioeconomic and health inequalities.
universal health coverage. Latin American countries share Costa Rica and Mexico established parliamentary democracies in early 20th Century, but
many economic, political, social, and cultural similarities beginning in the late 1950s revolutions in Cuba and Venezuela were followed by military
(gure 1), but are also historically, socioculturally, and dictatorships in most Latin American countries with widening socioeconomic disparities.
politically diverse; they gained independence from their In the 1980s, health emerged as a fundamental human right and entitlement in
European colonisers in the 19th century, but many suered Latin Americaregardless of social position or capacity to payand a democratic
military dictatorships with human rights abuses and have platform for reclaiming citizens rights.
experienced some of the worst income inequalities Social movements, led by civil society, shaped heath-system reforms in most
worldwide (appendix). The rich historical, sociocultural, countries, while in Mexico, Costa Rica, and Colombia rapid epidemiological transition
and political context of Latin American countries has was the critical driver.
profoundly shaped health-system reforms and the Latin American countries have developed a distinct approach to health-system
trajectory of universal health coverage underpinned by the reforms, which combined demand side changes to alleviate poverty and
principles of equity, solidarity, and collective action to comprehensive primary health care to extend service access. These reforms fostered
overcome social inequalitiesa distinguishing feature of inclusion, citizen empowerment, and health equity, established legal rights to health
the Latin American health-system reform experience, with and health protection, and achieved universal health coverage.
lessons that are relevant for countries that are progressing Social health insurance or tax based nancing have been used with dierent
towards universal health coverage. health-system, organisation, governance, and service delivery approaches to
We used an analytical framework,7 and data from introduce explicit entitlements for health benets.
several sources (appendix) to explore in the study The Latin American countries have developed country-level and regional capacity
countriesArgentina, Brazil, Chile, Colombia, Costa to learn from country and regional experiences, and used this capacity to rene
Rica, Cuba, Mexico, Peru, Uruguay, and Venezuelahow health-system reforms to establish context-sensitive approaches to universal health
the interplay of demographic, epidemiological, economic, coverage to improve health outcomes.
political, and sociocultural factors (table) has provided the
Mexico Honduras Cuba Dominican Republic colleagues11 provide an in-depth analysis of the historical
GDP US$9747 GDP US$2335 GDP NA GDP US$5736 antecedents of health-system reforms and Andrade and
494% public 481% public 947% public 493% public
colleagues12 describe the social determinants of health in
Latin America.
Guatamala
GDP US$3351 Nicaragua
355% public GDP US$1754 Venezuela Contextual challenges driving change in Latin
543% public GDP US$12 729
736% public American health systems
El Salvador
Demographic and epidemiological context: the
Colombia
GDP US$3790 GDP US$7752 epidemiological transition
633% public 748% public The decline in the total fertility rate to near or below
replacement levels of 21 (table) and rise in life expectancy
Panama Brazil
GDP US$9534 GDP US$11 340 (gure 2) in Latin America brought about rapid demo-
Costa Rica
GDP US$9396 675% public 457% public graphic and epidemiological changes, which increased the
701% public burden of non-communicable diseases and chronic illness
Peru in health systems designed to provide episodic and acute
Ecuador GDP US$6568 care (gure 3). Health systems in Latin America could not
GDP US$5425 561% public Paraguay
410% public GDP US$3813 eectively respond to the rapid epidemiological transition.
386% public In countries such as Mexico, Costa Rica, and Colombia,
this change was the crucial driver for health-system reform,
Bolivia
GDP US$2576 whereas in others, political, social, and economic factors,
Uruguay
Total health expenditure
708% public
GDP US$14 449
which are discussed later, were the major drivers of health-
(% GDP) 676% public system reform and provided the impetus for universal
97109 Chile health coverage.
8295 GDP US$15 356 Argentina
7381 470% public GDP US$11 452
6168 606% public Political context: democratic decit
4854
Not applicable
Threatened by the revolutions that swept through Venezuela
(1958) and Cuba (1959), beginning in the 1960s armies in
Figure 1: Per-person income, total health expenditure, and health expenditure from public sources most Latin American countries forcefully quashed civilian
Health expenditure from public sources is shown as a percentage of total health expenditure. Data from The World rule to establish military dictatorships. These dictatorships
Bank.9 GDP=gross domestic product. NA=not applicable.
lasted until around the 1980s in Brazil (196485), Peru
T Dmytraczenko PhD, Caribbean or Haiti because these countries had a dierent (196263 and 196880), Chile (197390), Argentina (196673
A Wagsta PhD); School of history to the Latin American countries studied. We and 197683), and Uruguay (197385). Costa Rica and
Public Health, University of
provide a summary of the economic, demographic, Mexico, which had established parliamentary democracies
Chile, Santiago, Chile
(P Frenz PhD); School of Public population health, and health-systems indicators for these in the early 20th century, avoided military rule (a one-party
Health and Administration countries and compare them with the world regions and rule prevailed in Mexico until 2000), whereas in Colombia
(FASPA), Universidad Peruana the world averages (appendix). military interventions briey overthrew governments in
Cayetano Heredia, Lima, Peru
(Prof P Garcia PhD); National
The social and political orders that emerged after 1953 and 1958. The Cuban revolution, which began in 1952,
Institute of Public Health of independence to establish democracy were diverse in established in 1959 a socialist state ruled from 1965 by one
Mexico, Cuernavaca, Mexico the ten study countries. Various governance, political partythe Communist Party of Cuba.
(O Gmez-Dants MPH); arrangements, and governments emerged after the end The military dictatorships in Latin America undermined
Institute for Global Health
Equity and Innovation, Dalla
of military regimes in Argentina, Brazil, Chile, Colombia, human rights, suppressed democratic rights of citizens,
Lana School of Public Health, Costa Rica, Peru, Uruguay, and Venezuela; at the end of and, with the exception of Cuba, curtailed investment in
University of Toronto, ON, state corporatism in Mexico, and after revolutions in the social sectors, including the publicly nanced and
Canada (Prof C Muntaner PhD); Cuba and Venezuela, with varying amounts of citizenship delivered elements of health systems. Limits on citizens
Pan American Health
Organization, Braslia, Brazil
and civil rights. These experiences in governance also entitlements disenfranchised subgroups of the population,
(J Braga de Paula MSc, shaped the approaches adopted for health-system reforms especially the poor, and widened socioeconomic and
F Rgoli MD); and National and universal health coverage. health inequalities, prompting the civil society in countries
School of Public Health, This report is organised in ve sections. The intro- such as Argentina, Brazil, Chile, Peru, and Uruguay to
Havana, Cuba
(Prof P Castell-Florit Serrate PhD)
duction is followed by an analysis of the contextual create social movements to restore democracy, address
Correspondence to:
challenges driving change in Latin American health inequalities, and reclaim citizens rights.
Prof Rifat Atun, Harvard School systems. We next analyse health-system reforms aimed at Economic context: instability and persistent inequal-
of Public Health, Harvard achieving universal health coverage in the study countries. ities In the 1970s and 1980s, uncontrollably high ination,
University, Boston, MA 02115, We then discuss the key achievements of health-system which exceeded 1000% in Argentina, Brazil, and Peru;
USA
ratun@hsph.harvard.edu
reforms and universal health coverage in the study boom and bust economic cycles; and recessions
countries and the lessons learned. The nal section characterised the economic situation in Latin America,
See Online for appendix
discusses the future challenges for Latin American health placing scal constraints on government expenditures
systems. In the Lancet Latin America Series, Cotlear and on health systems, with adverse outcomes for health.15
Argentina Brazil Chile Colombia Costa Rica Cuba Mexico Peru Uruguay Venezuela
Total population (millions)* 411 1987 175 477 48 113 1208 300 34 300
Life expectancy at birth (years)
Men 721 701 760 701 769 772 745 714 729 714
Women 797 770 822 774 818 812 794 766 801 774
Fertility rate, total 22 18 18 21 18 15 23 25 20 25
(births per woman)
Age dependency ratio (% of 544% 468% 451% 515% 445% 420% 545% 549% 564% 534%
working-age population)*
GDP (constant 2005 NA 11366 1650 2029 275 553 9971 1275 255 1919
US$ billion)*
GDP per person NA 57212 94471 42524 57160 48983 82509 42525 74974 64069
(constant 2005 US$)*
Per-person health expenditure 8918 11206 10745 4320 9429 6061 6196 2890 11049 5551
(present US$)
Total health expenditure 81% 89% 75% 61% 109% 100% 62% 48% 80% 52%
(% of GDP)
Out-of-pocket health 247% 313% 372% 170% 272% 53% 465% 384% 131% 570%
expenditure (% of total)
Population health coverage by subsystem
Public Universal Universal Universal Universal Universal 0% Public health 370% 453% 100%
(basic services) entitlement: entitlement coverage of coverage insurance entitlement
804% exclusive for benets Basic Health Care (Seguro to primary
coverage by of the Explicit Plan (population Popular) care (Barrio
unied health Guarantees health). 290% 470% Adentro)
system of Universal limited health
Access Plan services
Social security 510% 0% 735% National 397% general 0% 100% Institute of 210% (plus 450% 175%
Health Fund social security Social Security 30% armed
system. 514% 375%. forces and
contributory Institute of police)
scheme Social Security
and Services
54%
Private 79% 196% 163% NA 0% 0% 45% 55% 18% 117%
Supplementary
Other 32% 0% 67% (army). 39% 0% 0% 45% 374% with- Armed
35% no out social or forces 53%.
insurance private Police 23%
insurance
Data from The World Bank.9 NA=not available. *Data from 2012. Data from 2011. Data from 2010. Modied from data from Pan American Health Organization;10 coverage levels might exceed 100% because
some family members are covered by more than one scheme.
Argentina (1980 and 1982) and subsequently Peru (1980 coinciding with social reforms aimed at alleviating poverty,
and 1984), Costa Rica (1981, 1983, and 1984), Mexico (1982), such as conditional cash transfer schemes. Cuba remained
Venezuela (1982), Brazil (1983 and 198687), Chile (1983), a closed economy exposed only to the socialist bloc of
and Uruguay (1983 and 1987) defaulted on their sovereign countries. However, the break-up of the Soviet Union
debt, precipitating the Latin American debt crisis, which forced the Russian Federation to suddenly cease nancing
led to the intervention of the International Monetary Fund, to Cuba,23 precipitating severe contraction of the Cuban
beginning in 1982. A period of neoliberal macroeconomic economy followed by decades of economic instability.
reforms ensued in the late 1980s, with a common pattern of In the health sector, the reforms aected by the
policies enshrined in the so-called Washington Consensus,16 Washington Consensus were not monolithic, uniform, or
aimed at reducing government expenditures and imposing unidirectional. Leaders and researchers in Latin American
scal discipline (panel 1).22 Although several countries countries were not passive recipients of ideaspolicy
resisted these reforms, the pressures were felt throughout makers in several countries were able to develop their
Latin America. The economic crisis and associated high own direction, content, and momentum for reforms. For
ination led to widening socioeconomic and income example, unlike Chile, where the military government
inequalities, with persistently unfavourable Gini indices introduced neoliberal market reforms, in Mexico and
(appendix), which only began to decline after 2005, possibly Costa Rica, policy innovations in health were home
Disability-adjusted life-years
1 200 000
Life expectancy at birth (years)
1 000 000
800 000
Argentina
70 Brazil 600 000
Chile
Colombia 400 000
Costa Rica
Cuba 200 000
Mexico
Peru 0
Uruguay
Venezuela
60 B Non-communicable diseases
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11
19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 20 40 000 000
Year
35 000 000
Disability-adjusted life-years
Figure 2: Life expectancy at birth 30 000 000
Data from The World Bank.9
25 000 000
2 000 000
introduction of new social policies and welfare reforms
aimed at reducing poverty and inequality until the 1990s.
1 500 000
For example, Brazil, Colombia, Mexico, and Venezuela
introduced labour market and social welfare reforms.
1 000 000
Argentina, Brazil, Chile, Colombia, Mexico, Peru,
and Uruguay, as part of social and welfare reforms,
500 000
implemented conditional cash transfer schemes to reduce
poverty, empower women, and expand access to and uptake
0
of nutrition, education, and health.2527 Several conditional
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Panel 1: The Washington Consensus Panel 2: Health as a human right and citizens entitlement
The Washington Consensusa term coined by the economist In Argentina and Costa Rica, the constitutions do not stipulate a right to health, but
John Williamson16refers to economic policy reforms, often used constitutional courts have used international treaties (Universal Declaration of Human Rights
as International Monetary Fund conditionality for countries that and International Covenant on Economic, Social, and Cultural Rights) and provisions for other
need international nancing,17 that are designed supposedly to rights (right to life in Article 21 of Costa Ricas constitution) to establish a right to health.41
bring to beneciary countries macroeconomic stability, Cuba established health as a legal right after the 1959 revolution, guaranteeing free
economic growth, and integration into the global economy. universal health coverage delivered by the Cuban National Health Service, which was
Williamson described ten elements18 as characterising the established in the 1970s.4244
Washington Consensus: Chile, starting in 1980 with Article 19 of the Political Constitution drawn up by the military
1 Fiscal discipline to avoid large government budget decits. dictatorship, guaranteed right to health protection and established the states duty to ensure
2 Reordering public expenditure prioritiesie, redirecting free and equal access to health actions as prescribed by law,45 whereby citizens can choose
spending from subsidies to basic health and education. between public or private health systems. The neoliberal Pinochet health reforms46 created a
3 Tax reform, broadening the tax base with moderate dual health system with profound divisions in nancing, benets, and conditions of aliation
marginal tax rates. between the public social insurance system (Fondo Nacional de Salud) and private insurers
4 Liberalising interest ratesie, market-driven nancial (Isapre). To reduce inequities, the 2005 Health Guarantees Law 19.966 (Acceso Universal con
liberalisation of capital markets. Garantas Explcitas [AUGE]) introduced enforceable rights to health services for 40 diseases,
5 A competitive exchange rate, managed to encourage with administrative and judicial mechanisms,47 which was increased to 80 in 2013.48
export growth.
6 Trade liberalisation to reduce barriers to import and export. In Brazil, the 1988 Constitution, shaped by a democratic struggle and the Movement for
7 Liberalisation of inward foreign direct investmentie, Sanitary Reform (Movimento de Reforma Sanitria) established health as a fundamental right
reduced barriers to foreign investment. and a responsibility of the State, with provisions to create a unied national health system.49
8 Privatisation of state enterprises. In 1991, the new Colombian Constitution established a series of rights and a Constitutional
9 Deregulation to ease entry and exit of new rms into Court to protect individual rights.50 In an important decision in 2008, the Constitutional Court
economic sectors. upheld the right to health, directing the Colombian State to unify contributory and subsidised
10 Property rights, especially for the informal sector. insurance schemes and achieve universal health coverage.51
An important assumption underpinning the package of In 1999, Articles 83 and 84 of the Venezuelan Constitution armed health as a fundamental
economic reforms that collectively characterised the Washington human right guaranteed by the state.52
Consensus was that the structural adjustment of the economy Peru introduced Comprehensive Health Insurance in 2002, after the transition to a
would be followed by economic stability and sustained growth. democratic government, with legal entitlement to health insurance and health-care services
In turn, economic growth would lead to rising employment in for poor and uninsured populations. Health is not a constitutional right in Peru.53 Social
the formal sector, which would increasingly nance and movements are ghting for expanded access and reduced user fees54 and educating citizens
maintain the existing contributory social protection systems. on their rights to quality services.55
Hence, there would be no need for tax-based social protection
systems with solidarity in functioning. Instead, the role of the Article four of the Constitution of Mexico established health as a right for all citizens,56 but
state would be subsidiary to contributory insurance, and limited this right was not fully realised until 2003 when the Mexican Congress approved revisions to
to providing a social protection oor for welfare and health the General Health Law to establish the System of Social Protection in Health, with the
services for the unemployed and those unable to work. popular health insurance programme Seguro Popular expanding coverage to almost
52 million people by 2012.57
However, the promise of economic growth and expansion of the
formal sector did not materialise, prompting many mainstream In 2005, the Government of Uruguay recognised health as a legal right and a public good,
economists to point out the substantial negative social eects of establishing the basis for universal health coverage and national health insurance, with a
the economic policies inspired by the Washington Consensus.1921 National Health Fund that pools payroll contributions and subsidies.58 In 2008, Law 18211
created an integrated national health system of public and private providers, guaranteeing
The limited reach of employment-based social insurance access to comprehensive care for all citizens.59
schemes has spurred many Latin American governments to
gradually expand social protection beyond schemes linked to
employment status.
coverage was created and implemented. We discuss the
similarities and distinguishing features of these reforms
of social position or capacity to payand an important for each health-system functionorganisation and
platform for reclaiming citizens rights (panel 2).60 governance, nancing, resource management, and service
deliveryhighlighting key changes in countries with
Health-system reforms in Argentina, Brazil, examples, and briey describing changes in each country.
Chile, Colombia, Costa Rica, Cuba, Mexico, Peru,
Uruguay, and Venezuela Organisation and governance
The speed and content of health-system reforms varied in In Latin America, there were four major areas of change
the countries studied, as did the way universal health in organisation and governance of health systems. The
rst involved reorganisation of health systems to the health systems or among subsystems. Londoo and
address structural fragmentation. The second involved Frenk,63 who explored the relations between populations
decentralisation of decision making to provincial, state, and institutions in Latin American health systems,
and municipal government levels. The third emphasised proposed a new organisational model on the basis of
improvement of regulatory functions, and the fourth structural pluralism, which would turn the current
involved separation of nancing (ie, purchaser) and [health] system[s] around by organising it according to
provider functions to improve health-system eciency. functions rather than social groups.63 For example,
The rst area of change was particularly important in Chile, Colombia, and Mexico introduced organisational
Latin America, where only Brazil, Cuba, and Costa Rica changes that emphasised the intrinsic value of health for
have unied health systems and most health systems citizenship, with structural pluralism to expand health
are organised as several parallel subsystems. Beginning service coverage to poorest population segments, but
in the 1990s, countries without unied systems could not eliminate the dierential access produced by
introduced government-nanced insurance schemes the segregation.
and health service provision to cover poor people The second area of change involved decentralisation of
and informal workers. This institutional organisation health-system functions to local levels of government.
further reinforced the verticalised subsystems with Decentralisation was motivated by the desire to strengthen
fragmentation of nancing and service delivery and led local governance, delineate functions between central and
to segregation of population groups according to local levels of government, and strengthen capabilities
employment and socioeconomic status,11 and left the and performance at each level. All too often, this change
poorest segments without eective coverage. was driven by civil society accompanied by strengthened
This segregation, Frenk argued,61 created medical monitoring and evaluation to address the inability of the
apartheid and undermined eorts aimed at reducing centre to hold local levels of government accountable for
inequalities,61,62 because although the health-system poor performance.10
functions were integrated within each vertical In Brazil, Colombia, Peru, Uruguay, and Venezuela, civil
subsystem, these functions were not integrated across society provided the impetus for decentralisation, which
Panel 4: Expanding insurance coverage for uninsured citizens through budget transfers
The Brazilian unied health system is nanced by Federal in the formal sector, including employer contributions, a voluntary
Government transfers (205% of the Federal revenue), health insurance regimen for independent workers, and a
municipalities (at least 15% of the municipalities revenue), and non-contributory regimen for poor households. The Costa Rica
states (at least 12% of the states budget), in line with Law 141 Social Security Fund pools funding from all sources (employees,
enacted in 2012, which regulates implementation of employers, and the state) and covers the whole population.88
constitutional amendment 29 (EC29) and requires minimum The Cuban health system is publicly funded. Private health care
growth in the federal contribution to health to the nominal is outlawed. Out-of-pocket expenditures are around 10% of
change in the previous years GDP. total health expenditures, the lowest in Latin America.89,90
Chile increased public spending in 19902000 to eliminate user In 2003, Mexico increased public funding to establish Seguro
fees, introduce free primary health care for all FONASA Populara new public insurance scheme for poor families
beneciaries, and reduce hospital and specialist waiting lists expanding insurance coverage and access to health care for almost
through opportunity of care and complex benets programmes.83 52 million Mexican citizens. A special fund covers catastrophic
In 2004, Law 19.966 established the Universal Access Plan illness and complex disorders such as paediatric cancers.87,91
(Acceso Universal con Garantas Explcitas [AUGE]), with explicit
guarantees for predened health disorders, universal coverage for Since the 1990s, Peru has attempted to achieve universal health
all citizens, and access to quality services and nancial protection coverage and decentralisation with social participation.92 In
to ensure equity.84 In 200011, on average, real health spending 2009, the Framework Law on Universal Health Insurance
in Chile increased annually by 83%.85 The share of public health mandated gradual expansion of comprehensive health
spending rose from 462% of total in 2000 to 561% in 2012, with insurance to all citizens, subsidised by government transfers,
a three-times increase in budget and municipal contributions, with basic services that were gradually increased to align with
whereas out-of-pocket expenditures declined from 488% in the social security package.93 The Peruvian health system is
2000 to 371% in 2012.48,86 Citizens reporting no insurance funded from three sources: private (mostly out of pocket; 35%),
enrolment fell from 11% in 2000 to 3% in 2011, and in 2011 the social security contributions by employers (31%), and the
population enrolled with FONASA increased to 801%.86 government budget (31%).10 Total health expenditures as a
proportion of GDP increased from 2006 (gures 4A and 4B).
In 1993, after the Constitution of Rights in 1991, Colombia
introduced a universal health insurance scheme consisting of a In Uruguay, in 2008, new laws helped to create an integrated
contributory scheme (Plan Obligatorio de Salud) nanced by a health-care delivery system, with a national health fund that
payroll tax on formal-sector workers, a tax on employers, and a pools health insurance contributions from workers with
subsidised scheme (Plan Obligatorio de Salud Subsidiado) for government budget transfers for the unemployed and the poor.
low-income or informal-sector workers nanced by government Government funding for health rose from US$190 million in
transfers. Coverage of the insured population increased from 2005 to $690 million in 2011,10 with higher total and per-person
157% in 1993 to 882% in 2009, although a two-tier system health expenditures (gures 4A and 4B).95
exists.87 The Colombian Government is introducing Venezuela has a fragmented health nancing system, with
health-system reforms to address inequities and to achieve private and public funding. Since 1999, government health
universal health coverage. nancing and total health expenditures have increased, with
In Costa Rica, government budget transfers subsidise the expanded coverage of poor populations, but private
contributory regimen, which is compulsory for workers employed expenditures remain high (gures 4A and 4B).
was also used as a mechanism to deepen democratisation representatives from associations of state secretariats
and citizenship by strengthening social participation [Conselho Nacional dos Secretrios de Sadeo; ve state
(appendix). For example, in 1988, the Brazilian National secretaries], municipal secretariats [Conselho Nacional de
Constituent Assembly identied universal health coverage Secretarias Municipais de Sade; ve municipal secretaries],
with decentralisation and community participation as a and the ministry of health [ve representatives]), and at
principle of equality. In 1990, the Organic Law for the state level the bipartite committee (comprising
Brazilian Health System dened state-level and representatives of the state and municipal secretariats,
municipality-level responsibilities in the management of appointed by the municipal health secretaries councils
the health system, the mechanisms for inter-governmental [Conselho de Secretarias Municipais de Sade] from each
transfer of funds, and the arrangements for community state) enables participative decision making.
participation. At each level, health conferences and In Mexico, decentralisation was partly political,
structures (the National Health Council at federal level, redistributing power from the centre, and partly
27 state health councils, and around 5000 municipal health functional, aimed at strengthening local governance and
councils) enable participative decision making. At the accountability. Between 1983 and 1988, Mexican states
federal level, the tripartite committee (comprising were given the choice of assuming powers through
70
However, in Latin America, eective regulation of health
60 insurers and providers in public and private sectors has
50 been challenging. Private insurers practise so-called cream
skimming by enrolling low-risk high-income population
40
segments, with adverse eects on equity, cost, service
30 quality, and appropriateness in Argentina, Brazil, Chile,
20 Colombia, Mexico, and Peru.6870 Regulation of public
insurers and providers has been hampered by bureaucracy
10
and rigid public sector laws that have hindered eective
0 management and competition (panel 3).78,79
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
1995
2000
2005
2010
Panel 5: Comprehensive primary health care: the platform for universal health coverage
In the 1970s, Brazil had a segregated health systemthe rich and health-care networks, which comprise 2040 neighbourhood-
salaried workers had access to private hospitals in urban settings, based family doctor and nurse oces and provide care for
whereas limited public services existed for the poor and 30 00060 000 people,109 managing around 80% of health
unemployed.101 Preventive health care was nanced by social problems.110 The scope of primary health care was expanded in
security.49 The 1988 constitution established a unied health 2008 and includes health promotion, disease prevention,
system for all citizens, with the principles of universalism, equity, diagnostic services, emergency care, maternal and child
integration, and democracy.102 From 1994, the family health health, chronic illnesses (eg, mental illness and cardiovascular
programme (Programa Sade da Famlia), the community health disease), elderly care, long-term care, and cancer control.111
agents programme, and the per-person payments to In Mexico, ambulatory health-care services were expanded with
municipalities (Piso Asistencial Basico) provided increased funding the introduction of Seguro Popular, which in 2012 included a
and expansion of comprehensive primary health care to the benets package of 284 cost-eective primary-care and
poorest regions. By 2010, the unied health system covered 75% secondary-care interventions and was free for beneciaries at the
of the population and 94% of the municipalities.103 In 2012, point of delivery.112 Ambulatory services for Seguro Popular are
33 400 family health teams covered 100 million Brazilian citizens oered through primary-level and secondary-level hospitals and
(548% of the population) and 257 000 health community clinics. Additionally, mobile health teams, health promoters, and
agents covered 119 million people (654% of the population),12 community health coordinators provide outreach services. The
and achieved improved health outcomes, including for infant Mexican Social Security Institution for Workers and Civil Servants
mortality104 and chronic illnesses.105 also oer a comprehensive package of personal and primary
Chile began to expand primary health care in the 1950s. From the health-care services to their beneciaries.113
1990s, increased investments helped to further develop primary The Peruvian health system is fragmented: the public sector
health care based on Alma Ata principles and to eliminate direct fees serves the poor and indigent populations through ministry of
for beneciaries of the public health insurance fund. A division of health and regional health bureaus; the social security system
primary health care was created within the health ministry to caters for the salaried workers and their families, the military, and
expand rural health services and to transform municipal health the police; and the private sector serves the wealthier population.
facilities into family care centres (comprising doctors, nurses, health In 2011, the health ministry introduced the Comprehensive
technicians, dentists, psychologists, and nutritionists), which Family and Community Care Model, with disease prevention,
provided integrated family and community health programmes health promotion, and rehabilitation services to expand
and served as reference centres for smaller community family coverage, and incentives to encourage primary health-care
health centres.106 Primary health-care workers were granted public physicians to work in poor and remote areas.10
sector employee status, with centrally managed pay and career
opportunities.107 The Acceso Universal con Garantas Explcitas (AUGE) In Uruguay, in 2008, Law 18211 increased health-system nancing
reforms of 2005 reinforced primary health care as the centre of by the government and created the Integrated National Health
health-care networks. By 2012, an extensive primary health-care System, which is responsible for organising and managing the
network covered the entire country.108 publicprivate health-care delivery network. The health-system
changes have prioritised primary health care on the basis of Alma
Soon after the Alma Ata Declaration, Costa Rica introduced Ata principles and elimination of copayments to expand access.114
comprehensive primary health care managed by the health
ministry, which targeted lower income groups, rural households, In 1999, Venezuela introduced laws to create an integrated
and informal sector workers. In the 1990s, primary health-care public health system underpinned by primary health care and
services were transferred to the Costa Rica Social Insurance Fund to suspended user fees for emergency services in public health-care
create an integrated health-care network. Population coverage of providers. In 2003, Venezuela developed a new model (Barrio
primary health care increased from 25% in 1996 to around 90% in Adentro), in which primary health-care centres and teams provide
2005,88 with universal health coverage achieved shortly after. comprehensive integrated care to families within a catchment
Costa Rica has placed primary health care at the core of health area. The new model involves community participation in the
service networks to achieve impressive health outcomes and design and implementation of primary health-care services and
progressive health-system nancing, in which the poorest 20% of public health interventions, and emphasises population health,
the population benet from 30% of the health expenditures and equity, and intersectoral action with interventions such as secure
the richest 20% (who earn 48% of national income) from 11%.88 housing and income support. Barrio Adentro has expanded
primary health-care access to the poorest populations and
Comprehensive primary health care underpins the Cuban improved their health outcomes.115
health system. Polyclinics serve as a hub for primary
between the dierent public insurers and their care facilities in Mexico is limited to emergency
respective facilities, although the portability between obstetric services. Although Cuba maintained a
dierent public insurers and their respective health- publicly funded and provided integrated health system,
1986
1988
2002
2006
2008
1998
1990
1980
1994
1996
2000
1984
2004
1992
2010
approach to health, citizen participation, community
empowerment, and intersectoral collaboration,117 and
B Births attended by trained sta
positioned primary health care as the platform for
100
achieving equity and universal health coverage (panel 5).12
Proportion of women receiving skilled antenatal care (%) Proportion of women receiving skilled birth attendance (%)
and to progress towards universal health coverage; in for the poorest groups, with a narrowing of the dierence
particular, Brazil, Chile, Colombia, Costa Rica, Cuba, and between the poorest 20% and richest 20% and similarly
Mexico have achieved universal health nancing with between the poorest 40% and the richest 40% (gures 6A
meaningful access to an expanded package of health and 6B). The improvements in mean level and equity for
services. The eorts in many countries to establish a payer all countries for both indicators were achieved by
system to overcome fragmentation and segregation in increasing access to the poorest segments of the population
nancing have to be combined with organisational (ie, access was already high at upper levels of the income
reforms to overcome the fragmentation in service delivery. distribution and did not change much in the period
Between 1995 and 2010, almost all of the study countries analysed). However, despite improvements, there is still
increased total health expenditures in absolute terms and opportunity for further improvements in all countries,
as a proportion of gross domestic product, with a greater particularly in Peru and Colombia (gures 6A and 6B).
proportion of total health expenditures coming from The content of services and benets were augmented
public sources (gures 4A and 4B). Increased health (eg, in Brazil, Chile, Colombia, Peru, and Mexico) to meet
nancing has enabled expansion of health insurance the demands of epidemiological transition, especially for
coverage for poor and rural populations. However, private the poorest population segments. The unied health
health expenditures, most of which are out of pocket, systems of Brazil, Costa Rica, and Cuba, which have
remain high (gure 4C). comprehensive and integrated primary health care,
provide eective participative models for management of
Expanded coverage of health services on the basis of communicable diseases, maternal and child health, and
comprehensive primary health care non-communicable diseases.
A distinguishing feature of the health-system reforms in
Latin America was the strong focus on development of Improvements in health outcomes
comprehensive primary health care on the basis of Alma Along with economic development and rising incomes,
Ata principles as the platform of primary health care and improvements in health systems and universal health
the vehicle for achieving universal health coverage, coverage have contributed to improved health outcomes
reducing inequities, and democratising health through for women (reduced maternal mortality ratio) and children
participation. The countries studied expanded coverage of (reduced under-5 and infant mortality rates; gure 7) and
primary health-care services and prioritised targeting of the for communicable diseases such as malaria, neglected
poorer population segments through supply-side (expanded tropical diseases, and tuberculosis, which predominantly
coverage, scale up of services, and dened or guaranteed aect the poor.132,133
health benets packages) and demand-side interventions
(conditional cash transfers to expand access), particularly Improvements in nancial protection
for immunisation and antenatal care (gures 5A and 5B). Several studies that have investigated health-system
For maternity services in the countries where series data nancing in Latin America,134138 including in relation to
exist (Brazil, Colombia, Mexico, and Peru), our analysis universal health coverage,139 have shown the benets of
shows that antenatal coverage (at least four skilled universal health coverage in providing nancial risk
antenatal care visits and skilled birth attendance) increased protection during illness. In Brazil, Costa Rica, and Mexico
20
20
20
20
19
19
20
20
20
19
19
19
20
20
19
20
20
20
19
19
19
19
Nicaragua, and Peru that used 200308 household survey
B Under-5 mortality
data showed that the amount of catastrophic health
80 Argentina Mexico
expenditure varied from less than 1% of households in Brazil Peru
Costa Rica, where social security covers most of the 70
Chile Uruguay
Colombia Venezuela
population, to 25% in Colombia, Bolivia, Brazil, Mexico,
Under-5 mortality rate per 1000 livebirths
Costa Rica
and Peru, and 711% in Argentina, Dominican Republic, 60
Ecuador, Guatemala, and Nicaragua. Depending on the
indicator used, catastrophic health spending was 1015% 50
in Nicaragua, Guatemala, Dominican Republic, Argentina,
40
and urban Chile. Households without any form of private
or social insurance were at greater risk of catastrophic
30
health expenditures. The same study140 also identied that
rural or poor households and those with children or elderly 20
members were especially at risk of suering catastrophic
health expendituregroups that should be targeted when 10
designing universal health coverage policies to improve
equity of health nancing and nancial protection.136 0
0
91
2
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
However, Mexicos experience suggests that although
9
9
20
20
20
20
19
19
20
20
20
19
19
19
20
20
19
20
20
20
19
19
19
19
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