1. Art and Diseño

Comment
Interest in universal health care has recently risen
thanks to the question of Universal Health Coverage
as the basis for post-2015 arrangements. However,
these terms should be carefully examined because
they acquire different connotations according to
different social, political, and financial interests.
Some argue that it is possible to achieve universal
coverage through social, private, or public insurance—
mandatory, in various combinations, mediated by
the segmentation of the population according to the
acquisitive capacities of social groups. This position
assumes that health is primarily a responsibility of the
people, with medical care financed by individuals and
employers, but not by the state, or at least not as central
financial responsibility. For the state, funding could
only be extended to groups in extreme poverty or at
risk. The experiences of countries using the model of
Universal Coverage criteria for public social insurance—
such as Colombia, Mexico, and Chile—have not made
substantial improvements because of their commercial
orientation and welfare costs.
Meanwhile the Latin American Association of Social
Medicine—ALAMES—argues for the right to health
for all citizens, without distinction, with the state as
the guarantor of finance and administration. Cuba,
with nearly 50 years of this model, and Brazil, with
over 25 years of experience, show through their health
indicators the possibility of implementing a policy based
on law and finance, which are state funded, less costly,
and extend to all people without distinction.
The drive for “Universal Health Coverage” is currently
very intense. Everybody seems to agree on this objective.
However, it is important to stress that universal health
coverage is an ambiguous term. This is particularly
evident in Latin America where two different notions
are used. One refers to forms of health insurance, be
they voluntary or compulsory and public or private, and
in variable combinations. The other refers to a single
public health system—ie, a unified tax-funded health
system as an obligation of the state.
It is critical to distinguish between the two notions
and to set uniform criteria of analysis to compare their
achievements. In this context, these are: population
and medical coverage in their categories of universal
or segmented access and use of service and possible
barriers; origin and management of health funds; type
of providers; health expenditure, public and private;
distribution of costs and amount of out-of-pocket
expenditure; impact on public health actions and
health conditions; and equity, popular participation,
and transparency. Taken together, these reveal the
extent to which the right to health, a widely held social
value, is attained.
The Latin American experience of health reform
can only be understood in the context of structural
adjustment that swept the subcontinent since the
1980s. Health ministries and social security institutions
were profoundly weakened by these policies. Thus, the
public and quasi-public health sector went through a
long period of financial and resource destitution, which
sparked a reform process, in most countries under the
supervision of the World Bank.
The hegemonic model of reform is presently the
“universal” health insurance that is unlike European
models. It is built on principles of the market (internal
or external), commodification, managed competition,
and pluralism. The most well-known examples are:
Chile, with compulsory insurance and parallel private
and public systems; Colombia, with compulsory
insurance and competition between multiple fund
managers and providers; and Mexico, with a mixed
system of compulsory (social security) and voluntary
(Seguro Popular) insurance, theoretically with separation
between regulation, fund-management/service purch­
asing and provision functions, but in practice with very
limited direct participation of the private sector. The
three systems have different health packages according
to the amount of the premium, public subsidies, and
transactional costs.1–3
Although high population coverage is claimed, none
of the three systems has achieved it—eg, Mexico, with
an estimated 20% without insurance coverage.4 There is
also a methodological problem, since “coverage” is taken
to mean “insurance coverage”, other aspects of public
coverage are not contemplated when figures are given
for progress, a therefore controversial indicator used in
the 2000 World Health Report to classify “performance”.
Medical coverage—ie, health interventions covered by
insurance—is usually limited to “basic packages” that
translate into limited and unequal access to and use
www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61493-8
Turnley for Harper’s/Corbis
The right to health: what model for Latin America?
Published Online
October 16, 2014
http://dx.doi.org/10.1016/
S0140-6736(14)61493-8
1
Comment
of necessary services.5–7 This problem is compounded
by the unfair geographic and social distribution of
resources,6–8 which affects underserved groups and
regions. Additionally, limited packages promote private
complementary health insurance or an additional fee.7,9,10
The logic of explicit packages with copayments and
the requirement to pay for services not covered by
insurance, the unfair distribution of services, and the
difficulty of regulating private fund-managers and
providers have direct impacts on the use of services or
out-of-pocket expenditure. For instance, in Colombia
these restrictions have caused tens of thousands of
protection writs against the State since they infringe the
constitutional right to life.11 Another graphic example
is Mexico, where for one peso paid out of pocket by its
beneficiaries, Seguro Popular spends 0·93 pesos.4
Chile tried to resolve this problem with AUGE,
which grants a fixed time limit to address a number
of common and severe diseases, AUGE has increased
timely access to treatment for these diseases but the
lack of public sector capacity to meet the demand
has spurred the transfer of public resources to
private providers, thereby being detrimental to other
not-AUGE diseases.12
Health expenditure, both public and private, has
increased in most cases where health insurance reforms
are implemented—around 2% of GDP in Colombia3
to less than 1% of GDP in Mexico.4 Several problems
should be considered. One is that a considerable part
of the new resources favours the private sector or are
spent on transactional costs. The bankruptcy of the
Colombian social security system is also marked by gross
corruption, as has been stated by the Constitutional
Court13 and the Accountability Office.14 Furthermore, in
fragmented systems like Mexico, the budget increase
has generated distributional battles4 that may result
in a loss of rights for large groups of the population.
The person-centred insurance model tends to have a
negative impact on public health because its pluralist
focus weakens epidemiological surveillance and collective
interventions.15,16 Finally, there is no consistent evidence
that population health has improved17 and some critics
even maintain that health impact should not be a
criterion of evaluation.17 This concise analysis shows that
universal health insurance in Latin America does not
grant the right to health, understood as equal access to
the necessary services for equal need.
2
By contrast with the intrinsic restrictions of universal
health insurance, the problems of the single public
health system (SPHS) are operational or concern
implementation. The SPHSs are de-commodified,
integrated, and publicly funded health systems, granted
by the State. In Latin America, the two leading examples
are Brazil18 and Cuba, but recently countries such as
Venezuela,19,20 Bolivia,21 and Ecuador,22 using a more
comprehensive frame, such as “living well”, “vivir bien”,
or “sumac kawsay”, have adopted this reform model
after years of neoliberal health policy. This approach has
generally been legislated into Constitutions and is the
result of a broad-based social mobilisation. This paradigm
offers, by definition, complete population and medical
coverage. The access and use of services then depends
mainly on different type of barriers: geographic, cultural,
bureaucratic, and the attitude of the health team. These
barriers are particularly frequent in newly established
systems and in poor countries given their lack of
physical and human resources. Nevertheless, access has
broadened massively in all these countries and Brazil is
close to universal coverage (97%), with 80% depending
for access exclusively on the single public health system.
98% of those searching for medical care receive it.23
A second advantage of the SPHSs is that the much
discussed pooling of risks and funds is complete since
they have a single health fund. A common shortcoming
of the SPHSs is that public institutions with salaried staff
are insufficient, which obliges contracting with private
providers for the treatment of complex interventions.
This approach drains financial resources from the
public budget and also increases contracting of private
complementary health plans.24
Public health expenditure has increased with the
implementation of the SPHSs, but even when regulatory
legislation exists public expenditure has proven to
be vulnerable to economic instability. Out-of-pocket
expenditure depends largely on the capacity of the
public system to provide services and drugs and on
the contracting of complementary health plans. In this
respect, for example, it should be stressed that Brazilian
insurance companies are selling low-coverage plans for
profit and then transfer patients to the public system for
most treatments.25
Since SPHSs offer integrated care they have better
conditions to promote and implement public health
actions, such as health education, promotion, prevention,
www.thelancet.com Published online October 16, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61493-8
Comment
and early detection of disease. They are also better suited
to intersectoral action with other ministries and tend to
form part of progressive social and economic policies that
address a range of social determinants of health. Although
it is problematic to prove causality between health service
organisation and improved health conditions, countries
with SPHSs have shown advances in population health
and in life security.26,27 SPHSs in Latin America still have
problems to resolve, but are on their way to grant the right
to health.
Today, popular and social participation in health is an
unavoidable and much to be appreciated quality. The
health insurance model claims social participation, given
that the payer-provider split is supposed to allow the
population to “vote with its feet” through choice. Social
participation is at the heart of SPHSs for two reasons.
One is that in Latin America it is the result of massive
social participation, and the other is that participation is
institutionalised through health councils at all levels.
Intercultural relations are also important in Latin
America, together with the concepts of “gender”, “work”,
and “environment”. These ideas need to be considered
in the construction of health policies and strategies.
Intercultural relations are important in the debate over
universal health insurance and SPHS because the basic
focus of the health insurance model is on the individual
and the biomedical, while the SPHS is constructed on the
basis of the universal wellbeing of the person, the family,
and the community where people live and develop
their potential. In the community, ancient and popular
cultures and knowledge allow the health sector to build
respectful relationships with the population in which
promotion and prevention form part of everyday life.28
To end, we want to state that ALAMES does not
pretend to represent the view of all “civil society”. We
regret that civil organisations were offered only a single
contribution in a crucial debate that concerns the use
of “Universal Health Coverage” as an instrument to
strengthen private insurance.
*Nila Heredia, Asa Cristina Laurell, Oscar Feo, José Noronha,
Rafael González-Guzmán, Mauricio Torres-Tovar
ALAMES, Casilla Postal 7021, La Paz, Bolivia (NH); ALAMES,
Callejón de Chilpa 23–9, Col. La Concepción, Coyoacán, Mexico DF,
Mexico (ACL); ALAMES, Maracay, Aragua, Venezuela (OF);
ALAMES, Centro Brasileiro de Estudos de Saúde (CEBES),
Manguinhos, Rio de Janeiro, Brazil (JN); ALAMES, Departamento
de Salud Pública, Facultad de Medicina, Universidad Nacional
Autónoma de Mexico, Ciudad Universitaria, Mexico DF, Mexico
(RG-G); and Universidad Nacional de Colombia, ALAMES e IAHP,
Bogotá, Colombia (MT-T)
[email protected]
We declare no competing interests.
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