Achieving effective universal health coverage with equity: evidence from Chile
Health Policy and Planning
Achieving effective universal health coverage with equity: evidence from Chile
Patricia Frenz 2
Iris Delgado 1
Jay S Kaufman 0
Sam Harper 0
0 Department of Epidemiology , Biostatistics, and Occupational Health , McGill University , Montreal, Quebec , Canada H3A 1A2
1 Centro de Epidemiolog ́ıa y Pol ́ıticas de Salud, Facultad de Medicina, Universidad de Desarrollo , Santiago, Chile, 7710162
2 Escuela de Salud Pu ́blica Salvador Allende, Universidad de Chile , Independencia 939 Santiago, Chile, 8380453
Accepted
Chile’s ‘health guarantees’ approach to providing universal and equitable
coverage for quality healthcare in a dual public–private health system has
generated global interest. The programme, called AUGE, defines legally
enforceable rights to explicit healthcare benefits for priority health conditions,
which incrementally covered 56 problems representing 75% of the disease
burden between 2005 and 2009. It was accompanied by other health reform
measures to increase public financing and public sector planning to secure the
guarantees nationwide, as well as the state’s stewardship role. We analysed data
from household surveys conducted before and after the AUGE reform to
estimate changes in levels of unmet health need, defined as the lack of a
healthcare visit for a health problem occurring in the last 30 days, by age, sex,
income, education, health insurance, residence and ethnicity; fitting logistic
regression models and using predictive margins. The overall prevalence of unmet
health need was much lower in 2009 (17.6%, 95% CI: 16.5%, 18.6%) than in
2000 (30.0%, 95% CI: 28.3%, 31.7%). Differences by income and education
extremes and rural–urban residence disappeared. In 2009, people who had been
in treatment for a condition covered by AUGE in the past year had a lower
adjusted prevalence of unmet need for their recent problem (11.7%, 95% CI:
10.5%, 13.2%) than who had not (21.0%, 95% CI: 19.6%, 22.4%). Despite
limitations including cross-sectional and self-reported data, our findings suggest
that the Chilean health system has become more equitable and responsive to
need. While these changes cannot be directly attributed to AUGE, they were
coincident with the AUGE reforms. However, healthcare equity concerns are still
present, relating to quality of care, health system barriers and differential access
for health conditions that are not covered by AUGE.
Healthcare reform, health inequalities, health systems research, Chile
KEY
MESSAGES
Chile’s Universal Access with Explicit Guarantees program (AUGE) is one of the few practical applications of a social
guarantees approach to realizing the right to health, based on enforceable rights and explicit benefits related universal
healthcare for priority health conditions.
Using 2000 and 2009 household survey data to compare different measures of healthcare inequalities, our findings
suggest that the Chilean health system has become more equitable after AUGE and other reform measures were
implemented: (1) across social groups there are manifestly lower levels of unmet need, defined as the lack of a healthcare
visit for a health problem in the last 30 days, with flattening income and education gradients; (2) the percentage of
individuals who were not affiliated with any health subsystem substantially decreased and the public insurance share has
increased; (3) higher proportions of individuals, especially low-income groups, obtained free healthcare; and (4) there
were higher utilization rates for all types of services by lower income groups.
However, there are persisting equity challenges that need to be addressed: differential access by gender, ethnicity and
age-groups, concerns about adequacy and quality of care, health system barriers faced by the less well-off, possible
displacement of non-AUGE problems to comply with guarantees, and the continued stratification of the public–private
health system.
Introduction
Whether low- and middle-income countries (LMIC) with mixed
health systems can meet health needs fairly, especially for
disadvantaged social groups, is an important policy question for
national and global healthcare initiatives
(Gilson et al. 2007;
Nishtar 2010; World Health Organization 2010)
. Chile’s policy
responses to expanding healthcare coverage have often been
cited as models for other countries of the benefits of diverse
health system approaches. Historically, Chile has quickly
adopted new proposals from the international policy context,
notably (1) social medicine with the creation of the country’s
National Health Service in 1952, whose development led to
basic universal coverage by the 1960s; (2) neoliberal
privatization under Pinochet’s military dictatorship, which introduced
private health insurance in 1981; and more recently (3) a
rightbased system of universal health guarantees for complex
benefits, established by law in 2005
(Musgrove 1993; Unger
et al. 2008; World Bank 2008)
. The health guarantees a (...truncated)