Achieving effective universal health coverage with equity: evidence from Chile

Health Policy and Planning, Sep 2014

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.

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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)


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Patricia Frenz, Iris Delgado, Jay S Kaufman, Sam Harper. Achieving effective universal health coverage with equity: evidence from Chile, Health Policy and Planning, 2014, pp. 717-731, 29/6, DOI: 10.1093/heapol/czt054