Overcoming inequalities in a mixed health system: the new Chilean miracle?

By Claudio Mendez

How do we overcome inequalities in a mixed health system? This is an important question, which for me does not have a clear, evidence-based answer. One of the reasons why this question remains unanswered is that the politics of health systems are not usually addressed when considering the issue. Even though the framework for the Social Determinants of Health recognizes that politics is a driver for achieving health equity, some researchers advocate for health systems above political ideologies, while others strive for health systems democratization.

Mixed health systems, where both publicly- and privately-financed healthcare services co-exist; can illustrate the role of politics quite well. Some consider mixed health systems to be cases of political and health policy failure in low- and middle-income countries. For example, Nishtar described Mixed Health Systems Syndrome as a phenomenon that occurs when healthcare delivery shows compromised quality and equity. As such, sooner or later mixed health systems lead to diminished performance.

Latin American countries can demonstrate how mixed health systems weaken performance. At first, public and private health insurance and delivery services were stratified by occupational groups and as their economies prospered, by income. The impact of these arrangements on health inequalities, however, has not been widely studied. Furthermore, mixed arrangements for financing and provision of health services are still technical tenets of health reforms in diverse political contexts.

So, what can low- and middle-income country health systems do to effectively redress inequalities? Is universal health coverage the key to strengthening mixed health systems?

In pursuit of equity

Among Latin American countries, Chile was the first and most radical case of market-based health reform, imposed by the military dictatorship. Following the return of democracy, several waves of health policy sought to strengthen public financing and public health care service provision – but without transforming the structure of the mixed system. Thus, deepening health inequalities were inevitable. The policy question was quite obvious: can a mixed health system achieve greater equity levels with a universal health coverage approach?

Chile’s answer was the rights-based health care reform implemented in 2005, better known as the AUGE reform (universal access with explicit guarantees). The reform’s aim was to improve population health, guaranteeing the right to health to tackle health inequalities. Eight years after its implementation, in a recently published study, Patricia Frenz et al. addressed the key issues in overcoming inequalities in mixed health systems and also identified important challenges going forwards.

By analyzing household survey data before and after AUGE reform implementation, Frenz and her team found that the Chilean health system has become more equitable in responding to health care needs since the AUGE reform – with guaranteed universal coverage of health services for a selected group of health problems, established through an explicit priority setting process. Nevertheless, income-related inequalities in service utilization still persist.

Even though equity is an ongoing challenge for the Chilean health system, this research also shows that politics and policies matter when tackling health inequalities from a universal health coverage approach. For low- and middle-income countries this is relevant because better governance is crucial in the move towards universal health coverage and realizing the right to health.

With regard to the future of health systems strengthening, aligning health system objectives with the underlying societal principles and values should be the bottom line for effectively tackling inequalities in health systems.

Claudio A. Méndez is Assistant Professor of Health Systems and Policy at the Instituto de Salud Pública, Facultad de Medicina, Universidad Austral de Chile.


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