Health care for all?
Access to adequate and affordable health care is one of the main social protection challenges in Latin America. In this it needs to be recognised from the outset that in health care coverage is not the same as access. Basic treatments are usually offered universally, and financed out of general revenues. But "no coverage status" (that is without a contribution record for the public system or private/employer-sponsored insurance) tends to be associated with less and lower-quality treatment.
Initial health-care reforms in Latin America were intended to increase contributory coverage. With the help of the market and private enterprise, it was expected that individuals would be enabled to satisfy their health needs from their own resources. However, available data suggest that even the opposite may have happened (Mesa-Lago, 2008a). For this reason, subsequent reforms have tended to universalise access, breaking the link to regular contributions – which are often lacking given the pervasiveness of informality. Nearly all countries in the region have introduced basic health packages covering the whole population, for an increasing number of medical conditions. Two of the more notable are the Mexican Seguro Popular de Salud established in 2003, and the Chilean Plan Auge established in 2005, which covers 56 conditions.
This universality contrasts with recent estimates by the World Bank of contributory health insurance coverage rates for Latin America by income level (Figure 2.11). With the sole exception of Costa Rica, contributory coverage rates increase sharply with income.
Non-contributory health systems effectively equalise coverage rates by income groups in Chile and Mexico, the only countries in our sample with available information (Figure 2.12) – albeit at very different levels: 92% and 34% on average, respectively.
Figure 2.11. Contributory health insurance coverage, by income quintile (percentage of quintile covered)
Figure 2.12. Health coverage rate of workers, by income level (percentage of group covered)
Despite successful steps towards universal provision of health care in the region, the problem of segmentation remains and in some cases has even worsened. A two-tier contributory and non-contributory system, where lack of resources means the lower tier is characterised by low quality, compounds the problem of low contributory coverage. The result is that out-of-pocket health-care expenditure is regressive, with the lowest quintiles – extending in some cases into the middle sectors – spending a higher percentage of their income on health care than do more affluent quintiles.40
Figures 2.13 and 2.14 take a closer look at coverage rates for the middle sectors using the same occupational groups we defined earlier for pensions. The data cover Chile and Mexico. In both countries, formal workers are mainly covered by contributory health insurance whereas the informal (employees and self-employed in all sectors) are covered primarily by non-contributory schemes. This is particularly notable among the agricultural self-employed in both countries. The exceptions are the self-employed with tertiary education – the professionals – who are principally covered by contributory health insurance.
Figure 2.13. Health coverage rate of the middle sectors (percentage covered, 2006)
In addition to closing the coverage gap and achieving effective universal health care (from "rights to reality", as Ribe et al., 2010, put it), there are additional challenges to face. Basic health programmes which focus on specific medical conditions, for example, may send the message that health-care systems are only for acute care, rather than health promotion or the management of chronic illness. At the same time, even where the right to health is a constitutional one, a significant part of the population is not aware of this, nor how they could access the services available in practice.41
Figure 2.14. Health coverage rate of the middle sectors by type of worker in Mexico (percentage of population covered, 2006)
Reaching the middle sectors, who combine broad use of the systems with the political engagement and education to effect change, may be key. Better health care within the social-insurance system could entice the middle and affluent sectors to join and contribute. Better co-ordination – and eventually integration – between existing contributory and non-contributory schemes would also help break the cycle of segmentation. Such reforms may be particularly important to the middle sectors in a context of a regressive health system, given the persistent (and flexible) informality in this group.