Elsevier

The Lancet

Volume 385, Issue 9974, 28 March–3 April 2015, Pages 1230-1247
The Lancet

Series
Health-system reform and universal health coverage in Latin America

https://doi.org/10.1016/S0140-6736(14)61646-9Get rights and content

Summary

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens—with defined and enlarged benefits packages—and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Introduction

Well-functioning health systems improve population health, provide social protection, respond to legitimate expectations of citizens, contribute to economic growth,1, 2, 3, 4, 5, 6 and underpin universal health coverage.7 Political stability, committed leadership, sustained economic growth, and strong health systems are crucial for achieving universal health coverage, which is hindered by income inequalities.8

Starting in the late 1980s, many countries in Latin America began social sector reforms to alleviate poverty and reduce socioeconomic inequalities, including reforms in the 1990s to strengthen health systems and introduce universal health coverage. Latin American countries share many economic, political, social, and cultural similarities (figure 1), but are also historically, socioculturally, and politically diverse; they gained independence from their European colonisers in the 19th century, but many suffered military dictatorships with human rights abuses and have experienced some of the worst income inequalities worldwide (appendix). The rich historical, sociocultural, and political context of Latin American countries has profoundly shaped health-system reforms and the trajectory of universal health coverage underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities—a distinguishing feature of the Latin American health-system reform experience, with lessons that are relevant for countries that are progressing towards universal health coverage.

We used an analytical framework,7 and data from several sources (appendix) to explore in the study countries—Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Peru, Uruguay, and Venezuela—how the interplay of demographic, epidemiological, economic, political, and sociocultural factors (table) has provided the impetus for these countries to strengthen their health systems and progress towards universal health coverage. We selected these countries because they have introduced health-system reforms to achieve universal health coverage and because relevant data are available. As with the other reports in the Lancet Latin America Series, we have not analysed the English-speaking countries of the Caribbean or Haiti because these countries had a different history to the Latin American countries studied. We provide a summary of the economic, demographic, population health, and health-systems indicators for these countries and compare them with the world regions and the world averages (appendix).

Key messages

  • Latin American countries are characterised by sociocultural, economic, and political diversity, with wide socioeconomic and health inequalities.

  • Costa Rica and Mexico established parliamentary democracies in early 20th Century, but beginning in the late 1950s revolutions in Cuba and Venezuela were followed by military dictatorships in most Latin American countries with widening socioeconomic disparities.

  • In the 1980s, health emerged as a fundamental human right and entitlement in Latin America—regardless of social position or capacity to pay—and a democratic platform for reclaiming citizens' rights.

  • Social movements, led by civil society, shaped heath-system reforms in most countries, while in Mexico, Costa Rica, and Colombia rapid epidemiological transition was the critical driver.

  • Latin American countries have developed a distinct approach to health-system reforms, which combined demand side changes to alleviate poverty and comprehensive primary health care to extend service access. These reforms fostered inclusion, citizen empowerment, and health equity, established legal rights to health and health protection, and achieved universal health coverage.

  • Social health insurance or tax based financing have been used with different health-system, organisation, governance, and service delivery approaches to introduce explicit entitlements for health benefits.

  • The Latin American countries have developed country-level and regional capacity to learn from country and regional experiences, and used this capacity to refine health-system reforms to establish context-sensitive approaches to universal health coverage to improve health outcomes.

The social and political orders that emerged after independence to establish democracy were diverse in the ten study countries. Various governance, political arrangements, and governments emerged after the end of military regimes in Argentina, Brazil, Chile, Colombia, Costa Rica, Peru, Uruguay, and Venezuela; at the end of state corporatism in Mexico, and after revolutions in Cuba and Venezuela, with varying amounts of citizenship and civil rights. These experiences in governance also shaped the approaches adopted for health-system reforms and universal health coverage.

This report is organised in five sections. The introduction is followed by an analysis of the contextual challenges driving change in Latin American health systems. We next analyse health-system reforms aimed at achieving universal health coverage in the study countries. We then discuss the key achievements of health-system reforms and universal health coverage in the study countries and the lessons learned. The final section discusses the future challenges for Latin American health systems. In the Lancet Latin America Series, Cotlear and colleagues11 provide an in-depth analysis of the historical antecedents of health-system reforms and Andrade and colleagues12 describe the social determinants of health in Latin America.

Section snippets

Demographic and epidemiological context: the epidemiological transition

The decline in the total fertility rate to near or below replacement levels of 2·1 (table) and rise in life expectancy (figure 2) in Latin America brought about rapid demographic and epidemiological changes, which increased the burden of non-communicable diseases and chronic illness in health systems designed to provide episodic and acute care (figure 3). Health systems in Latin America could not effectively respond to the rapid epidemiological transition. In countries such as Mexico, Costa

Health-system reforms in Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Peru, Uruguay, and Venezuela

The speed and content of health-system reforms varied in the countries studied, as did the way universal health coverage was created and implemented. We discuss the similarities and distinguishing features of these reforms for each health-system function—organisation and governance, financing, resource management, and service delivery—highlighting key changes in countries with examples, and briefly describing changes in each country.

Health-system reform and progress towards universal health coverage in Latin America: key achievements and lessons learned

The countries studied established health as a citizen's right or, in the case of Mexico, “the right to the protection of health”, and introduced health-system reforms with diverse organisational, governance, financing, and service delivery arrangements to expand access to health services, improve health outcome, and increase financial risk protection. A period of economic expansion, and in several study countries the era of stability after military dictatorships that reduced military

Future challenges for Latin American health systems

Undoubtedly, in the Latin American countries studied, health-system reforms have fostered inclusion, citizen empowerment, and health equity; established legal rights to health and health protection; and achieved universal health coverage. Civil society played a prominent part in securing citizens' rights and the right to health. In most of the countries studied, these reforms were motivated by social justice and equity and the desire for democracy and citizens' rights in those countries in

References (140)

  • FM Knaul et al.

    The quest for universal health coverage: achieving social protection for all in Mexico

    Lancet

    (2012)
  • J Frenk et al.

    Evidence-based health policy: three generations of reform in Mexico

    Lancet

    (2003)
  • FM Knaul et al.

    Evidence is good for your health system: policy reform to remedy catastrophic and impoverishing health spending in Mexico

    Lancet

    (2006)
  • R Atun

    Health systems, systems thinking and innovation

    Health Policy Plan

    (2012)
  • RA Atun et al.

    Health expenditure: an ‘investment’ rather than a cost? Working Paper 05/01. Royal Institute of International Affairs. International Economics Programme. Chatham House, London

  • J Sachs

    Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health

    (2001)
  • TW Schultz

    Nobel lecture: the economics of being poor

    J Polit Econ

    (1980)
  • RA Atun et al.

    Advancing economic growth: investing in health. The Royal Institute of International Affairs. Chatham House; London

  • D Stuckler et al.

    The political economy of universal health coverage

  • Indicators

  • Health in the Americas: regional outlook and country profiles. Scientific and Technical Publication No.636

    (2012)
  • D Cotlear et al.

    Overcoming social segregation in health care in Latin America

    Lancet

    (2014)
  • LO Monteiro de Andrade et al.

    Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries

    Lancet

    (2014)
  • Global Burden of Disease. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

  • Health, Nutrition and Population Division. HNP. Protecting pro-poor health services during financial crises. Lessons from experience

    (2009)
  • Trade, foreign policy, diplomacy and health. Washington Consensus

  • J Williamson

    Did the Washington Consensus fail? Outline of speech at the Center for Strategic and International Studies Washington, DC

  • A de la Torre et al.

    The Washington Consensus: assessing a damaged brand

  • D Rodrik

    Goodbye Washington Consensus, hello Washington confusion?

    J Econ Lit

    (2006)
  • JE Stiglitz

    Globalization and its discontents

    (2002)
  • J Williamson

    Democracy and the Washington Consensus

    World Dev

    (1993)
  • ARM Ritter

    Shifting realities in special period Cuba

    Lat Am Res Rev

    (2010)
  • JE Stiglitz

    Whither reform? Towards a new agenda for Latin America

    CEPAL Rev

    (2003)
  • LB Rawlings et al.

    Evaluating the impact of conditional cash transfer programs: lessons from Latin America. World Bank Policy Research Working Paper 3119

    (2003)
  • S Cecchini et al.

    Conditional cash transfer programmes: the recent experience in Latin America and the Caribbean

    (2011)
  • S Cecchini et al.

    Conditional cash transfers and health in Latin America

    Lancet

    (2014)
  • PJ Gertler et al.

    Impact evaluation of maternal child provincial health investment project in Argentina. Plan Nacer

    (2011)
  • Decreto n° 5.209, de 17 de setembro de 2004 - Regulamenta a L- 010.836-2004 - Programa Bolsa Família

  • C Solidario

    Ley que establece un sistema de protección social para familias en situación de extrema pobreza denominado “Chile Solidario”, N° 19.949 de 2004. Santiago de Chile

  • MH Lavinas et al.

    Mi Familia Progresa (MIFAPRO). Ejercicio de Apreciación Sustantiva

    (2011)
  • P Gertler

    Do conditional cash transfers improve child health? Evidence from PROGRESA's control randomized experiment, health, health care, and economic development

    Am Econ Rev

    (2004)
  • E Perova et al.

    Welfare impacts of the “Juntos” program in Peru: evidence from a non-experimental evaluation

    (2009)
  • N Jones et al.

    Cash transfers to tackle childhood poverty and vulnerability: an analysis of Peru's Juntos programme

    Environ Urban

    (2008)
  • F Borraz et al.

    Impact of the Uruguayan conditional cash transfer program

    Cuad Econ

    (2009)
  • M Lagarde et al.

    The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries

    Cochrane Database Syst Rev

    (2009)
  • A Escobar et al.

    The making of social movements in Latin America: identity, strategy, and democracy

    (1992)
  • H Matsuura

    The effect of a constitutional right to health on population health in 157 countries, 1970–2007: the role of democratic governance. The program on the global demography of aging. PGDA Working Paper No. 106; 2013. Harvard School for Public Health

  • P De Vos

    “No one left abandoned”: Cuba's national health system since the 1959 revolution

    Int J Health Serv

    (2005)
  • Cited by (0)

    View full text