The trap underlying 'universal health coverage': The struggle to realise the right to health in Latin America

Drawing on the experience of Latin America, Rafael Gonzalez Guzman and Nashielly Cortes Hernandez warn that behind the proposal of UHC lies a hidden agenda related to the commodification of healthcare through the participation of insurance companies and large private healthcare providers who profit from public funds allocated for health.

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'UNIVERSAL health coverage' (UHC) is a concept that is being widely deliberated upon across the globe. Prominent in popularising the concept have been the Rockefeller Foundation, the World Bank, the US Agency for International Development (USAID) and even the World Health Organisation (WHO). The concept is generally presented as a cube with three axes representing the number of people covered by health systems; the number of medical interventions provided; and the amount of money necessary for financial protection that would cover for catastrophic expenses on healthcare incurred by poor families. However, behind this proposal for UHC lies a hidden agenda related to the commodification of healthcare through the participation of insurance and large private healthcare providers who seek to extract profits from public funds allocated for health. Typically, in many settings, UHC provides insurance coverage to the poor1 for a limited package of services.

The terms 'universal' and 'coverage' appear to denote comprehensiveness and fairness, but their concrete application in some countries of Latin America is indicative of a clear trend. It is typified by the participation of insurance companies (the term 'coverage' is insurance language), which open up public funds for health to for-profit healthcare providers. While, to start with, local private providers are involved, they can rapidly be replaced by transnational companies. Some of these are now entering several Latin American countries that pursue neoliberal policies (Colombia, Chile, the Dominican Republic and Peru). The progressive and intentional weakening of public services and the entry of private service providers is promoted on the grounds that private sector participation improves the quality of services provided. However, there is no systematic evidence supporting the contention that private providers are more efficient.2

UHC promotes inequity in healthcare because there is a wide variation in insurance coverage available to different sets of the population. Inequity is embedded in the system: private plans for the rich have wider benefits; plans for formal sector workers have wide benefits but they face overcrowding and long waiting times; and informal sector or rural workers are covered by a very limited package of services. The reality is even worse, because this new structure also leaves out significant sections of the population. Therefore UHC acts against the fundamental right of every person to have secure access to healthcare.

Experience with UHC in some countries in Latin America

In the Dominican Republic, two major super-specialty hospitals were transferred to private providers. This model was subsequently extended to other 'self-managed' hospitals and primary care centres, which receive from the state per capita payments for each person insured. The state funds are managed by Health Risk Administrators (ARS) - private companies which stand to profit through a reduction in benefits available to those who are insured. In addition, those insured are also required to make co-payments for certain conditions, or pay the entire cost if a procedure is not included in the insurance package. Contrary to the popular discourse that UHC results in reduction of out-of-pocket expenses on healthcare, such expenses incurred by families increased by 60% between 2007 and 2012. A new form of segmentation of the health system is emerging, based on the ability to pay, even while on paper universal coverage has been achieved!  At the same time the ARS are making huge profits, valued at a return of almost 20% on investment per annum.3

Colombia was one of the first countries in Latin America to introduce UHC. In the process the public system was dismantled and health insurance companies (EPS) emerged as key players in the health system. These companies have two distinct schemes, one for formal workers and another for informal workers, peasants or others who have documents to prove that they lie below the poverty line. The latter scheme has a limited package of benefits and patients must pay if the services required are not included in the package.

Both insurance companies and healthcare providers seek to increase their profits by reducing the range of services provided, even in cases where services are included in a package. This has led to a very large number of complaints called tutelas (tutelas relate to a provision in the Colombian constitution that allows citizens to file complaints when their right to health is not upheld) being filed against insurance companies. Most of these complaints pertain to deficiency in providing services included in the benefit package announced by insurance companies. Adding to the public sentiment against the insurance companies has been several reports in the Colombian press regarding the large profits enjoyed by these companies and the very high salaries drawn by the company directors.

Yet, in 2014, the Colombian government approved a change in the law that limited the financial resources that can be used for health. It also approved a new provision that would override the use of tutelas to seek remedy against deficiencies in the services provided by insurance companies. The Colombian Constitutional Court modified the proposal by the government and replaced the limited packages of services provided by insurance companies with a 'negative list' of benefits that would be excluded from the insurance package.4 This is likely to have the same effect, as earlier, of limiting coverage.

Peru is presently engaged in a process to reform its health system with active support from USAID. Peru offers a very limited insurance package that covers the poorest, who do not have social security protection as part of their conditions of employment. It is a very limited package that reproduces inequity in healthcare. One part of the reforms initiated by the government facilitates the entry of private finance through their agents, who would be allowed to operate public funds in health as profit-making ventures. Although the reform is being promoted under the slogan of financial protection, out-of-pocket expenditure on health has increased from $3.4 billion in 2009 to $4.35 billion in 2013.5

The government of Mexico has attempted to follow the example of Colombia over the past decades. The first phase of reforms, involving structural adjustment policies, led to a weakened public system and an increase in fees for services for people without social security, thereby reducing access of the poorest people to healthcare services. In the next phase, instead of lowering fees, an insurance package with limited services called popular insurance (seguro popular or SP) was introduced to address the healthcare needs of those not covered by social security. For example, patients with myocardial infarction would be covered by the package only if they are under 60 years old. Also excluded from the package is dialysis, frequently needed for patients with chronic diabetes (diabetes is the leading cause of death in Mexico). Services not included in the package need to be paid for to the service provider and the fees for such services are often very high. Like in Peru, out-of pocket payments are very high - for each peso spent out of pocket by the people insured through SP, the insurance companies spend only 0.93 pesos.6

In the Mexican system at present, insurance companies manage the funds allocated to the universal scheme (SP) that offers a very limited package of services. It has the effect of limiting access to a much smaller package of benefits as compared to what was traditionally available through social security. At the same time the system facilitates the entry of private providers, which are linked to the insurance scheme.

A recent World Bank study, which evaluated the insurance-based model of UHC, concluded that UHC-based reforms had not improved the health conditions of concerned populations. This is because the reforms implicit in UHC relate only to financial protection and promote a market for healthcare services that is exploited by insurance companies and private providers. The insurance-based model of UHC also has the effect of pushing up public health budgets.7 These reforms also create new forms of inequity as a consequence of different insurance packages that differentially service the needs of the rich and the poor.

Another effect observed in Colombia, Peru and Mexico is the deterioration of the conditions of work of health workers.8 For example, in Mexico, health workers in SP earn between 50% and 60% less than what workers earned before the reforms,9 and the conditions of work for physicians, nurses and other health workers in the private sector are worse than for those in public services.

The alternative experience

Several countries in the Latin American region which pursued neoliberal policies saw an increase in poverty and a widening of the gap between a handful of rich and millions of working people. Social mobilisation overthrew many neoliberal governments, leading to the emergence of so-called progressive governments (such as in Venezuela, Bolivia, Ecuador, Brazil, El Salvador, Uruguay and Argentina). Instead of implementing neoliberal policies, these governments are promoting policies that support the right to health and the de-commodification of healthcare.10

In these countries the core principle being followed is that equal needs in health must receive the same attention, independent of the ability to pay. The best way to pursue this principle lies in the construction of a public, single, free-of-charge and accessible health system. In most parts of Latin America, before the advent of neoliberal reforms, public health systems were built that were a mix of the Beveridge and Bismarck models prevalent in Europe. The construction of the public systems was often achieved as a result of a range of popular struggles in the 20th century. In contrast to neoliberal regimes, progressive governments in Latin America are engaged in the strengthening and unification of public institutions with a view to creating a single system that provides universal access to the entire population. Instead of a mix of public and private funding and co-payments by patients, the system is sought to be financed by a progressive taxation system and employer contributions as part of social security. The proportions of the two vary depending on the specific characteristics of each country.

This model has been called an impossible utopia, but has existed for decades in Cuba - a country with some of the best health indicators in the entire continent. Such a system still exists in many countries of Europe and also in Canada. The current Latin American perspective towards building inclusive public systems differs from that in Europe with the addition of a very important component: popular participation in the construction and conduct of the system. The idea promoted is that the right to health cannot be achieved through market mechanisms and requires the active involvement of popular and citizens' organisations.

The construction of such a system (which is public, single and universal) is not easy. Important challenges include: the long history of scarce allocation of resources for public systems; the inequality in funds between different public institutions obstructing their unification in the short term; opposition by medical elites and a section of politicians and the bureaucracy; inadequate human resources and the opposition from some universities to developing appropriate curricula; the presence of a large private sector; and also the trend in some sectors (like white-collar workers) to demand private provision and expensive insurance coverage. Progressive governments require support in order to navigate these challenges and make innovative advances.

Venezuela is an example of this trend. As part of the country's Bolivarian Revolution, the Hugo Chavez government decreed that any person could access social security services, services provided by the health ministry and those provided by the armed forces. But even with this, millions of poor people did not have secure access to healthcare facilities. Workers in many sectors had private insurance plans paid by public or private employers (almost 500 different insurance plans). The Constituent Assembly established the creation of one universal, single, public and free health system.11 But the advance towards this system has not been easy.

The first and most important step in this direction was the nationwide application of the experience of solidarity born in the slums of Caracas through the Barrio Adentro Mission.12 Across the country a network of healthcare facilities, supported by Cuban general practitioners, was established in the first phase. In 2013 this network had 13,713 primary care centres that provided almost 500 million consultations a year. In the second phase integrated healthcare centres (CDI) were built that provide emergency care services and a range of diagnostic support. In 2012 the Barrio Adentro Mission had 1,939 CDIs. Beside each CDI was constructed a rehabilitation unit for the care of disabled people. Currently the third phase is beginning with construction of new hospitals, including specialty hospitals (for example, for paediatric surgery), and an increase in the number of public hospital beds.13 In Barrio Adentro all services are free and accessible to everyone. Unlike in the case of limited insurance plans, all users receive equal treatment. Alongside this the popular participation of local communities is contributing to the building of bottom-up structures of governance of the health system.

Meanwhile the Venezuelan government has built a new university (the Bolivarian University) which is engaged in training thousands of new doctors who will replace the Cuban doctors. Currently more than 17,000 integrated community physicians have graduated, and many of them are pursuing postgraduate studies in family medicine. The advances in building a public system for healthcare run parallel to several other social programmes to reduce poverty and inequity in Venezuela, such as programmes aimed at reducing the number of informal jobs, decreasing significantly the incidence of malnutrition, and building thousands of new houses for the poor.

Another important experience is ongoing in El Salvador. The progressive government of Mauricio Funes and now of Salvador Sanchez Ceren inherited a public health system that had been dismantled and privatised in several areas by the previous, neoliberal government. With the support of popular mobilisation the government initiated a process to reform the system. Fees for healthcare services were abolished, thus making all services free for the entire population. This simple measure increased access to healthcare by 30-40%. The health budget was increased for all levels of the system. Networks of community health centres were built in regions that had poor services to start with. Public hospitals, dismantled by the previous regime, were rebuilt and the number of hospital beds increased significantly. The new government introduced a new drug law that checked the activities of multinational drug companies and increased access to drugs.14,15 The reforms in El Salvador weren't just driven by professional and technical experts. The National Health Forum, a broad-based popular organisation that is independent16 of the government, also played a key role in shaping the reforms.

In only six years since the initiation of the reforms, positive results are visible in the form of an improvement in the health situation and a reduction of inequity in access to healthcare. El Salvador, classified as one of the poorest in the region, is one of the few countries in Latin America to have achieved the Millennium Development Goal target for maternal mortality. As in Venezuela, health reforms in El Salvador are being pursued hand in hand with social policies that improve the conditions of living and reduce social inequalities.

Brazil, the biggest country in Latin America with a population of 190 million, is another country that has made significant progress towards development of a unified public health system. A 'Single Health System' (SUS) was created as a product of a broad-based social mobilisation which fused together, in 1988, the struggle for democracy and the struggle for the right to health. Students, public health professionals, peasants, ecclesiastical communities, trade unions and political leaders participated in this mobilisation. This process culminated in a constitutional change, through which emerged SUS: a single public, universal, free-of-charge system that unified the social-security-based health system and the services of the Health Ministry (traditionally separated in almost all Latin American countries). This system is accessible to all Brazilians and provides free access to even complex interventions (for example, every year SUS provides facilities for 24,000 organ transplant operations, 84,000 cardiac surgeries and 62,000 oncologic surgeries).

While SUS was initiated after the overthrow of the dictatorship in 1988, it was initially starved of funds by the neoliberal governments that followed. This led to the development of a huge private medical sector which still accounts for about half of the country's healthcare costs. Since the last decade progressive governments, led by Lula and Dilma Rousseff, have been engaged in strengthening SUS. As a result, currently, SUS addresses the healthcare needs of about 160 million people and recent efforts target distant rural communities without medical facilities. However, the private sector continues to be powerful in Brazil and many people working in different sectors (including government employees) are covered by private insurance plans. While SUS provides support for expensive procedures not covered by private insurance plans, there still exist gaps in its ability to provide the entire range of services.17 Thus SUS is still dependent on private providers for the provision of some hospital-based services (such services are purchased by SUS from private providers). At present, the challenge in Brazil is to further strengthen the capacity of SUS so as to avoid the existing, though limited, dependence on the private sector for provision of hospital-based care services.18

Conclusion

The cases addressed above show two different trends regarding the progressive realisation of the right to health. The first trend is an attempt to reconcile the health needs of the population with the interests of insurance companies and private providers of healthcare. In countries which follow this logic, inequity is reproduced in new forms and public funds are utilised to support the profits of the private sector. The second trend is based upon the construction of public, single, free systems with popular participation. The logic underlying this system is that health is not a commodity but a right. Such a system does not include limited packages; the expansion and unification of a single system, providing services according to need, is the main task to be achieved. Barriers to the development of such a system can only be overcome through strong popular participation in its construction.                                           

Rafael Gonzalez Guzman is a Professor in the Faculty of Medicine at Universidad Nacional Autonoma de Mexico and Executive Secretary of the Latin American Social Medicine Association (ALAMES). Nashielly Cortes Hernandez is a Professor in the Faculty of Medicine at Universidad Nacional Autonoma de Mexico and is also with ALAMES.

Endnotes

1     Nila Heredia, Asa Cristina Laurell, Oscar Feo, Jose Noronha, Rafael Gonzalez-Guzman and Mauricio Torres-Tovar. The right to health: what model for Latin America? www.thelancet.com. Published online: 16 October 2014

2     Sanjay Basu, Jason Andrews, Sandeep Kishore, Rajesh Panjabi and David Stuckler. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLOS Medicine.

3     Jose Selig. Universalismo y Ciudadan¡a: debate sobre las reformas de la salud y seguridad social en Am‚rica Latina y Europa. El caso Dominicano, tendencias y resultados. Presentation at the 13th Latin American Congress of Social Medicine, November 2014.

4     M. Hernandez. La Novela de la Ley Estatutaria de Salud. Razon Publica, February 2015.

5     Alexandro Saco. Per£: articulaci¢n social - gremial frente a reforma neoliberal. La historia reciente. In: R. Gonzalez G., S. Barria and A. Sengupta. La Lucha por el Derecho a la salud en Am‚rica Latina. Universidad Nacional de El Salvador, El Salvador, 2014.

6     Asa Cristina Laurell. Impacto del seguro popular en el sistema de salud mexicano. CLACSO, Buenos Aires, 2013.

7     U. Giedion, E.A. Alfonso and Y. Diaz. The impact of universal coverage schemes in the developing world: a review of the existing evidence. World Bank, Washington, DC, 2013.

8     Colombia: reivindicar la medicina como una profesi¢n. Colegio Nacional de M‚dicos Generales de Colombia.

9     G. Nigenda, J.A. Ruiz, M. Aguilar and R. Arias. Regularizaci¢n Laboral de Trabajadores de la salud pagados con recursos del Seguro Popular en M‚xico. Sal Pub M‚xico 2012, 54(6):616-623.

10   R. Gonzalez G. Lucha social, gobiernos progresistas  y salud en Am‚rica Latina. In: R. Gonzalez G., S. Barria and A. Sengupta. La Lucha por el Derecho a la salud en Am‚rica Latina. Universidad Nacional de El Salvador, El Salvador, 2014.

11   Oscar Feo and Pasqualina Curcio. La salud en el proceso constituyente venezolano. Revista cubana de Salud P£blica, Vol. 30, No. 2, April-June 2004.

12   Charles L. Briggs and Clara Mantini-Briggs. 'Misi¢n Barrio Adentro': Medicina Social, Movimientos Sociales de los Pobres y Nuevas Coaliciones en Venezuela. Salud Colectiva, Vol. 3, No. 2, May-August 2007.

13   U.J. Leon. Cambio social y su impacto en la salud en Venezuela. In: R. Gonzalez G., S. Barria and A. Sengupta. La Lucha por el Derecho a la salud en Am‚rica Latina. Universidad Nacional de El Salvador, El Salvador, 2014.

14   Eduardo Espinoza. El cambio social, el cambio en salud y su impacto en la salud. In: R. Gonzalez G., S. Barria and A. Sengupta. La Lucha por el Derecho a la salud en Am‚rica Latina. Universidad Nacional de El Salvador, El Salvador, 2014.

15   V. Menjivar. La reforma de salud en El Salvador. Presentation at the 13th Latin American Congress of Social Medicine, November 2014.

16   M. Posadas. Construcci¢n de poder popular para profundizar la democracia, Foro Nacional de Salud. Presentation at the 13th Latin American Congress of Social Medicine, November 2014.

17   A. De Negri. Brasil: la lucha continua por un Sistema de salud universal. In: R. Gonzalez G., S. Barria and A. Sengupta. La Lucha por el Derecho a la salud en Am‚rica Latina. Universidad Nacional de El Salvador, El Salvador, 2014.

18   See: Carta do Brazil, Semin rio Democracia e Participa‡ao Popular como base para a constru‡ao do modelo de estado, sociedade e desenvolvimento.

*Third World Resurgence No. 296/297, April/May 2015, pp 23-27