The Meanings of Universal Health Care in Latin America

Abstract

In Latin America, competing definitions of universal health care are found. Variants include traditional universalism, basic universalism, and minimal or residual universalism. These definitions are informed by European traditions, a renewed emphasis on equity among Latin American social policy experts, and World Bank strategy. This essay explores these definitions as well as areas of overlap and points of difference between and among them using examples from several Latin American countries. The most important difference concerns the preventive and curative services not covered by the benefits packages of minimal universal programs, a gap expected to grow increasingly costly for patients.

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis

“…For example, universality is a value of almost every health system in Latin America [ 41 ] and a principle promoted by WHO [ 3 , 42 , 43 ]. However, while universality has been prioritised as a key goal, there is no consensus on its meaning and scope [ 29 , 41 , 44 – 46 ] and, therefore, it is not possible to design a common indicator to measure it or even agree on the extent to which it can be achieved [ 41 ] (Table 3 ).…”

“…In an egalitarian perspective, health services should be distributed equally for all: in the utilitarian perspective, health services should be distributed based on who gets more out of them; and in a Rawlsian perspective, inequalities in health are allowed if the status of the disadvantaged people is better than in a scenario of complete equality [ 23 , 53 ] Policies • The perspective underlying the goals shape how some issues gain prominence in the government agenda given that this is a precursor for identifying policy options. ◦ For example, there is no consensus on the meaning and scope of universality [ 29 , 41 , 44 – 46 ]. For legal and human right scholars, universality equates to the right to health and implies “equal or same entitlements” to the benefits of a health system [ 41 ].…”

“…From the perspective of health economists, universality is closely related to financial protection, which leads to a focus on policy options that prioritize prepaid mechanisms such as tax revenue, contributions from social health insurance, and private health insurance in order to minimize out-of-pocket payments and prevent financial bankruptcy. In contrast, from the perspective of public health, universality is considered in relation to defining population-level priorities in health, and the package of effective interventions that is needed to comprehensively address those needs [ 41 ] Politics • The comparison of the goal against what it has achieved is an important factor in agenda setting ◦ When governments compare their indicators of what the goal has achieved with their national expectations or indicators from other countries, a bad result could be a catalyst for agenda-setting [ 28 , 47 ] Policy development and implementation Institutions • Policies that are aligned with health-system goals are more likely to be prioritized for implementation ◦ This situation is especially the case when governments have signed on to international commitments such as the MDG [ 16 , 54 – 56 ] Ideas • The perspective underlying the goals influence on what policy option is more likely to be chosen ◦ This determines how policies are developed and which policy options are more likely to pass [ 24 , 32 , 36 , 44 , 47 , 57 – 59 ] • Policy alternatives that address intermediate goals may be preferred because they are more feasible to achieve ◦ Given that core values are very broad and imply the satisfaction of multiple dimensions, policies that focus on specific intermediate values might be preferred in policy development [ 60 ] • Goals are used as indicators for evaluating the general performance of the health system ◦ Indicators of equity, quality, solidarity, and universality are the most common ways to evaluate the global performance of health systems, even for policies that do not explicitly pursue the achievement of those goals [ 37 ] • Intermediate values are used as surrogate outcomes of evaluation of the performance of the health system ◦ Intermediate values are commonly used as dimensions or criteria to evaluate core values like equity or universality [ 61 ] Technical values Agenda setting Problems • Technical values are used to frame problems regarding efficiency or financial sustainability ◦ Governments usually pay attention to problems that are framed in terms of inefficiency or menaces to the fiscal sustainability of t...…”

“…◦ For example, there is no consensus on the meaning and scope of universality [ 29 , 41 , 44 – 46 ]. For legal and human right scholars, universality equates to the right to health and implies “equal or same entitlements” to the benefits of a health system [ 41 ].…”

Understanding the Role of Values in Health Policy Decision-Making From the Perspective of Policy-Makers and Stakeholders: A Multiple-Case Embedded Study in Chile and Colombia

“…Different authors have addressed the role of values in the health policy decision-making process in Latin America, principally focusing on values in health-system reforms. [8][9][10] Those approaches were captured in our critical interpretive synthesis, which identified 116 values in empirical and nonempirical papers about the role of values in policy decisionmaking in Latin America. Through the critical interpretive synthesis we developed a theoretical framework, tested in this study, which characterized values in 4 ways: (1) goalrelated values (ie, guiding principles of the health system);…”