Achieving effective universal health coverage with equity: evidence from Chile.
Chile's 'health guarantees' approach to providing universal and equitable coverage for quality healthcare in a dual public-private health system has generated global interest. The programme, called AUGE, defines legally enforceable rights to explicit healthcare benefits for priority health conditions, which incrementally covered 56 problems representing 75% of the disease burden between 2005 and 2009. It was accompanied by other health reform measures to increase public financing and public sector planning to secure the guarantees nationwide, as well as the state's stewardship role. We analysed data from household surveys conducted before and after the AUGE reform to estimate changes in levels of unmet health need, defined as the lack of a healthcare visit for a health problem occurring in the last 30 days, by age, sex, income, education, health insurance, residence and ethnicity; fitting logistic regression models and using predictive margins. The overall prevalence of unmet health need was much lower in 2009 (17.6%, 95% CI: 16.5%, 18.6%) than in 2000 (30.0%, 95% CI: 28.3%, 31.7%). Differences by income and education extremes and rural-urban residence disappeared. In 2009, people who had been in treatment for a condition covered by AUGE in the past year had a lower adjusted prevalence of unmet need for their recent problem (11.7%, 95% CI: 10.5%, 13.2%) than who had not (21.0%, 95% CI: 19.6%, 22.4%). Despite limitations including cross-sectional and self-reported data, our findings suggest that the Chilean health system has become more equitable and responsive to need. While these changes cannot be directly attributed to AUGE, they were coincident with the AUGE reforms. However, healthcare equity concerns are still present, relating to quality of care, health system barriers and differential access for health conditions that are not covered by AUGE.
Escuela de Salud Pública Salvador Allende, Universidad de Chile, Independencia 939 Santiago, Chile, 8380453 Centro de Epidemiología y Políticas de Salud, Facultad de Medicina, Universidad de Desarrollo, Santiago, Chile, 7710162 and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada H3A 1A2 pfrenz@med.uchile.cl.
Patricia
P
Frenz
Escuela de Salud Pública Salvador Allende, Universidad de Chile, Independencia 939 Santiago, Chile, 8380453 Centro de Epidemiología y Políticas de Salud, Facultad de Medicina, Universidad de Desarrollo, Santiago, Chile, 7710162 and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada H3A 1A2.
Iris
I
Delgado
Escuela de Salud Pública Salvador Allende, Universidad de Chile, Independencia 939 Santiago, Chile, 8380453 Centro de Epidemiología y Políticas de Salud, Facultad de Medicina, Universidad de Desarrollo, Santiago, Chile, 7710162 and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada H3A 1A2.
Jay S
JS
Kaufman
Escuela de Salud Pública Salvador Allende, Universidad de Chile, Independencia 939 Santiago, Chile, 8380453 Centro de Epidemiología y Políticas de Salud, Facultad de Medicina, Universidad de Desarrollo, Santiago, Chile, 7710162 and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada H3A 1A2.
Sam
S
Harper
D000293:Adolescent; D000328:Adult; D000368:Aged; D002677:Chile; D003430:Cross-Sectional Studies; D005260:Female; D006078:Government Programs; D018166:Health Care Reform; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007348:Insurance, Health; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017149:Private Sector; D017150:Public Sector; D012959:Socioeconomic Factors; D019472:Universal Health Insurance; D055815:Young Adult
Chile; Healthcare reform; health inequalities; health systems research