By Marco Antonio Nuñez
During these months of the COVID-19 pandemic in Chile, the need to align the constitutional process with long-postponed structural reforms to the health system has become evident among public health experts.
Capitalizing on this moment might avoid the possibility of a constitutional right to health becoming a dead letter or being reduced only to the prosecution of particular cases, postponing again the aspirations of the majority of Chileans.
Although the Chilean Constitution promulgated under the dictatorship in 1980 and subsequently reformed in several of its chapters recognizes “The right to the protection of health,” it has been tainted by authoritarianism from its origin, and promotes a subsidiary role of the state in health.
It has been 30 years since Chile recovered its democracy. This recovery has been characterized by economic growth and the adoption of redistributive social policies that have made it possible to drastically reduce poverty levels and achieve satisfactory health indicators in the Latin American context. However, major social inequalities still persist and the recognition of social rights in a constitution created in democracy is still pending.
In the last months of 2019, mobilized citizens strongly questioned institutional biases as well as the political and the social order. In the coming months, Chile will most likely draft a new Constitution written by a Constituent Assembly to be democratically elected in April 2021.
One of the most frequent and strongest demands made by citizens has been the right to health. Nationally representative surveys conducted in August 2020 show that 93% of Chilean citizens agree with the statement “the right to health should be guaranteed by the Constitution.”
There is, however, an urgent need to demystify the misunderstanding that the constitutional guarantee will be sufficient to improve equity, access, quality and financial protection in health. As Alicia Ely Yamin stated in a recent article on Chile, “significant attention should be paid to the alignment of norms with the institutional architecture and regulation of the health system.” A right to health should be aligned with legislative reforms in insurance and provision. In order to achieve this, it is imperative to reach a structural health reform agreement in Chile that achieves the following:
- Increased state contributions and decreased out-of-pocket expenditures. Social spending on health should be raised from 8.98% of the GDP to the U.K. or Canada average of 10%, without sacrificing funding for education, social security, or housing. A major indicator for evaluating a health system’s performance is the amount of out-of-pocket payments that people must make to finance their health expenses. In Chile, out-of-pocket spending remains remarkably high compared to other OECD countries. In 2015, out-of-pocket spending as a percentage of household consumption in Chile reached 4.1%, compared to the OECD average of 3%, and exceeded only by Hungary (4.4%), Greece (4.4%), South Korea (5.1%) and Switzerland (5.3%).
- A Universal Health Plan containing a comprehensive package of preventive and curative benefits, compulsory for public and private insurers, should be the leading axis of the constitutional guarantee of the right to health. Solidarity-based financing schemes from young to old, from healthy to sick, and from rich to poor with risk adjustment models that are financed by state contributions and a universal per capita health premium are the necessary components for the implementation of the Plan. We must agree on the expansion of Chile’s most successful health reform carried out by the government of Ricardo Lagos 15 years ago: the Explicit Health Guarantees Law (Ley de Garantías Explícitas en Salud).
- The reform of Patients’ Bill of Rights to explicitly define the rights and duties of users of health services, both in the public as well as in the private sector. We should, additionally, prevent massive litigation as an instrument of conflict resolution, since international experience (Colombia and Brazil) shows that groups with greater power and influence have better access to justice, resulting in a framework of privileges rather than social rights in health. Health priorities should be defined as a result of public policy, where cost effectiveness analysis and national burden of disease studies play an important role. Private companies should not be allowed to create artificial demand for technologies and medicines, and national health priorities should not be set by judges’ isolated rulings. The U.K. and Canadian experiences are enlightening in assuring the fair distribution of resources in the health system.
The task at hand is to reduce income-related gaps in access and quality of health care in Chile. Social rights, defined as guaranteed access to health coverage with decent standards regardless of people’s ability to pay, must become the fundamental pillars of the right to health in the new Chilean constitution. To secure these rights, comprehensive health sector reforms must follow during this new phase of democracy in Chile.
Marco Antonio Nuñez, MD, MPH, PhD, is a lecturer on Public Health at Finis Terrae University, School of Medicine and Director of PTG Salud, a public health policy think tank in Santiago, Chile.
As a medical student, he was elected President of the Chilean Student Federation in 1989, playing a key role in the democratic movement against Pinochet regime. He served as Director of North Santiago Health District and appointed Valparaiso Governor between 2001 and 2003. He was elected Member of the Chilean Parliament (2006 to 2018), four terms President of Legislative Health Commission, and President of the Chilean House of Representatives in 2015.
He holds a medical degree from University of Chile, a Master of Public Health from the Harvard T.H. Chan School of Public Health, and a Ph.D. in Health Policy from the Johns Hopkins Bloomberg School of Public Health.