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BMC Health Services Research

, 17:145

Utilization, expenditure, economics and financing systems


BackgroundContributory social health insurance for formal sector employees only has proven challenging for moving towards universal health coverage UHC. This is because the informally employed and the poor usually remain excluded. One way to expand UHC is to fully or partially subsidize health insurance contributions for excluded population groups through government budget transfers. This paper analyses the institutional design features of such government subsidization arrangements in Latin America and assesses their performance with respect to UHC progress. The aim is to identify UHC conducive institutional design features of such arrangements.

MethodsA literature search provided the information to analyse institutional design features, with a focus on the following aspects: eligibility-enrolment rules, financing and pooling arrangements, and purchasing and benefit package design. Based on secondary data analysis, UHC progress is assessed in terms of improved population coverage, financial protection and access to needed health care services.

ResultsSuch government subsidization arrangements currently exist in eight countries of Latin America Bolivia, Chile, Colombia, Costa Rica, Dominican Republic, Mexico, Peru, Uruguay. Institutional design features and UHC related performance vary significantly. Notably, countries with a universalist approach or indirect targeting have higher population coverage rates. Separate pools for the subsidized maintain inequitable access. The relatively large scopes of the benefit packages had a positive impact on financial protection and access to care.

Discussion and ConclusionIn the long term, merging different schemes into one integrated health financing system without opt-out options for the better-off is desirable, while equally expanding eligibility to cover those so far excluded. In the short and medium term, the harmonization of benefit packages could be a priority. UHC progress also depends on substantial supply side investments to ensure the availability of quality services, particularly in rural areas. Future research should generate more evidence on the implementation process and impact of subsidization arrangements on UHC progress.

KeywordsUniversal health coverage Vulnerable population groups Government subsidization of health insurance Financial protection AbbreviationsAUGEPlan de acceso universal de garantias explicitas Chile

FONASAFondo nacional de la salud Chile

GGHEGeneral government health expenditure

ILOInternational labour organization

ISAPREsInstituciones de salud previsional Chile

MOHMinistry of health

OECDOrganization for economic co-operation development

OOPOut-of-pocket expenditure

PAHOPan America health organization

SHISocial health insurance

THETotal health expenditure

UHCUniversal health coverage

WHOWorld health organization

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Autor: Inke Mathauer - Thorsten Behrendt


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