# Latin American Health Regimes in the Face of the Pandemic

*Les régimes de santé latino-américains face à la pandémie*

*Los regímenes de salud latinoamericanos ante la pandemia*

Ilán Bizberg

<figure><img src="image_1.png" /></figure>

OpenEdition
Journals

**Electronic version**

URL: https://journals.openedition.org/interventionseconomiques/16665

DOI: 10.4000/interventionseconomiques.16665

ISSN: 1710-7377

**Publisher**

Université du Québec à Montréal

**Electronic reference**

Ilán Bizberg, "Latin American Health Regimes in the Face of the Pandemic", *Revue Interventions économiques* [Online], 67 | 2022, Online since 01 April 2022, connection on 10 February 2026. URL: http://journals.openedition.org/interventionseconomiques/16665; DOI: https://doi.org/10.4000/interventionseconomiques.16665

<figure><img src="image_2.png" /></figure>
# Latin American Health Regimes in the Face of the Pandemic

*Les régimes de santé latino-américains face à la pandémie*

*Los regímenes de salud latinoamericanos ante la pandemia*

Ilán Bizberg

<figure><img src="image_3.png" /></figure>

OpenEdition
Journals

**Electronic version**

URL: https://journals.openedition.org/interventionseconomiques/16665

ISBN: 1710-7377

ISSN: 1710-7377

**Publisher**

Association d'Économie Politique
# Latin American Health Regimes in the Face of the Pandemic

Les régimes de santé latino-américains face à la pandémie

Los regímenes de salud latinoamericanos ante la pandemia

Ilán Bizberg

With the collaboration of Mauricio Jiménez Hernández.

## 01. Introduction

1. None of the Latin American countries has achieved fully universal, egalitarian, and efficient health regimes, although Uruguay and Costa Rica have probably come closest to this goal. Nevertheless, during the first decade and a half of the twenty-first century, several countries which saw the arrival to power of coalitions including the popular classes tried to develop their health systems by taking advantage of the commodity boom and the influx of financial resources from developed countries.

2. With the commodity boom of the first decade and a half of the 2000, several countries of the continent embarked upon a socio-developmentist growth mode based on the expansion of internal demand; sustained by redistribution through the increase of wages and the extension of the social protection system. This mode of development was promoted especially in Brazil, during the two presidencies of Lula da Silva and the first of Dilma Roussef, as well as in Argentina during the governments of Nestor Kirchner and Cristina Fernández de Kirchner. A similar process of direct (wages) and indirect (social policy) redistribution was undertaken in countries that followed a redistributive rentier model: Bolivia and Ecuador, although their health services remained much less developed. However, in these four countries, there has been a trend towards the universalization of health services. In contrast, in countries that followed a liberal economic model, based either on international subcontracting, such as Mexico, or a rentier one, such as Colombia and Peru, sustained on a non-distributive growth model based on profits, social policy has remained mainly residual or assistance-oriented. In
the latter, there has also been an expansion of the health organizations, nonetheless
centered on minimum universalization schemes (Bizberg, 2019).

The end of the commodity boom and the arrival of governmental coalitions dominated by financial and commodity exports interests in the countries that followed the socio-developmentist and redistributive rentier models put an end to the slow transformations of the health systems in poor countries such as Bolivia and Ecuador. It also strongly affected the efforts undertaken by Brazil in trying to consolidate one of Latin America's most ambitious health structures which, like Costa Rica's, is State-run. It is quite true that, even before this economic and political reversal, the SUS (created in 1988) had not been able to achieve its egalitarian and universal objectives, basically due to the lack of public investment and the absence of regulation of the private health sector. This situation led to an increase in private spending, not only among the rich and the middle classes but also among workers and civil servants, individually or through collective contracts. Likewise, in Argentina, a near-universal health system was seriously de-financed during the Menem administration (in the nineties) and since the downturn of the commodity boom, in the mid-2010s. This evolution resulted in greater inequalities between the different schemes that exist in these two countries: in Brazil amid the private health and the SUS, as well as regionally, in Argentina among the *Obras Sociales*, and between them and public health.

The health regimes of countries following international subcontracting and liberal rentier capitalisms underwent less dramatic modifications during the last years of the second decade of the century; on the one hand, because most of these systems are not as developed and, on the other, because the design of social protection policies in these economies has been mainly limited to assistance; most of these countries have simply extended basic, limited health services. However, there are important exceptions to this trend. On the one hand, Chile, a pioneer country in social policies in the twentieth century, has succeeded in re-building an almost universal health structure and in regulating its (previously unregulated) private health sector. Nonetheless, only a small percentage of the population can afford the latter (17 %) and the public sector is much less generously funded. On the other hand, Colombia has almost succeeded in covering the entire population in a mandatory contributory public service, by subsidizing the inclusion of its poorer population. Mexico with a similar model (the *Seguro Popular*, until 2020) continuously left around 20 % of its population without coverage owing to its voluntary and un-subsidized affiliation for all but the very poor population. Except for Chile, most of these countries regulate private health services very poorly.

The pandemic the world is currently undergoing has strained all the health systems of the continent; an exceptional situation that allows us to compare their performance and resilience. Some countries have weathered the crisis better than others. This resulted, in part, from the condition of the health services themselves, but also from the approach that different governments adopted to deal with the epidemic: some governments initially denied the severity of the disease (Brazil, Mexico), some that continue to do so (Brazil), others reacted late (Ecuador, Bolivia), while still others did everything they could to face the crisis from the very start (or even before, as soon as the pandemic hit the European countries), like Costa Rica, Uruguay, and Argentina.

In this article, we will analyze three aspects: 1. The specific trajectories of the different health systems, and more particularly the changes they underwent since the beginning of the commodity boom and the arrival to power of redistributive coalitions in certain
countries; 2. The specific characteristics of the different health organizations in terms
of coverage, structure, investment, infrastructure, and historical performance; and 3.
The performance of the various health regimes during the pandemic.

02. The Trajectories of the Health Systems

7

In Figure 1, we can see the differences between the social protection systems of two
blocks of countries: Argentina, Brazil, and Uruguay, and the rest. They coincide with
what Carmelo Mesa Lago considered as the pioneer countries which adopted social
protection before the Second World War (Uruguay, Argentina, Chile, Cuba, and Brazil;
one must add Costa Rica which developed after the war but caught up with this group)
and those that came afterward. The countries of the first group implemented
retirement programs since the 1920s and 1930s, and like other pioneering countries in
Europe, originally “... protected the best organized occupational groups [...] so they
evolved in a fragmented way, [...] leading to deep stratification [...] These systems “...
gradually incorporated larger groups [...] reaching [at their highest level] 70 % or more,
[becoming] virtually universal if non-contributory programs for the poor are taken into
account.“ In the second group of countries (Bolivia, Colombia, Costa Rica, Ecuador,
Mexico, Panama, Paraguay, Peru, and Venezuela), social protection programs were
implemented after World War II. “In these countries, there was a central institution in
charge of covering the whole population, but at the beginning, its action was limited to
the capital and the big cities, [...] the coverage ... [reached its highest point, between] 13
and 60 %. Specific programs protected the most powerful groups [...] [although] fewer
special funds were created than in the pioneer countries, so the degree of stratification
was lesser. ”(Mesa Lago, 1994: 17). Although this description refers to retirement
programs, it coincides with that for the health regimes, “... in 1990 the six countries in
the first group had almost universal health coverage, ranging from 74 % to 96 %, the
middle group had coverage between 16 % and 58 %, the third one, had coverage of less
than 20 %.”(Mesa Lago, 2008: 7)
<figure><img src="image_4.png" /><figcaption>FIGURE 1. GOVERNMENTAL SOCIAL SPENDING (% GDP)</figcaption></figure>

Source: Based on CEPALSTAT.

8 In figure 2 we can see that health spending follows the same trend. There is, however, one exception: Chile, which underwent a strong wave of privatization during the dictatorship, recently joined the group of countries that spend most. But, while the amount spent may be equivalent, there are important differences regarding the source of spending: government, private, or families, whether public health is managed by the state or by civil society organizations (unions or mutualists), and finally, the coverage of each of the subsystems.

<figure><img src="image_5.png" /><figcaption>FIGURE 2. TOTAL CURRENT EXPENDITURE ON HEALTH (% GDP)</figcaption></figure>

Source: Based on World Bank Open Data.

To begin with, it is useful to analyze both the coverage of each health subsystem, as well as the characteristics of the dominant one. In figure 3, we can see that the three so-called pioneer countries are, again, those which cover almost the entire population.
Nevertheless, there are significant differences regarding the structure of each system. There are countries with a majoritarian state-supported public scheme: Brazil, Chile, and Costa Rica. In others, such as Uruguay and Argentina, health services are based on contributions that are managed by civil society.

There are obvious exceptions: on the one hand, two countries: Costa Rica and Colombia have almost achieved universal coverage. As previously mentioned, Costa Rica joined the leading pack following the reforms undertaken after the 1940s. Colombia's universal coverage is based both on a contributory and a subsidized health structure administered by the State, which is, nevertheless, much less generous than that of the other countries mentioned. On the other hand, Chile also seems to have succeeded in covering the whole of its population with a public scheme, despite the importance of the private sector. We will see further on that, although Chile spends as much per capita as Uruguay, and more than Brazil and Argentina, these expenditures are largely private. This is also the case in Brazil, despite the existence of a public service sector (the SUS) with universal coverage.

It is obvious it is not enough to consider only expenditure, but that it is necessary to analyze their structure and specific characteristics. It will become evident that coverage universality can be achieved through different combinations of public, social, and private services. We will discuss how these combinations, and especially their hierarchy, determine the character of the regime: whether it is predominantly state, social, market, or familiarist. We will look first, however briefly, at their historical trajectory.

The so-called pioneer countries continue to have higher health coverage, as can be seen in Figure 3, even though their systems have followed different trajectories and although coverage is gained by different combinations of the State, social organizations, and the private sector. Two of the countries (Argentina and Uruguay) have preserved a regime dominated by social organizations (unions and mutualists) while developing a state sub-system to cover those that are not included in a contributive scheme. Only one country, Costa Rica, has succeeded in approaching the pioneer countries, with a single, state-run, centralized health model. With the 1988 Constitution, Brazil moved away from its corporatist/segmented trajectory and, like Costa Rica, founded a centralized public structure (the SUS), destined to become the Brazilian NHS, but which over the years has left more and more room for the private sector. Finally, even if in Chile the military dictatorship imposed a health scheme dominated by the private sector since the democratic transition it has developed its public service and subjected private health to increasingly strict regulation.
<figure><img src="image_6.png" /><figcaption>Figure 3. Health coverage by societal order.</figcaption></figure>

Source: Argentina, Dirección General de Estadística y Censos del Gobierno de la Ciudad de Buenos Aires; Bolivia, (Jardín et. al., 2019); Brazil, (Tikkanen et. al., 2020); Chile, (International Trade Administration, 2021); Colombia, Ministerio de Salud y Protección Social - República de Colombia; Costa Rica, (Arce Ramírez, 2020); Ecuador, Instituto Nacional de Estadística y Censos; México, Instituto Nacional de Estadística, Geografía e Informática; Perú, (Mezones-Holguín et. al., 2019); Uruguay, Ministerio de Salud Pública.

As a result, different types of health regimes have emerged in Latin America that cannot be analyzed with the usual typologies developed to describe the central countries and those that have been constructed in the continent using this scheme. This, in the first place, is because the latter health systems are more hybrid, a mixture between different types. Then, and above all, due to the greater role of the family and the existence of a private sector (including insurance companies, clinics and hospitals, pharmacies, and pharmaceutical companies) that is very loosely regulated, even in countries where the public structure is dominant, as in Brazil. To build a typology that better reflects the situation of the continent, we will base ourselves on what was pointed out by Karl Polanyi and developed by Bruno Théret with regards to the relationship between the four dimensions that constitute the socio-economic life of modern societies: The State, the social actors, the market and the family (Polanyi, 1944; Théret, 2011).

12

We can thus distinguish (Table 1) four regimes in Latin America: one, where the State predominates (Costa Rica), another where the welfare regime is funded and managed primordially by unions or mutualists (Argentina and Uruguay), a third where it's the market that dominates, and where the state provides medical services to sectors that cannot afford private insurance and services (which may be the majority of the population; this is why it is not called no residual) (Chile), and finally, where the regime is mainly familiarist and families have to cope with health expenditure as social or public health services are very deficient (Peru, Ecuador, Bolivia). Even if some countries come closer to one of the ideal types, as in all typologies, the national situations do not coincide with any ideal type, they are all more or fewer hybrids in so far as a single principle never prevails, even if it is dominant. On the other hand, there are true hybrids where two dimensions are equally dominant, as in the case of Mexico, Brazil, and Colombia. In Mexico there is a combination of social security and State services, together with another third without coverage; in addition, out-of-pocket expenditure is 40% of the total spending in health.
<table><caption>Table 1. Typology of the Latin American Health Regimes.</caption><thead><tr><th>Type/ Societal Order Hierarchy</th><th>Statist</th><th>Socio-corporatist</th><th>Commodified</th><th>Familiarist</th></tr></thead><tbody><tr><th>State</th><td>Dominant</td><td>Complementary</td><td>Subsidiary/regulatory</td><td>Marginal/strategic sectors</td></tr><tr><th>Society</th><td>Secondary</td><td>Dominant</td><td>Marginal</td><td>Marginal</td></tr><tr><th>Market</th><td>Residual</td><td>Residual</td><td>Dominant</td><td>Complementary</td></tr><tr><th>Domestic</th><td>Dependent on coverage and efficacy</td><td>Dependent on coverage and efficacy.</td><td>Complementary</td><td>Dominant</td></tr><tr><th>Country that approaches the ideal type</th><td>Costa Rica</td><td>Argentina, Uruguay</td><td>Chile</td><td>Perú, Bolivia</td></tr></tbody></table>

Source: Own elaboration.

13 The health systems of Uruguay and Argentina, remain highly segmented, as in their beginnings: a large part of the population (56 % in Uruguay and 64 % in Argentina) is insured in a subsystem based on contributions and health benefits administered by social actors: unions in Argentina and mutualists in Uruguay. There is, in addition, a structure that is governed and provided by the State and financed thru taxes; private health being much more limited.

14 The Uruguayan scheme is the only one in Latin America that resembles a European, or Canadian, socio-democratic health care regime since the state is the sole payer and financially covers 95 % of the population (Aran and Laca, 2011). Even if health care is managed by the mutualists, the payer is the State-administered FONASA, that concentrates both taxes and contributions from employers and employees and distributes them to the various providers: both to the health services administered directly by the State (Administración de Servicios de Salud del Estado - ASSE), which covers 37 % of the most modest population, and to the Instituciones de Asistencia Médica Colectiva (IAMC), which are private non-profit organizations that provide comprehensive health care to 56 % of Uruguayans (Aran and Laca 2011; 269). The existence of a single-payer that covers most health services greatly reduces the segmentation of services. As can be seen in the following figures, in recent years, per capita health expenditure in this country has risen sharply from 687 to 1,590 dollars (Figure 4), but this mainly concerns the share of public services, since the private part of expenditure has decreased from 58 % to 27 % and out-of-pocket expenses have also considerably reduced (17 %); they are, along with those of Colombia, the lowest of the continent; the out-of-pocket expenditure of Uruguay is comparable to that of the average of the European Union countries (16.6 %). All this justifies our typifying it as a socio-corporatist system financially controlled and regulated by the State that, in addition, complements it by public services.
<figure><img src="image_7.png" /><figcaption>FIGURE 4. CURRENT HEALTH EXPENDITURE PER CAPITA. (PPP)</figcaption></figure>

Source: Based on World Bank Open Data.

<figure><img src="image_8.png" /><figcaption>FIGURE 5. PRIVATE HEALTH EXPENDITURE (% OF TOTAL)</figcaption></figure>

Source: Based on World Bank Open Data.

15

Argentina's system is equally based on civil society, although it is more segmented than that of Uruguay. The *Obras Sociales* is administered by trade unions and financed by contributions from workers and employers (8 % of their salary) in full autonomy from the State; they cover 42 % of the population. If we add the national contributory subsystem (8 %) and the provincial *Obras Sociales* (14 %); the social sector represents 64 % of the total as can be seen in figure 3 (Repetto and Potenza, 2011). The remainder, 36 %, receive care in public hospitals or through private insurance (Belló *et al* 2011). Argentina has a high level of per capita spending, which has strongly increased since the years 2000, and which comes close to that of Uruguay. All the same, in Argentina, the share of private expenditure and out-of-pocket expenditure is higher than in Uruguay, around 40 % and 25 %, respectively. During the last 20 years, Argentina has gone through two contrary processes: during the first Kirchner period, the health coverage of both the social service and the public was considerably extended, and the latter improved (Cecchini, Filgueira and Robles, 2014: 35). Since the reduction of the price of commodities, around 2012, during the Kirchner presidency, but especially during the Macri government, health expenditure decreased. As a result, private expenditure increased, reaching 38 % of the total, although out-of-pocket expenditure
remained stable (28 %); which shows that the increase has been mainly due to the acquisition of insurance plans result of the degradation of public service and that of the *Obras Sociales*.

<figure><img src="image_9.png" /><figcaption>FIGURE 6. OUT-OF-POCKET EXPENDITURE (% DU TOTAL)</figcaption></figure>

Source: Based on World Bank Open Data.

16

Costa Rica comes nearest to a State health regime, as it has a centralized and unified state health structure. Since 1973 all the different public infrastructures and financial resources were transferred to the Social Security Fund (CCSS). Unlike Brazil and other State systems like the NHS, the CCSS is not funded primarily by taxes, but by contributions from employers and workers (Saenz et al, 2011). On the other hand, individuals in non-formal employment have the obligation of joining this fund, their contributions being paid by the State. Finally, the self-employed can join voluntarily (Santos Basso, 2005: 192). In 1998, the hospital “de-concentration law” brought about a transformation in the way of allocating resources to health establishments: from one based on the historical trajectory to an allocation according to the future needs calculated upon the established agreements (Martínez Franzoni and Sánchez-Ancochea, 2016: 170). This law also stimulated the duplication of doctors, in addition to spending on advisers and corruption, fiscal and administrative autonomy that was not accompanied by effective coordination (Ibid., 163-164). This has resulted in a decreased quality of the services, the retreat of users from the public sector, and the reinforcement of the private sector; all of which pose a challenge to the universalist institutional architecture of health protection in this country. (Ibid, 2016: 167-170). For example, while in 2003, 36 % of Costa Ricans felt that hospitals had not been modernized, in 2007 this percentage had risen to 74 %. (Poltronieri, 2011). On the other hand, in contrast with the countries which profited from the commodity boom, the international subcontracting economy of Costa Rica grew less quickly and encountered financial problems which contributed to the erosion of this integrated and efficient structure and the expansion of private care. Despite all this, the entire Costa Rican population can access medical care (Cercone and Pacheco Jiménez, 2008), and private services have not become dominant. Costa Rica has some of the lowest private (25 %) and out-of-pocket expenses (16 %) of the continent, similar to those of Uruguay.
17 Universal and State-led coverage of health services in Brazil was enshrined in the 1988 Constitution; the result of a democratization process involving a very intense mobilization of civil society organizations and movements, among them the “sanitaristas” who promoted a very advanced public health project for the continent. The SUS (Sistema Único de Saúde) is a universal, unified health system, modeled on the British NHS, and financed by taxes and contributions from the three federal levels: the federation, the states, and the municipalities. Formally, it covers the entire population and includes all diseases and ailments (in contrast to the former Mexican Seguro Popular and the Chilean FONASA, which define a list of diseases and acts), and has aimed to equalize access care, although it has not achieved to do so, as we will see below. (Becerril-Montekio et al., 2011a). In addition, the SUS does not charge any copayments, can direct patients to private hospitals or clinics, and is monitored by more than 5,000 municipal health councils, in which more than 100,000 citizens participate (ibid.).

18 Nevertheless, it is noteworthy that although the expenditure per capita has increased considerably in the last 30 years, both private expenditure and out-of-pocket expenditure have grown even faster, reaching the huge figure of 60 % of the total for the first, and 27 % for the second. The reason for the expansion of the latter is linked to problems inherent to the SUS: quality of services and waiting times (Becerril-Montekio et al., 2011a). Although the Brazilian system was set to be more homogeneous compared to segmented schemes, as it is based on a universal State structure, the fact that the share of private participation is so high, unlike the cases of Uruguay and Argentina, for example, explains an increased segmentation among private/state lines. After 20 years of existence of the SUS, public health care facilities grew from 22,000 in 1981 to 75,000 in 2009, and hospital beds in the public sector increased from 22 to 35 percent of the total; nevertheless in 2013 50 % of hospital beds were still private (Gragnolati, et al. 2013: 2-3) More recent data, for 2015, place the percentage of public hospital beds at 70 % (commonwealthfund.org). The study of Gragnolati found that the main source of health care in Brazil in 2008 was around 55 % in the US, around 27 % in private health insurance, and 18 % in out-of-pocket. While primary health care was practically all SUS, dentistry was less than 30 % in SUS facilities, 20 % in private insurance, and 50 % out-of-pocket. Finally, hospital admissions were 75 % SUS, 20 % private insurance, and 5 % out-of-pocket (Ibid.: 59). Data for 2015 considers that while 75 percent of Brazilian citizens rely solely on SUS, 23 percent had private medical/ hospital insurance (commonwealthfund.org.).

19 In the last 10 years, the share of private health care plans charging copayments has grown from 22 percent to 52 percent. In 2015, there were 6,154 general and specialized hospitals in Brazil, with 443,257 beds. Of these, 38 percent were public and 62 percent private. Among the public hospitals, 4 percent were federal, 25 percent were state-owned, and 70 percent were municipal. Amid private hospitals, 38 percent were nonprofit and 63 percent were for-profit. (commonwealthfund.org)

20 A study, based on a poll comparing Brazil with Colombia, displays the same trends. With regards to the type of services used: 74 % of those interviewed used the SUS exclusively, while 19.4 % attended private centers; people who used both were 6.6 %. In the case of the primary services, 80 % attended the public ones, while 18.7 % used the private ones. Concerning specialized attention, the percentage using public facilities
went down to 63 %. Finally, in the case of emergencies, the percentage rises to 87.4 % for public and 11.5 % for private. (García Subirats, 2014: 482)

21

This process of “privatization” began in the 1990s. Workers with stable purchasing power and the middle classes gradually abandoned the SUS to buy private insurance, either individually (the middle classes), or collectively, through union negotiations in large companies (Werneck, V. and M.L. Teixeira, 1997). 70 % of the Brazilians that have private insurance get it as an employment benefit (commonwealthfund.org); this is why these authors affirmed that Brazil was undergoing a process of ”Americanization”. This process, as we know, greatly affects the quality of public health services as the population with the best salaries abandons it. In addition, a relatively significant proportion of the new middle classes that emerged during the commodities boom also acquired some sort of private health insurance. While Brazil has a system that is, in principle, State-run, it risks to increasingly resemble that of Chile, which we have defined as a market-dominated one.

22

With the creation of the *Sistema General de Seguridad Social en Salud* (SGSSS) in 1993, the Colombian health system has become a public compulsory scheme based on contributions from employees and employers of the formal sectors of the economy (to which resources of direct taxes are added) and a subsidized subsystem based on individual contributions and public subsidies for the sectors of the population working informally or lacking sufficient resources. The SGSSS compels individuals to enroll in the *Entidades Promotoras de Salud* (EPS), which administer contributions and offer a defined health plan, delivered by either public or private health institutions (IPS). In this way, almost 100 % of Colombians are covered by 968 public and 4,565 private health institutes (EPS) (Bernal and Barbosa, 2015: 434).

23

The State concentrates the contributions of the workers (12.5 % of their income), those of the companies and of the State itself in the *Fondo de Solidaridad y Garantía*; 42.8 % of the total corresponding to the contributory scheme and 48.5 % to the subsidized (Guerrero et al., 2011: 150); and has thus, in fact, become the single payer. The only sector which is excluded from this scheme is that of 4.9 % of the population which has its services: teachers, army, police, public universities, and oil workers. In addition, it excludes some treatments and illnesses, and the health institutions charge user fees (Bernal and Barbosa, 2015: 43-5). A relatively recent study, based on a poll, that compares Brazil with Colombia, shows the weight of the public structure in allocating health services in the latter: 92.2 % of those interviewed used only the public SGSSS and only 5.6 % the private services, while the rest used both. More specifically, for primary health, 93.3 % of Colombians attended public services procedures and 5 % the private. In the case of specialized attention, the trend is similar, as 93.5 % attended public health centers. Finally, in the case of emergencies, they did so in 95 % in the public sector. (García Subirats et al., 2014: 482)

24

Nonetheless, the Colombian system suffers from inequalities between the population covered by the subsidized services and those covered by the contributory services, which have to do with the differences between the benefit packages and their level of funding (Garcia-Subirats et al., 2014). In addition, the EPSs of the subsidized sector send their affiliates to public health providers, while those of the contributive scheme send their patients to private providers; nevertheless, the law obliges the private EPSs to provide services to at least 60 % of public patients. There are also significant differences between what each EPS covers, although there is a minimum defined by the
mandatory health plan (Bernal and Barbosa, 2015 and Guerrero et al., 2011). In 2008, the law was amended to standardize both subsystems and prohibit private providers from refusing health care to patients coming from the public sector.

25

Nevertheless, although Colombia has an almost unified structure and private health and out-of-pocket spending are also among the lowest (17%), when it comes to per capita spending it is in the bottom tier. This situation has as its consequence, as will be seen in part II of this article, a significant lack of health infrastructure and one of the lowest historical performances, comparable to those of Peru, Bolivia, and Ecuador, that we have designated (following Martinez Franzoni) as familiarist.

26

It is well known that the Chilean military government undertook the most radical privatization experiment on the continent. It privatized pensions, moving from “pay as you go” to one based on individual capitalization; it similarly gave increasing leeway to private education and health. The military government replaced a unified health system, the *Sistema Nacional de Salud*, with a decentralized public service that covers the population that does not have private insurance or that has been expelled from it because of being too ill or not being able to pay co-payments. The project was that private insurance would become majoritarian, but this never happened, as it is too expensive for the majority of Chileans. The private ISAPRES cover 17.5% of the population (Becerril-Montekio et al., 2011b), mainly the middle and upper classes (Draibe, 1997: 224). Both sectors receive resources from the FONASA, a fund that collects contributions from formal workers in the private and public sectors, as well as those who contribute independently; obviously, the private sector is also paid for directly by its affiliates.

27

Post-democratic transition governments, especially those of Lagos and Bachelet, assumed changes to diminish the most unfair aspects of the system, although they did not change it in substance. They extended the coverage of the public services and imposed regulations on the private ISAPRES (Mesa-Lago, 2009: 13). In 2008, the Bachelet government introduced compulsory membership for all workers. It also imposed the so-called *Plan de Acceso Universal a Garantías Explícitas* (AUGE), which defines the services that both public and private health services must include; it began with 40 in 2008 and gradually increased to reach 80 by the end of 2017. It also imposed a limit on co-payments; they should not exceed 20% of the total hospitalization costs (Robles Farías, 2013: 28; Becerril Montekio et al., 2011b; Cecchini, Filgueira and Robles, 2014). It is a fact that the last three socialist governments have, on the one hand, introduced measures to regulate the private health sector, and on the other, have considerably strengthened public care. Notwithstanding, after all, we consider the Chilean a market-dominated regime, even though the ISAPRES are not the majority because they determine its character. Public services cover individuals who cannot be integrated by private insurance, who are too old to be insured, or who are too sick and are kicked out of it. The State is thus, in effect, subsidiary to the market; in fact, private spending accounts for half of the total, although the sector covers only 17% of the population. A large portion of these expenses is out-of-pocket, which means that Chileans not only pay for private insurance but spend on co-payments and other costs not covered by their insurance. This makes Chile the most US-like health system in the continent, a highly commodified regime.

28

Finally, the rest of the Latin American schemes considered in this article, those of Mexico, Peru, Ecuador, and Bolivia, have simply extended the previously existing
focused policies to provide minimal health services to the uncovered population. And in fact, they have left behind a large number of people without protection, as can be seen in Figure 3. The health structures in these countries depend very heavily on private spending: around 50% for Mexico and Ecuador; in addition, in these two countries, a large proportion of expenses are “out of pocket”, around 40%. In Peru, private spending is somewhat lower, around 40%, and out-of-pocket expenses are 30%. Bolivia is the country with the highest proportion of the uncovered population.

29

We have called the systems of Peru, Bolivia, and Ecuador, familiarist because a large part of the population is without coverage, and individuals and families have to face a large number of private expenses which are not due to payments to private insurance, but to out-of-pocket expenses. Private insurance coverage is, even in a hybrid system as the one of Mexico, quite limited, around 7% of the population, while in countries where this type of insurance is considerable, it is around 17% for Chile and 25% for Brazil. The familiarist character is defined by the fact that the major source of health expenditure comes from families and is paid directly to doctors and private clinics, or the purchase of medicines, as very often these are neither provided by the social security sector, nor by the public institutions.

30

The Mexican system is a hybrid between a social security scheme (IMSS and ISSSTE), a public health sector (Secretaría de Salud/INSABI), and a private sector that serves both the richest segment of the population, but also the poor and the middle classes that have to recur to it due to the deficiencies of the other two. The two major contributory sectors: the IMSS (private workers) and the ISSSTE (civil servants) are overburdened and underfunded. The public sector, under the direction of the Ministry of Health, which provides services to the informal population (about 50% of the population), has the same shortcomings but aggravated due to the proportion of the population that it covers. This situation has meant that the subsystem of the Ministry of Health deals, in effect, only with accidents and serious illnesses. In the early 2000s, this third pillar was integrated into the *Seguro Popular*, a contributory program, that included the population that the two social security services did not incorporate. The state-financed the contributions for the population of the poorest three deciles, while the rest of the population had to pay relatively small contributions; this was the reason why it did not achieve to include the totality of the population. It was believed that this form of integration would give this population a concrete and enforceable right to health in contrast to the previous situation when they had, in principle, access to this scheme but no recognized incorporation. Although this program aimed at universal coverage, it failed to attract most of the informal workers; according to the OECD, the *Seguro Popular* allowed the health structure to cover around 80% of the population. In addition, while the percentage of out-of-pocket expenditure was slightly reduced, the fact that public expenditure and infrastructure did not increase in the same proportion as the number of affiliates explains why these expenses remain the highest in the group of countries that we consider (figure 6). Finally, the current government of López Obrador replaced the Seguro Popular with a universal system, the *Instituto Nacional de Bienestar* (INSABI), barely three months before the onset of the health crisis; it is, of course, in its infancy in terms of organization and remains fundamentally underfunded, it has also abandoned its contributory principle, which gave formal rights to those included. This has added to the structural problems in dealing with the pandemic.
31

In Peru, 36 % of the population is not affiliated with any health plan. The reason why a high percentage of Peruvians do not have coverage is that the main structure, the *Sistema Integral de Salud*, is, like the extinct Mexican *Seguro Popular*, contributory and voluntary. On the other hand, if in principle all Peruvians have access to the public health services offered by the Ministry of Health (MINSA), they must pay a recovery allowance which "... is variable, and subject to the discretion of the organizations..." (Alcalde-Rabanal et al., 2011: 274). Finally, it is underfunded. Under these conditions, Peruvians prefer to go either to a private clinic or to a private doctor, rather than waiting their turn in public clinics, losing a day's work, and, in the end, having to pay for the prescriptions. This accounts for the high out-of-pocket expenses. In most countries of the continent there are pharmacies where a doctor prescribes drugs or treatment, after an "on the spot", cheap or even free consultation, when the medicines are purchased at the same dispensary.

32

Although the distributive rentier countries (Bolivia and Ecuador) sought to universalize health care through public sector expansion during the commodity boom, they did not succeed, due to the enormous costs involved; their current systems remain at levels similar to those of Mexico and Peru in terms of coverage. In Bolivia and Ecuador, there also exists a social security sector that concentrates formal workers with the best wage and working conditions and a small private sector that protects the middle and upper classes.

33

The case of Bolivia is interesting because the Constitution of this country includes all the Bolivian population in the services of the Ministry of Health and Sports, and it has, since 2003, a redistributive social policy that significantly expanded this public structure. Public spending as a proportion of GDP has been increasing steadily since the mid-1990s and exceeds that of Peru and Mexico in terms of per capita expenditure. The social security sector consists of eight health funds and two mixed funds that cover formal workers and their families (Ledo and Soria 2011: 112). The current public health insurance came about from the expansion of the *Seguro Universal Materno Infantil* (SUMI) implemented in 2003, that intended to include all children under 5 and all women of childbearing age, and covers around 41 % of the population (Ledo and Soria 2011: 112). There is also a voluntary social security subsystem that the self-employed can join but, as in the case of Mexico, Peru, and Ecuador, leaves many of them uninsured. As a result, according to data available for 2013, 60 % of Bolivians did not have health insurance.

34

Finally, Ecuador is not too different from Bolivia. Since the reform of the Constitution of 1998, health was defined as a right, in 2006 the government created the universal health insurance scheme and increased taxes on foreign oil companies, raising the royalty on profits from 50 to 90, (Conaghan, 2011), to increase social programs significantly from 2007 to 2018; this country spends more on health relative to GDP than Mexico, Peru, and even Costa Rica and Colombia. Nonetheless, the goal of universal coverage has not been achieved, since it protects a little less than half of the Ecuadorians. What has increased the most in this country is private spending and especially out-of-pocket spending.

## 03. The Health Regimes in the Face of the Pandemic

35

The health crisis that hit the world in December 2019, and Latin America head-on in March 2020, has been a terrible health tragedy that has claimed millions of lives. It is
also an opportunity to measure the performance of the various health regimes of the continent. Although the number of contagions would be an excellent indicator of the country's ability to control the epidemic, the fact that this indicator depends on the number of tests that each country does, and that there are significant differences in this respect, makes it unreliable. The number of deaths that each country records is equally untrustworthy, as countries differ in the way and efficacy of (voluntary or unintentionally) counting deceases. The number of deaths in excess from the last year compared to that of previous years is thus the most reliable indicator.

36

To be able to assess the causes of the divergences among countries, we will refer both to the qualitative characteristics of the health systems, analyzed in the first part of this article, as to quantitative indicators and then, briefly, to the political responses of the government.

37

In table 2 as well as in the following figure (we have assessed the situation of the different countries regarding health infrastructure, as well as the performance of the different health systems, before the pandemic. In terms of infrastructure, the pioneer countries Uruguay, Argentina, Chile, Brazil, and Costa Rica, were the best endowed, without too many dissimilarities, although, as we have seen, these five countries have three different types of regime. On the other hand, in terms of performance, two high-performing countries (Brazil and Argentina) are below average.

<table><caption>Table 2. Infrastructure, performance and excess deaths</caption><thead><tr><th></th><th>Infrastructure index</th><th>performance index</th><th>Excess deaths by 100,000 inhabitants</th><th></th><th></th><th></th><th></th></tr></thead><tbody><tr><td>ARG</td><td>72.59</td><td>79.4</td><td>254</td><td></td><td></td><td></td><td></td></tr><tr><td>BOL</td><td>22.87</td><td>44.49</td><td>416</td><td>Correlations</td><td></td><td></td><td></td></tr><tr><td>BRA</td><td>58</td><td>76.34</td><td>355</td><td></td><td></td><td></td><td></td></tr><tr><td>CHI</td><td>42.42</td><td>87.65</td><td>231</td><td>Infrastructure</td><td>1</td><td>0.62</td><td>-0.5</td></tr><tr><td>COL</td><td>39.93</td><td>74.73</td><td>326</td><td>performance</td><td>0.62</td><td>1</td><td>-0.5</td></tr><tr><td>COS</td><td>42.13</td><td>84.54</td><td>129</td><td>deaths</td><td>-0.504</td><td>-0.5</td><td>1</td></tr><tr><td>ECU</td><td>33.33</td><td>67.21</td><td>435</td><td></td><td></td><td></td><td></td></tr><tr><td>MEX</td><td>39.39</td><td>78.19</td><td>479</td><td></td><td></td><td></td><td></td></tr><tr><td>PER</td><td>31.38</td><td>70.08</td><td>707</td><td></td><td></td><td></td><td></td></tr><tr><td>URU</td><td>67.98</td><td>85.25</td><td>174</td><td></td><td></td><td></td><td></td></tr></tbody></table>

Source: See Annex at the end of the article.
<figure><img src="image_10.png" /><figcaption>**Figure 7. Excess Deaths (size of the circles) according to infrastructure and performance**</figcaption></figure>

38

In general terms, the pandemic has been a humanitarian disaster of great proportions except in a few countries: Uruguay and Costa Rica. We have divided our countries into three groups: Peru, Ecuador, Bolivia, and Mexico have had (more recent data is for October 2021) more than 400 deaths per 100,000 inhabitants. An intermediate group was formed by Brazil, Argentina, Colombia, and Chile, with several deaths between 200 and 355. And two countries that have had the lowest rates: Costa Rica and Uruguay, which had less than 200 deaths per 100,000 inhabitants.

39

The correlation between infrastructure, performance, and the number of deaths is very significant. We can see that the two countries which stand out in terms of infrastructure and performance are also those which had the fewest deaths during the pandemic. On the opposite situation, the countries with the least infrastructure and the lowest performance are those that have had the most deaths: Bolivia, Ecuador, Peru, and Mexico.

40

We have already mentioned how the two countries that stand out from the rest: Costa Rica and Uruguay, have the most solid health structures, even if they are very different in character and structure: one is a state governed scheme, the other is socio-corporatist. In addition, it is also interesting that Costa Rica, with less infrastructure, achieves similar performance to Uruguay; something which could be the result of less segmentation when compared with the latter. They are indeed small countries, but, Bolivia and Ecuador are also relatively small, and perform very badly.

41

The very poor performance of the three countries that we have named familiarist: Peru, Bolivia, and Ecuador, as well as Mexico where, although it cannot be strictly considered as this type of regime because there is a large social security and public health subsector, family expenditures in health are the highest in our sample (40 % of total health expenditure are out-of-pocket), corresponds, in the first place, with the fact that a considerable part of the population is without coverage and that total health expenditure, is low (both out-of-pocket and total health expenditure are closely related to excess deaths during the pandemic as we can see in figure 9 and 11).
42

The circumstance that families depend on their means, entails that they are quite helpless facing health problems and more understandably of a pandemic like the one we are now undergoing. The fact that health depends so heavily on out-of-pocket expenses means that people hesitate before going to the doctor or the hospital, and do so only when their condition worsens; in the case of the coronavirus, this has resulted that many of the sick approached the clinics once it was too late when they were seriously ill, or that they died at home. We have learned that for Covid, the delay in the start of treatment before the autoimmune shock begins and the individual lacks oxygen is fundamental in deciding a cure or an aggravation that can lead to death, either in the hospital during a late arrival, or at home. In almost all the countries of the continent, we have seen the emergency purchases of oxygen tanks, which testifies to the fact that many patients tried, in the first place, to get by at home, and only when they were very serious they start looking for a hospital. In some countries, most notably in Mexico, almost half of the Covid related deaths occurred at home. In fact, between 40 % and 50 % of Mexican Covid patients that were interned in any of the public hospital subsystems have died, while in the private sector the percentage is around 20 % (Sánchez-Talanquer et al., 2020: 28). This does not only show that care provided in public hospitals is deficient but also, at least partially, that many patients arrived once they were too sick.

43

While the extreme cases can be quite clearly explained, the situation of Argentina, Chile, Brazil, and Colombia require further analysis. The answer of why these systems did not fare as well as one could have expected looking at our indexes of infrastructure and past performance that are similar to those countries that fared better, has to do with recent trends in terms of public investment in health, but especially with their structure (basically its dependence on out-of-pocket expenditure and the sources of inequality).

44

Argentina, a country with an infrastructure and a performance of health services (before the pandemic) among the highest in the continent, has not been performing as would correspond to this situation. While Uruguay and Argentina are very similar in terms of infrastructure and performance, as well as in terms of health expenditure as a percentage of GDP, and the number of doctors, it has not performed as well in the face of the pandemic. We have mentioned how, especially during the Macri government (Dec. 2015- Dec. 2019), the social and public health structures deteriorated due to the reduction of public investment; this can be seen in figure 2 and 4, but especially in the figures that indicate an increase in private health expenditure, that went from a historical low in 2015 (35 %) to around 40 % in 2018, although out-of-pocket expenses remained stable. Nonetheless, if one compares the out-of-pocket expenditure of Argentina with the other countries, it is in mid-range, together with Brazil, Bolivia, and Peru. We can see in Table 3 that there is a very strong correlation between the level of total expenditure on health (-071), the government expenditure as a percentage of GDP (-0.77), and out-of-pocket expenditure (0.44) with deaths during the pandemic; negative in the first two cases, and positive in the third. So, the fact that public health expenditure was reduced, in the first place, and that out-of-pocket in this country is higher than in the other countries which are similar in terms of infrastructure and performance may explain part of the situation.

45

Another part of the explanation is the structure of the Argentinian health system. But structure may mean many things. In the first place, its most basic and obvious meaning
is the difference between having or not having health coverage, something that determines how frequently people consult a doctor (Ballesteros, 2014). Most of the articles we have consulted consider that the main factor that explains inequality in Latin America is income level, as most schemes have a pro-rich and pro-educated (both coincide most of the time)¹. Nonetheless, this fact does not allow us to distinguish between the Latin American countries as they all fall in the same situation.

<table><caption>Table 3. Correlations with Excess mortality</caption><thead><tr><th>Variable</th><th>Correlation with Excess deaths per 100,000 inhabitants</th></tr></thead><tbody><tr><td>Number of beds per thousand inhabitants.</td><td>-0.31</td></tr><tr><td>Average number of intensive care beds per hundred thousand inhabitants.</td><td>-0.42</td></tr><tr><td>Number of doctors per thousand inhabitants</td><td>-0.71</td></tr><tr><td>Number of nurses per thousand inhabitants</td><td>-0.14</td></tr><tr><td>Ventilators per hundred thousand inhabitants</td><td>-0.29</td></tr><tr><td>Total expenditure on health per capita, PPP</td><td>-0.69</td></tr><tr><td>Total expenditure on health as a % of GDP</td><td>-0.71</td></tr><tr><td>Private expenditure on health as % of total health expenditure</td><td>0.28</td></tr><tr><td>Government expenditure on health as % of total health expenditure</td><td>-0.27</td></tr><tr><td>Government expenditure on health as % of gross domestic product (GDP).</td><td>-0.77</td></tr><tr><td>Out-of-pocket expenditure 2017</td><td>0.44</td></tr><tr><td>GDP growth 2020</td><td>-0.80</td></tr><tr><td>Percentage of GDP spent on trying to mitigate the economic effect of the pandemic</td><td>0.47</td></tr></tbody></table>

Source: See annex at the end of the article.

46

As we have explained, the Argentinian health system is highly segmented, based on the *Obras Sociales* on the one hand, and a public sector, on the other. This segmentation is the source of inequalities both in funding and in quality of services, first amid the various *Obras Sociales* managed by the unions, and among them and the public and private sector. Some of the *Obras Sociales* fare better than others, and these are superior, in general, to the public services. On the other hand, there are important regional differences: between the capital and the suburbs of Buenos Aires (the *conurbado*), as well as between the capital and the provinces (Palacios et al., 2020). Financial and infrastructure resources are highly concentrated in Buenos Aires, Cordoba, and Rosario. For example, in the capital, there are 10.2 doctors and 7.3 beds per 1,000 inhabitants, while in the province of Misiones there are 1.2 and 1.1 respectively. This explains why the capital had a much better performance (around 30% fewer deaths) than the *conurbado*; while the number of beds is not as strongly correlated with the prevention of deaths (-0.31 for regular beds, -0.42 for intensive care beds), several doctors are highly correlated (-0.71). Another study that also signals geographic inequality centers on cervical cancer considered “... a disease symbolic of health inequality; primarily a cancer of the poor, socially vulnerable women, even though there are simple and relatively low-cost means of preventing it” (Arrossi et al., 2008: 50). This study found that in addition to the rich/educated/labor active/ bias, there was a geographic one, as the mortality rate in the province of Jujuy is almost four times higher than that of the province of Buenos Aires (Ibíd.). Women from the
Northwest and Northeast regions (the least developed areas of the country) were almost three times more likely to be under users of pap screening [...] have the country's highest cervical cancer mortality". (Ibid.: 56).

47

Brazil, with a comparatively fairly well-equipped and efficient health system (Table 2), also displayed poor performance in the face of the health crisis. On the one hand, it has a significant shortage of doctors akin to that of the familiarist regimes, even if other infrastructure factors are high (figure 8). Given the strong correlation between the number of doctors and deaths, this may be part of the explanation. A complementary elucidation is the low level of public expenditure and, therefore, a large proportion of private expenditure, especially out-of-pocket; Brazil is, among the countries with the highest level of infrastructure and performance, the one with the utmost out-of-pocket expenditure: around 27 % (Figure 6). Although the studies we consulted coincided with the fact that, like in Argentina, there are significant differences between health access between the rural and urban areas, and between poorer regions of the country (North and Northeast), and that these characteristics reinforce each other (Figueireido 2018), some other studies stress the fact that one of the main sources of inequality lies between those who are privately insured (25 % of the population) and those who rely only on the SUS (Capelas Barbosa and Cookson, 2019; García-Subirats et al., 2014). So, while in Argentina, the less effective management of the crisis (compared with Uruguay and Costa Rica) was probably partly due to the segmentation of the health system and especially (as Uruguay is also a segmented health scheme) the rural /urban and regional inequalities (that coincide with levels of income), in Brazil, in addition to these same rural/urban and regional differences, the SUS has been sapped by private insurance (Barbosa and Cookson, op. cit.).

<figure><img src="image_11.png" /><figcaption>Figure 8. Number of Doctors per 1000 inhabitants vs. excess deaths</figcaption></figure>

Source: See annex.

48

But it is quite probable that another crucial factor to explain the ruinous management of the health crisis is the total irresponsibility of the federal government headed by president Bolsonaro, who never took the health crisis seriously, was against the use of
masks and vaccines, and made coordination at the national level inoperative (in a
manner that is comparable to that which occurred in the United States under Trump);
nonetheless, the governments of some states, like Sao Paulo and Rio, have managed to
cope better. While a federal structure that operates effectively (Canada and Germany)
has worked better than many centralized countries (England, France), federal
structures where there is no coordination between the federation and the federal
states, have shown a very poor performance (the United States and Brazil).

49

Chile is another case that deserves to be discussed at greater length. It is a system that has been reformed by social democratic governments over the past 20 years and has succeeded in achieving universal coverage. It has a health infrastructure that is on par for the continent, but the top in our performance index. It also has one of the highest levels of total expenditure concerning GDP (Figure 2) and the highest per capita expenditure (with Uruguay) (figure 4). The reasons why this country failed to measure up to our benchmark countries during the pandemic seem to be similar to those we defined for the case of Brazil. Although Chile is a centralized country that does not have the regional inequalities of Brazil, it is comparable in the high level of privacy and, especially, out-of-pocket spending (Figure 10 and 11); among the highest in the continent. These are variables that have a very strong correlation with deceases during the pandemic, that characterize the familiarist regimes which have had the worst performance. Like all other health systems in Latin America (with their differences), the Chilean is lopsided toward the wealthy, and the best predictor of health service usage is education and employment status. However, a special feature of the Chilean scheme is that it also discriminates by type of health disbursement, that is by the difference between who has private insurance (and thus also spends more on out-of-pocket in a privatized health sector, where insurance fees and co-payments are very high) and who depends only on the public health services (Nuñez and Chi, 2013; Vasquez et al., 2013). As Vasquez et al. write, “... while 79 % of the total population was in FONASA, public insurance covered a greater share (87.5 %) of the population age 65 or older. On the other hand, ISAPRES beneficiaries, who accounted for 13 % of the total population, were disproportionately rich, with 45 % belonging to the top income quintile.” This data shows that FONASA, thus the government, subsidizes the private sector. Both sectors get resources from the government (coming from the contributions of 7 % of the individual’s gross income), and any individual can be treated by the public sector although he is enrolled in an ISAPRES many use the public health sector for emergencies, hospitalizations, and intensive care treatments. And this happens either when individuals affiliated in the private sector become too sick to afford to pay the high co-payments or when they stop being able to pay the annual fee for the insurance that increases annually or once they retire. In this manner, the ISAPRES concentrate on young and healthy individuals in their productive years, while the public sector concentrates on the old and sick.
<figure><img src="image_12.png" /><figcaption>Figure 9. Total health expenditure (% GDP) vs. excess deaths</figcaption></figure>

Source: See annex.

Finally, Colombia is also an "outlier", but in a different direction as the three countries we have just discussed, it has not fared as badly as one would have expected if one considers that it has one of the lowest infrastructure and performance levels of the continent, and a relatively low total health expenditure (similar to Ecuador, Bolivia, and Peru) but has not had the number of deaths of these countries or even Mexico (Table 2 and Figure 9). This may be explained by the fact that its health system has succeeded in covering practically its entire population, something that has translated into a very low level of private and (especially) out-of-pocket spending (Figures 5, 6, 10, and 11); both are crucial variables for defining excess deaths. From the discussion on Chile and Brazil, we have learned about the effects of inequality that dependence on private health services and out-of-pocket fees entail. The latter is also the case for all countries that do not have universal coverage, that we have called familiarist, as well as Mexico; in all these cases, people hesitate for a long time to go to the doctor or hospital, because it will cost them dearly and could even lead to catastrophic expenses that could ruin them.

As we have previously discussed, the Colombian health system can be considered a single-payer regime, as the State obliges all the population to enroll in either a private or public health plan, concentrates the contributions of all workers, and subsidizes the individuals that lack sufficient resources to pay for their plan. It is however segmented between a contributive, social security sector, and a subsidized public one that allots different benefits and attends patients either in public or in private health centers. Nonetheless, in comparison with an akin structure, that of Brazil, with a parallel private sector to that of SUS, the latter suffers from very high usage of emergency services and "... a certain weakness in treating chronic diseases in primary attention [...] as compared to Colombia" (Garcia Subirats et. al. 2014). This is most probably due to long waiting periods in the case of Brazil which increases the inequality between the public and private sectors. Another study shows that the 1993 reform in Colombia

50
increased the use of preventive and curative outpatient services, a 22 % increase in the supply of drugs and, even more importantly, a 53 % reduction in out-of-pocket expenses for outpatients and 50 % for inpatients (Ruiz Gómez et al, 2013). In this way, we can risk concluding that the Colombian health system, admittedly segmented and having an income bias like the rest of Latin American ones, has had a better performance in the face of the pandemic than similar countries with respect to infrastructure and past performance, due to reduced private health expenditure and, more importantly (and with a higher correlation index), low out-of-pocket expenditure.

<figure><img src="image_13.png" /><figcaption>**Figure 10.** Private current expenditure (% total health expenditure) vs. excess deaths</figcaption></figure>

Source: See annex.
<figure><img src="image_14.png" /><figcaption>Figure 11. Out-of-pocket expenditure vs. excess deaths</figcaption></figure>

Source: See annex.

## 04. Conclusion

51 The most significant indicators (of the limited ones we have considered in this paper) to explain the number of deaths are those we expected: while the number of doctors per capita and the percentage of total health expenditure about GDP has a negative correlation, the level of private and out-of-pocket expenditures has a positive correlation. Countries with the fewest doctors and lowest public spending; Peru, Bolivia, Ecuador, and Mexico have a high number of deaths per capita, on the contrary, the countries with the most doctors and health expenditure, Costa Rica and Uruguay have had the fewest.

52 Nonetheless, we also found specificities in terms of the type of health regime, those that have shown to be the best able to fight the epidemic have been the ones of the two countries that are the most universal, regardless if they are socio-corporatist or stateled (Uruguay and Costa Rica). Although they represent different types of health regimes, both Uruguay's and Costa Rica's have coped relatively well with the health crisis. While Uruguay is segmented, as it is managed by mutualists and unions, Costa Rica has a unified state structure. It should be noted that Costa Rica had a very high performance before the crisis, and also in the face of the pandemic, with less infrastructure; this reinforces the idea that a centralized regime can spend less to be efficient.

53 The historical performance of health services based on the percentage of children vaccinated, maternal death, cancer preparedness index, etc. does not always match with infrastructure, although the correlations between the two are quite high (0.59). In fact, in a few countries, there are significant disparities, namely Chile, Mexico, and Costa Rica. Chile has a predominantly market-dominated, historically efficient health
system (index = 88), but a lower infrastructure index. Faced with the crisis, it was in the
middle group in terms of the number of deaths in the proportion of the population,
which is most probably the consequence of the lack of infrastructure (while the private
sector is very well provided, the public one is much less so) and on the fact that out-of-
pocket health expenditure is very high. Mexico has one of the worst performances in
face of the epidemic, despite a fairly high historical performance; what played a
decisive role in this case, as in the Chilean case, was the lack of infrastructure and a
very high out-of-pocket expense (the highest of all the countries considered). The fact
that health depends so heavily on out-of-pocket expenses means that people hesitate
before going to the doctor or the hospital until they are very sick.

54

Argentina, with the highest infrastructure and historical performance and lower out-of-pocket expenses, performed worse than Uruguay and Costa Rica. This can be explained on the one hand by the investment reduction in health since the crisis of the commodities, but above all by the inequities of a system that is highly segmented and that concentrates resources and infrastructure in the capital and some other big cities. Brazil also has a fairly high level of infrastructure and a high level of past performance, but that has been strongly hit by the epidemic. We can also consider that this is also the consequence of the reduction of health spending since 2015, but above all due to the inequity that exists between private and public care.

55

Colombia is another exception, its health system has one the poorest infrastructures and lowest performances in the continent in terms of our indexes; only Ecuador, Bolivia, and Peru have the weaker infrastructure and worst performance. Nevertheless, in the face of the epidemic, it has fared better than these three countries and even Mexico and Brazil. This may be explained by a health system that covers almost the entire population, a fact which results in a very low level of private expenditure, but above all of the out-of-pocket expenses; we have discussed how the latter has had very deleterious effects during the pandemic.

56

Finally, in the cases of Mexico and Brazil, we also have to account for a situation that is
difficult to quantify: the irresponsible posture of its leaders in the face of the epidemic.
The Mexican president did not take the health crisis seriously at the beginning, and
even when the situation worsened and the government began to advise social
distancing (without imposing a strict containment and providing support to the
informal or formal sectors to achieve this) it did not advise the widespread use of face
masks; in fact, the Mexican president has on very few occasions shown up in public
wearing a mask. The case of Brazilian President Bolsonaro is much worse, as he has not
only avoided advising on mask-wearing and social distancing but has sabotaged these
measures when taken by State governments, hindered the purchase of vaccines, and
boycotted vaccination (like US President Trump in his time). In fact, like most other
leaders in Latin America, they did not call for strict confinement because in the
continent the informal sector is so large that these measures would be impossible to
implement, but they clearly (at the beginning and specific moments in the case of the
Mexican president, always in the case of the Brazilian) prioritized the economy rather
than life itself; a gamble that failed as we can see in Figure 12, where the economies of
the countries with more deaths have also fallen sharply. In the case of Bolivia, Peru,
and Ecuador, rather than a populist government, the political variable that partly
explains their performance is political instability. Argentina, Chile, and Colombia
imposed harder confinement measures than other countries of the continent, which led to a deep fall of the economy, but probably saved lives.

<figure><img src="image_15.png" /><figcaption>Figure 12. GDP variation vs excess deaths</figcaption></figure>

Source: See annex and ECLAC, 2021 for GDP.

## 05. Appendix

Sources of tables 2 and 3 and of the following figures.

<table><thead><tr><th>Image</th><th>10014F0400005BF700003612020E71C04B6175C9.emf</th></tr><tr><th>Country</th><th>Excess Mortality</th><th>Excess deaths per 100,000 inhabitants</th><th>Time frame</th></tr></thead><tbody><tr><td>Argentina*</td><td>115416</td><td>254</td><td>March/20-7/Oct/21</td></tr><tr><td>Bolivia</td><td>48378</td><td>416</td><td>Jan/20 -July/21</td></tr><tr><td>Brazil</td><td>746715</td><td>355</td><td>Jan/20 - Aug/21</td></tr><tr><td>Chile</td><td>43834</td><td>231</td><td>Jan/20 - 20/Sept/21</td></tr><tr><td>Colombia</td><td>163956</td><td>326</td><td>Jan/20 - 5/July/21</td></tr><tr><td>Costa Rica**</td><td>6584</td><td>129</td><td>March/20-7/Oct/21</td></tr><tr><td>Ecuador</td><td>75559</td><td>435</td><td>Jan/20 - 20/Sept/21</td></tr><tr><td>Mexico</td><td>603507</td><td>479</td><td>Jan/20 - 30/Aug/21</td></tr><tr><td>Peru</td><td>229863</td><td>707</td><td>Jan/20-20/Sept/21</td></tr><tr><td>Uruguay***</td><td>6062</td><td>174</td><td>March/20-7/Oct/21</td></tr></tbody></table>

https://ourworldindata.org/excess-mortality-covid

*https://datosmacro.expansion.com/otros/coronavirus/argentina
\*\*https://datosmacro.expansion.com/otros/coronavirus/Costa-Rica

\*\*\*https://datosmacro.expansion.com/otros/coronavirus/Uruguay

## 5.1 The indexes

58 They are both constructed as a simple average of the percentages of the variables considered for each index. The variables that are not expressed in percentages are converted into these by a simple rule of three. The highest value for each variable is rounded up to set the 100% benchmark, and each country's percentage is then defined with respect to it.

59 The following variables are used for each of the indexes:

* **Infrastructure**: Number of beds per thousand inhabitants 2017 *; 2. Average number of intensive care beds per 100,000 inhabitants *; Number of doctors per thousand inhabitants (2017) *; Number of nurses per thousand inhabitants *; Radiotherapy units per million inhabitants (latest year available) *; Global Health Security Index 2019 **; Mechanical ventilators per hundred thousand inhabitants ***.

* **Performance**: Percentage of the population vaccinated per year *; Percentage of women examined at least four times during pregnancy *; Maternal mortality rate per 100,000 births *; Mortality in children under five per 1000 births *; Cancer Preparedness Index ****

*OECD, World Bank Group (2020), "Health at a Glance: Latinamerica and the Caribbean 2020", OECD Publishing, París, https://www.oecd-ilibrary.org/sites/6089164f-en/index.html?itemId=/content/publication/6089164f-en;

\*\*2019 Global Health Index, https://www.ghsindex.org/;

\*\*\*Global Health Intelligence (2020), "Infografía sobre el nivel de preparación de hospitales latinoamericanos ante coronavirus",

\*\*\*\*World Cancer Initiative (2020), "Preparación para el abordaje del cáncer en América Latina", https://www.iccp-portal.org/system/files/resources/PREPARACION_PARA_ABORDAJE_CANCER_AMERICA_LATINA.pdf

## BIBLIOGRAPHY

Alcade-Rabanal, J. E., O. Lazo-González, and G. Nigenda (2011). Sistema de salud de Perú, *Revista Salud Pública de México*, vol. 53, No. 2, 243-254.

Aran, Daniel and Hernán Laca (2011). Sistema de salud de Uruguay. *Revista Salud Pública de México*, 53 (2), 265-274.

Arce Ramírez, Claudio Arturo (2020), "Financiamiento y cobertura del Seguro de Salud en Costa Rica: desafíos de un modelo exitoso", *Gestión en salud y seguridad social*, vol. 1, No.1, pp. 12-20
Arrossi, Silvina, et al. (2008). Social inequality in Pap smear coverage: identifying under-users of cervical cancer screening in Argentina, *Reproductive Health Matters*, vol. 16. No. 32, pp. 50-58.

Ballesteros, Matías (2014). Un análisis sobre las desigualdades en el acceso a los servicios de salud en la población adulta urbana de Argentina a partir de datos secundarios, *Documento de Jóvenes Invetigadores* Buenos Aires: Instituto de Investigaciones Gino Germani, Facultad de Ciencias Sociales, UBA, no. 41, 109 pages.

Barba Solano, Carlos and Enrique Valencia Lomelí (2015). Diversos universalismos en las trayectorias de las políticas de salud en México y Brasil, manuscript, Universidad de Guadalajara, presented at the XXXIII international Congress of LASA.

Barbosa, Estela Capelas and Richard Cookson (2019). Multiple inequity in health care: An example from Brazil", *Social Science & Medicine*, vol. 228, pp. 1-8

Belló, Mariana and Victor M. Beccerril-Montekio (2011). Sistema de Salud de Argentina, *Revista Salud Pública de México*, Vol 53, no. 2, pp. 96-108.

Bizberg, Ilan (2019). *Diversity of Capitalisms in Latin America*, Cham, Palgrave-Macmillan, 362 pages.

Becerril-Montekio, Victor M. et al. (2011a). Sistema de salud de Brasil, *Salud Pública de México*, vol. 53, no. 2, pp. 120-131.

Becerril-Montekio, Victor M. et al (2011b). Sistema de salud de Chile, *Revista Salud Pública de México*, vol. 53, no. 2, pp. 132-143.

Bernal, Oscar and Samuel Barbosa (2015). La nueva reforma a la salud en Colombia: el derecho, el aseguramiento y el sistema de salud, *Revista Salud Pública de México*, Vo. 57, no. 5, pp. 433-440.

Boyer, Robert (2014). Is More Equality Possible in Latin America ? A Challenge in a World of Contrasted but Interdependent Inequality Regimes, *Working Paper Series*, Berlin, desigUALdades.net International Research Network on Interdependent Inequalities in Latin America.net, no. 67, 94 pages.

Cecchini Simone, Fernando Filgueira and Claudia Robles (2014). *Sistemas de protección social en América Latina y el Caribe. Una perspectiva comparada*, Santiago de Chile, CEPAL, 50 pages.

ECLAC (2021). *2020 Preliminary Overview of the Economies of Latin America and the Caribbean*, Santiago, United Nations.

Cercone, James and José Pacheco Jiménez (2008). Costa Rica: ‘Good Practice’ in Expanding Health Care Coverage – Lessons from Reforms in Low- and Middle-Income Countries, in Pablo Gottret, George J. Schieber and Hugh Waters (eds.), *Good Practices in Health Financing: Lessons from Reforms in Low- and Middle Income Countries*, Washington D.C., The World Bank

Commonwealthfund.org. https://www.commonwealthfund.org/international-health-policy-center/countries/brazil

Conaghan, Catherine (2011). Ecuador. Rafael Correa and the citizen's revolution, in Steven Levitsky and Kenneth Roberts, *The resurgence of the Latin American left*, Baltimore, The Johns Hopkins University Press, pp. 260-282.

Draibe, S. M. (1997). A política social na América latina: o que ensinam as experiências recentes de reformas ?, in Eli Diniz and Sergio de Azevedo (Eds.), *Reforma do Estado e Democracia no Brasil*. Brasília, Editora Universidade de Brasília.

Fundación de Investigaciones Económicas Latinoamericanas (FIEL) (2007). *La Desigualdad en la Salud*, Buenos Aires, Fundación de Investigaciones Económicas latinoamericanas, 94 pages.
Figueireido Santos, J.A. (2018). Classe Social, território e desigualdade de saúde no Brasil, *Saúde Soc.*, vol. 27, no.2, pp. 556-572.

Garcia-Subirats, I. et al. (2014). Determinantes del uso de distintos niveles asistenciales en el Sistema General de Seguridad Social en Salud y Sistema Único de Salud en Colombia y Brasil, *Gaceta Sanitaria*, vol. 28, No. 6, pp: 480-488.

Gragnolati, Michele, Magnus Lindelow, and Bernard Couttolenc (2013). *Twenty Years of Health System Reform in Brazil: An Assessment of the Sistema Único de Saúde*. Directions in Development, Washington DC, World Bank, 112 pages.

Guerrero, R., Gallegos, A. I., Becerril-Montekio, V., & Vásquez, J. (2011). Sistema de Salud de Colombia, *Revista Salud Pública de México*, vol. 53, no. 2, pp. 144-155.

International Trade Administration (2021), “Chile-Healthcare”, 16 January, https://www.trade.gov/knowledge-product/chile-healthcare

Jardín, Juan Pablo et. al. (2019), “Health Expenditure based on Insurance type and age prior to Implementation of universal health coverage in Bolivia”, *Gaceta Médica Boliviana*, vol. 42, No.2, pp. 194-197

Lautier, B. (2007). Les politiques sociales au Brésil durant le goouvernement de Lula: aumône d'Etat ou droits sociaux ?, *Problèmes d'Amérique latine*, vol. 63, pp. 51-76.

Ledo, C. and Soria, R. (2011). Sistema de Salud de Bolivia, *Revista Salud Pública de México*, vol. 53, no. 2, pp. 109-119.

Martínez Franzoni, Juliana and Diego Sánchez-Ancochea (2016). *The Quest for Universal Social Policy in the South: Actors, Ideas and Architectures*, Cambridge, Cambridge University Press.

Mesa-Lago, C. (1994). *Changing Social Security in Latin America. Towards alleviating the Social Costs of Economic Reform*, Boulder and London, Lynne Rienner Publishers, 213 pages.

Mesa-Lago, C. (2008). *Reassembling Social Security. A Survey of pensions and health care reforms in Latin America*, Oxford, Oxford University Press, 448 pages.

Mezones-Holguín, Edward et.al. (2019), “Cobertura de aseguramiento en salud: el caso peruano desde la ley de aseguramiento universal”, *Revista Peruana de Medicina Experimental y Salud Pública*, vol. 36, No.2, pp. 196-206

Núñez, Alicia and Chunhuei Chi (2013). Equity in Health utilization in Chile, *International Journal for Equity in Health*, vol. 12, no. 58, pp. 1-16.

Palacios, Alfredo, Natalia Espinola and Carlos Rojas-Roque (2020). “Need and inequality in the use of health care services in a fragmented and decentralized health system: evidence for Argentina”, *International Journal for Equity in Health*, vol. 19, no. 67, pp. 1-14.

Poltronieri, Jorge (2011). *Proyecto de Investigación Estructuras de la Opinión Pública, Comunicado de prensa, Encuesta de opinión pública XXIII - Panorama global*, San José, Costa Rica, CIRMA/UCR, 45 pages.

Polanyi, Karl. (1944). *The Great Transformation*. New York: Farrar & Rinehart, 360 pages.

Repetto, Fabián and Fernanda Potenza dal Masetto (2011). Protección social en la Argentina, *Serie Politicas Sociales*, Santiago de Chile, CEPAL. no. 174, 68 pages.

Robles Farías, Claudia (2013). *Sistemas de protección social en América Latina y el Caribe, Chile*. Santiago, Cepal, 52 pages.
Ruiz Gómez Fernando, Teana Zapata Jaramillo, and Liz Garavito Beltrán (2013). Colombian health care system: results on equity for five health dimensions, 2003–2008, *Revista Panamericana de Salud Pública*, vol. 33, no. 2, pp. 107–115.

Sáenz, María del Rosario et al. (2011). Sistema de salud de Cesosta Rica, *Salud Publica*, vol. 53, no. 2, pp. 156-167.

Santos Basso, Óscar Luis (2005), Costa Rica, in Instituto de Investigaciones Jurídicas, Centro Interamericano de Estudios de Seguridad Social, *El nuevo derecho de las pensiones en América Latina*, pp. 187-253.

Sánchez-Talanquer, Mariano et al. (2020). *La respuesta de México al COVID: estudio de caso*, Institute for Global Health Sciences, UCSF, 131 pages

Théret, Bruno (2011). "The place of national systems of social protection and political representation in socio-economic regulation: a morphogenetic structuralist view on institutional change in comparative perspective with special references to Japan and France", *Evolutionary institutional economic review*, vol. 7, no. 2, pp. 177-208.

Tikkanen, Roosa et al (2020). *International profiles of Health Care Systems*, The Commonwealth Fund, 228 pages. https://www.commonwealthfund.org/sites/default/files/2020-12/International_Profiles_of_Health_Care_Systems_Dec2020.pdf

Vásquez, Felipe, Guillermo Paraje, and Manuel Estay (2013). Income-related inequality in health and health care utilization in Chile, 2000–2009, *Revista Panamericana de Salud Pública*, vol. 33 no. 2, pp. 98-106.

Werneck Vianna, Maria Lúcia Teixeira y M. L. Texeira (1997). A americanização (perversa) da seguridade social no Brasil in Eli Diniz and Sergio de Azevedo (ed.), *Reforma do estado e democracia no Brasil: dilemas e perspectivas*, Brasília, Editora Universidade de Brasília, pp. 295-348.

## NOTES

1. And one could also include in the pro-rich and pro-educated bias of the health system, such a bias towards a basic health condition. Many studies have shown that poorer and less educated populations (for example FIEL, 2007) and the effects of bad health conditions as a risk in the case of Covid have been thoroughly proven.

## ABSTRACTS

None of the Latin American countries has achieved fully universal, egalitarian, and efficient health systems, although Uruguay and Costa Rica have probably come closest to this goal. The pandemic the world is currently undergoing has strained all the health organizations of the continent; an exceptional situation that allows us to compare their performance and resilience. It is clear that some countries have weathered the crisis better than others in part due to the condition of the health services themselves, but also from the approach that different governments adopted to deal with the epidemic. I will analyze three aspects: 1. The specific
trajectories of the different health systems, and more particularly the changes they underwent since the beginning of the commodity boom and the arrival to power of redistributive coalitions in certain countries; 2. The specific characteristics of the different health organizations in terms of coverage, structure, investment, infrastructure, and historical performance; and 3. The performance of the various health regimes during the pandemic.

Aucun des pays d'Amérique latine n'a pas pu mettre en place des systèmes de santé pleinement universels, égalitaires et efficaces, bien que l'Uruguay et le Costa Rica se soient probablement rapprochés le plus de cet objectif. La pandémie que le monde traverse actuellement a mis à rude épreuve tous les systèmes de santé du continent ; une situation exceptionnelle qui nous permet de comparer leurs performances et leur résilience. Il est clair que certains pays ont mieux résisté à la crise que d'autres en partie en raison de l'état des services de santé eux-mêmes, mais aussi de l'approche adoptée par les différents gouvernements pour faire face à l'épidémie. J'analyserai trois aspects: 1. Les trajectoires spécifiques des différents systèmes de santé, et plus particulièrement les changements qu'ils ont subis depuis le début du boom des matières premières et l'arrivée au pouvoir de coalitions redistributives dans certains pays; 2. Les caractéristiques spécifiques des différents organisations de santé en termes de couverture, de structure, d'investissement, d'infrastructure et de performance historique; et 3. La performance des divers régimes de santé pendant la pandémie.

Ninguno de los países latinoamericanos ha logrado construir sistemas de salud plenamente universales, igualitarios y eficientes, aunque probablemente Uruguay y Costa Rica se hayan acercado más a esta meta. La pandemia que atraviesa el mundo actualmente ha afectado a todos los sistemas de salud del continente; una situación excepcional que nos permite comparar su desempeño y resiliencia. Es evidente que algunos de ellos han resistido la crisis mejor que otros, en parte debido a la condición de los propios servicios de salud, pero también por el enfoque que adoptaron los diferentes gobiernos para hacer frente a la epidemia. Analizaré tres aspectos: 1. Las trayectorias específicas de los diferentes sistemas de salud y, más particularmente, los cambios que experimentaron desde el inicio del boom de las commodities y la llegada al poder de las coaliciones redistributivas en ciertos países; 2. Las características específicas de las diferentes organizaciones de salud en términos de cobertura, estructura, inversión, infraestructura y desempeño histórico; y 3. El desempeño de los distintos sistemas de salud durante la pandemia.

## INDEX

**Mots-clés:** pandémie, systèmes de santé, Amérique latine, performance, politique

**Palabras claves:** pandemia, sistemas de salud, América latina, desempeño, política

**Keywords:** pandemic, health systems, Latin America, performance, politics

## AUTHOR

ILÁN BIZBERG

Professeur, El Colegio de México, ilan@colmex.mx