However, despite the hard work and dedication of many of these people, such systems too frequently suffer from low coverage and low productivity. Most of the health systems in Latin America which rely upon fixed payment mechanisms suffer from low coverage. Among the many reasons for this low coverage is the fixed payment mechanism which allows doctors and health system managers to make decisions about the location and quality of care independently of the country's health needs. The choices are frequently made to provide more services in the major urban centers, with little incentive for doctors to provide care in rural or poor urban areas. The resulting concentration of spending in wealthier areas is a central factor in the unequal access to services and in the bias toward preventive rather than curative care.
Low productivity is another consequence of fixed payment mechanisms.
Regardless of the quality of the bureaucracy, it is notoriously difficult to assure that the right services are provided where they are needed under such a system. In the early 1990s, one third of Ecuador's public hospital beds were unusable because of damaged roofs and one third of Peru's publicly operated health posts were not staffed. Occupancy rates for hospitals are extremely low in countries like Belize and the Dominican Republic. Absenteeism and short hours are common, particularly for doctors who have a strong incentive to provide services to private patients who pay for each consultation. However, their systems are relatively expensive because of low productivity, and hence they are increasingly difficult to sustain.