Chile has a long awaited opportunity to vote for a new public and universal healthcare systemBMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o2146 (Published 02 September 2022) Cite this as: BMJ 2022;378:o2146
- Luis Ignacio De La Torre Chamy, president1,
- Camila Micaela Escobar Liquitay, senior researcher2,
- Eva Madrid, professor3,
- Juan Víctor Ariel Franco, research associate4
- 1Valparaiso Regional Council, Chilean College of Physicians, Department of Gynaecology and Obstetrics, School of Medicine, Universidad de Valparaíso, Chile.
- 2Research department, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
- 3Interdisciplinary Centre for Health Studies CIESAL, Universidad de Valparaíso, Chile.
- 4Institute of General Practice, Medical Faculty, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.
In October 2019, Chileans took to the streets to protest about ongoing problems such as social justice, socio-economic inequalities, and poor quality healthcare. They demanded a new constitution.12 As a result, a constitutional assembly was elected to develop a new constitution, and it has proposed a draft new constitution to be voted on 3 September 2022. One of the main changes includes a comprehensive reform of the healthcare system which was established in 1981 under the last military dictatorship (1973-1989). It allowed people to choose to fund either public or private insurers, which established the widespread privatisation of the healthcare system and gave preferential access to those who could afford it.3 In the past 20 years, several initiatives have countered this process, including the Health Guarantees Act (2000), which mandated that all providers must guarantee high quality care for priority health conditions. This was later expanded with the Catastrophic Illnesses Act (2015).34
Currently, 17% of the Chilean population—those with higher incomes—contribute to private healthcare insurance companies, but private healthcare providers give medical assistance to both private and public users, and half of their health services are given to public users.5 Chile is a high income country and has promising health indicators compared with other countries in the Latin American region for communicable diseases, malnutrition, perinatal health, infant mortality, and life expectancy, but with a high prevalence of smoking, alcohol consumption, and obesity.67 Some of these positive changes to health indicators have been possible by increasing investment in healthcare, currently 9.8% of the gross domestic product (GDP), with high out-of-pocket expenditure decreasing from 45% in 2005 to 32% in 2020, but still elevated compared to the OECD average of 20%.8 Nevertheless, there is a steadily increasing dissatisfaction among the Chilean population due to persistent unsolved healthcare inequalities, including long waiting times and elevated out-of-pocket costs, which has a particularly high impact for people affected by conditions that are not covered by healthcare acts. Patients can incur substantial personal debt or resort to crowdfunding to access the private system, where prompt care is available.
The new draft of the constitution presents a publicly funded universal National Health System governed by principles of equity, solidarity, and interculturality. The proposed system would be built on an Integrated Health Service Delivery Network, including the public and private sectors, with a strong focus on primary care. A recent success in integrating all providers under the authority of the Ministry of Health to deal with covid has provided a positive experience for this movement. This proposal provides a major cultural shift regarding equitable opportunities to access healthcare by increasing targeted healthcare expenditure with a focus on the inclusion of disadvantaged populations. Moreover, the current 9.8% of GDP plus additional health contributions from the employer and the state will place Chile at the level of other developed countries.8 Additionally, the draft also explicitly mentions the concept of wellbeing, including physical and mental health, as well as prioritising palliative care and a dignified death, which would result in an important and positive improvement in quality of life. If approved, periodic national health surveys will become crucial in evaluating users’ satisfaction in a country where it is difficult to further increase macro health indicators.9
The leading detractors of the proposed system have argued that the role of the private sector as healthcare providers has not been fully clarified. For instance, according to the draft proposal, publicly funded primary care would have to receive 3.5 million current users from private providers. Moreover, referral to specialists from primary care may challenge the 60 years of traditionally free election of providers, considering that private healthcare plays a fundamental role—50% of medical attention, 30% of surgical procedures and 40% of diagnostic tests—and cannot be excluded from the system.6 Additional doubts were cast as to how the constitutionally recognised interculturality, including the use and teaching of ancestral medicine, and how it would be operationalised in terms of guidance, funding, and their interplay with mainstream evidence-based interventions.
Supporters and detractors of the draft constitution have polarised views and healthcare is an issue that generates the highest levels of expectation in the population. The perception of the current system as being inefficient is so clear, and expectations are so high, that it may be difficult to meet them with the available resources. If the current draft is approved, it will be crucial to invest heavily in the healthcare infrastructure to comply with the goals of the new system, as well as to carefully legislate and regulate the system. But what is certain is that the reform of the healthcare system presents an opportunity for Chile to reduce the existing inequalities and meet the needs of its population.
Competing interests: none declared.
Provenance and peer review: not commissioned, not peer reviewed.