Horizontal inequity in access to health care in four South American cities.

• Author: Balsa, Ana I.
• Position: Report
• Pages: 31(26)

1 Introduction

In the past decade several South American countries introduced reforms aimed at improving equity in access to health care. In Chile, the "Plan AUGE" enforced minimum standards of service delivery for all insurance carriers. Uruguay initiated in 2008 a process towards a National Health Insurance System, and is gradually incorporating different cohorts of the population to the new scheme. Argentina's efforts have focused on strengthening primary care and decentralizing health care provision, and Brazil has continued to consolidate its public universal health system introduced in the 90's.

Research stemming from the EquiLAC project (a World Bank project with the support of Spanish and Danish governments) and the IHEP collaboration (a PAHO project funded by the United Nations) has contributed to inform some of these reform processes by quantifying and comparing inequities across a number of Latin American countries (Suárez Berenfuela, 2000; PAHO, 2002). (1)

In this study, we use healthcare concentration indices to shed light on this question. Using the methodology proposed by van Doorslaer et al. (2004, 2006) we measure, decompose, and compare socioeconomic inequalities in various indicators of healthcare utilization across four South American major cities: Buenos Aires (Argentina), Santiago (Chile), Sao Paulo (Brazil), and Montevideo (Uruguay). We analyze data from the WHO Survey on Health, Wellbeing and Ageing (SABE), a survey administered in 2000 to elderly adults living in major cities from Latin America and the Caribbean.

Underlying our analysis is the concept of horizontal equity in health care, which proposes equal treatment to those with equal needs. Much of the empirical literature in this area has explored the associations between the institutional organization of healthcare systems and horizontal equity in access and use (Culyer and Newhouse, 2003; Macinko and Starfield, 2002). One example is the ECuity Project, a multiyear study funded by the European Union, national governments and other organizations, aimed at analyzing health and healthcare inequities in OECD countries. Results for European countries, most of which have universal coverage health systems, found little inequity in visits to general practitioners but a concentration of specialty visits favoring high-income groups in countries where private insurance coverage or private practice options were offered as channels to quicker or preferential access (van Doorslaer et al., 2004, 2006; ?). These studies suggest that the fragmentation of healthcare systems, mostly due to the allowance of private coverage options, is the main culprit for inequality in access to care (García Gómez and López, 2004).

In Latin America, however, levels of income inequality are higher than those in Europe. While fragmented healthcare systems are probably behind the unequal access to care, high levels of inequality in access can also be expected within each delivery system (public or private). In this scenario, policy recommendations aimed only at system defragmentation can fall short of providing adequate solutions to the problem.

The contribution of this study is twofold. First, we quantify and identify, for each city, the services that make each system more inequitable, both when compared with other services in the country as across cities. Our findings regarding inequalities in preventive care are quite informative given the new shifts in policy towards primary levels of attention. Second, our decomposition analysis shows that inequities within each insurance sub-system are more important inequalizing forces than those between systems, i.e., the fragmentation of insurance systems. Factors such as copayments within the private system or socioeconomic differences in the ability of beneficiaries to make empowered decisions about health care and navigate the system seem to be more important determinants of the observed inequities.

2 Institutional background

The four countries under study have mixed health systems, with coexisting public and private insurers and providers. They show significant differences, however, in the nature of public and private coverage. In Brazil, the public system ("Sistema Único de Saude", Unique Health System) warrants universal coverage to all citizens. The system is based on a decentralized regional network regulated by the Ministry of Public Health and financed with public resources. Due to the regional economic disparities that characterize the country, and because federal support does not pursue redistributive goals, richer states present higher per capita health expenditure. The private system, on the other hand, is a fragmented conjunction of plans that include prepaid group practices, medical cooperatives, employer provided insurance, and indemnity plans. Approximately 75% of the population is exclusively covered by public health insurance. The rate is lower in the city of Sao Paulo because of its higher levels of income (62% according to SABE estimates). Although everyone has the right to use the public system, those with private coverage are unlikely to make use of it, except for high cost procedures, such as cancer treatment, which are generally not covered by private insurers.

In Chile, public coverage is provided through the National Health Fund (FONASA), while the ISAPRES ("Instituciones de Salud Previsional" or Social Security Health Institutions) are the institutions in charge of offering private insurance. Contributors to social security can choose whether to receive coverage from the ISAPRES or the FONASA, but once they opt for the private entities, they are not entitled to get coverage from the National Health Fund. In addition to covering formal employees or retirees that have chosen public insurance, the FONASA provides coverage to low-income individuals. The ISAPRES are allowed to negotiate complementary packages with their clients that offer improved access to health services against increased premiums. Because of the higher health risks associated with aging, the ISAPRES discriminate against the elderly, either through prices or by reducing coverage. This explains why most elderly individuals in Santiago (84% according to SABE estimates) choose public coverage. Only 5% of older adults had coverage from the ISAPRES in 2000 and 10

The Argentinean healthcare system is divided in three subsystems: public, social security ("Obras Sociales"), and private. The public system provides free access to health services to low-income groups and individuals who lack other coverage. The social security system is a compulsory scheme that covers formal dependent workers and retirees. It is financed by wage contributions that are redistributed across different "Obras Sociales" to ensure increased equality in the provision of care. Retired social security beneficiaries receive coverage from the largest entity in the "Obras Sociales" system: the "Instituto Nacional de Servicios Sociales para Jubilados y Pensionados" (Social Services Administration for Retirees and Pensioners). The private sector is integrated by unregulated private entities that offer voluntary partial or comprehensive insurance to higher income individuals and provide higher quality services. According to data from SABE, in 2000 51% of elderly individuals in Buenos Aires were beneficiaries of social security, 21% reported having public coverage, 10.4% were covered by private insurance, and 17% reported no insurance at all. Ten percent of social security beneficiaries had, in addition, complementary private insurance.

In Uruguay the public sector provides health coverage to the low-income population and individuals not covered by other insurance. The main agents in the private sector are the "Instituciones de Asistencia Medica Colectiva" (Institutions of Collective Medical Assistance), private non-profit institutions that act both as insurers and as direct providers of care. These institutions provide coverage to employees contributing to the social security system and sell voluntary insurance (at a regulated premium) to retirees, dependents, and other individuals not formally integrated to the labor market. The private sector includes also for profit health insurers that sell voluntary packages in an unregulated market. Private non-profit insurance covers approximately 45% of the population, although the rate rises to 60% when considering elderly adults only. About 38% of the elderly get coverage from the public system.

A series of equity-enhancing health care policies have been introduced since the administration of SABE in 2000. In Chile, the plan AUGE was introduced to guarantee minimum levels of care to beneficiaries of public and private insurance. Since 2005, health authorities began to explicitly list the package of preventive and curative health services that beneficiaries of all health insurances were entitled to. In addition, the new regulation established maximum time frames for the provision of services, required providers to get accreditation in order to ensure standards of quality, and limited copayments in the ISAPRES and FONASA to 20% of a nominal value of the service. In Uruguay, the government took in 2008 the first steps towards the conformation of a universal social health insurance system (the "Sistema Nacional Integrado de Salud" or National Health Insurance System), aimed at providing equal access to and quality of health care to all the population. The government is gradually incorporating new groups to the scheme. The first groups entitled to the new coverage (in addition to formal workers already contributing to social security) were dependents of formal workers under the age of 18 and low-income retirees. In Argentina, the 2004-2007 Federal Health Plan was designed to...