Abstract
BackgroundContributory social health insurance for formal sector employees only has proven challenging for moving towards universal health coverage (UHC). This is because the informally employed and the poor usually remain excluded. One way to expand UHC is to fully or partially subsidize health insurance contributions for excluded population groups through government budget transfers. This paper analyses the institutional design features of such government subsidization arrangements in Latin America and assesses their performance with respect to UHC progress. The aim is to identify UHC conducive institutional design features of such arrangements.MethodsA literature search provided the information to analyse institutional design features, with a focus on the following aspects: eligibility/enrolment rules, financing and pooling arrangements, and purchasing and benefit package design. Based on secondary data analysis, UHC progress is assessed in terms of improved population coverage, financial protection and access to needed health care services.ResultsSuch government subsidization arrangements currently exist in eight countries of Latin America (Bolivia, Chile, Colombia, Costa Rica, Dominican Republic, Mexico, Peru, Uruguay). Institutional design features and UHC related performance vary significantly. Notably, countries with a universalist approach or indirect targeting have higher population coverage rates. Separate pools for the subsidized maintain inequitable access. The relatively large scopes of the benefit packages had a positive impact on financial protection and access to care.Discussion and ConclusionIn the long term, merging different schemes into one integrated health financing system without opt-out options for the better-off is desirable, while equally expanding eligibility to cover those so far excluded. In the short and medium term, the harmonization of benefit packages could be a priority. UHC progress also depends on substantial supply side investments to ensure the availability of quality services, particularly in rural areas. Future research should generate more evidence on the implementation process and impact of subsidization arrangements on UHC progress.
Highlights
Contributory social health insurance for formal sector employees only has proven challenging for moving towards universal health coverage (UHC)
E.g. universal, indirect, direct; different targeting approaches can be in place at the same time for different groups
This paper explored the patterns of institutional design aspects of subsidization arrangements using state budget transfers with a focus on population groups outside formal sector employment and especially vulnerable population groups
Summary
Contributory social health insurance for formal sector employees only has proven challenging for moving towards universal health coverage (UHC). This is because the informally employed and the poor usually remain excluded. Latin America has a long social health insurance (SHI) tradition This had resulted in segmented systems, in which a SHI scheme covers almost exclusively formal sector employees only, and private health insurances those who can afford it. Progressing towards UHC has proven to be difficult in many of the countries with a SHI system, as to the inclusion of population groups outside the formal sector [1,2,3,4]. The health financing reform steps taken by countries in Latin America during the last decades toward these objectives reflect this diversity [7]
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