Analysis of Current Chilean Health System Reform
Chile has acted as a leader in the processes of health reform since the 1950’s, when it created the first National Health System in Latin America. Other key reforms occurred in the 1980’s under the Pinochet military government, where the system was changed in order to introduce competitive private insurance and health care providers. More recently, Chile has “reformed the reform” with a very innovative approach to prioritizing health expenditures through a system of guarantees for the top fifty-six specific health issues but without excluding services as other efforts at prioritizing through limited benefits packages have done. The reforms also involved changes in the rules of private insurance to reduce risk selection.
Starting in 2003, Harvard School of Public Health Lecturer Thomas Bossert has led a three-week, for-credit, winter term intensive field course to learn about recent key elements of the Chilean health system, the current reform process and the family health model. The program celebrated its 10th anniversary in January 2013, and is considered one of the most popular and best-evaluated courses at the HSPH. This course introduces students to the different key actors in the Chilean health system to get brief and intense different arguments about the health system problems and the abilities of the reform efforts to overcome these problems by engaging the students in daily lectures and visits with Chilean health care system representatives, senators, and public figures like former president Ricardo Lagos and his foundation. Over the years, the course has given Professor Bossert unusual access to many key actors with differing views on the process and effectiveness of reform and reform procedures, therefore allowing him a broad perspective of the latest on current issues and the future of reform.
In 2007-2008 with support from a DRCLAS Individual Grant, Lecturer Thomas Bossert completed thorough academic investigation of the reforms, including review and evaluation of the current health reform in Chile. This work served as the basis for an article in an international journal, and a case study for teaching his course on Health Reform at the Harvard School of Public Health, as well as acting as the basis for on-going research in specific reform areas for graduate students at Harvard. The project involves a major effort to collect the published data on the health reform in order to spread knowledge of the innovative aspects of the reforms beyond the Chilean borders.
Participating Harvard faculty: Thomas J. Bossert, Lecturer on International Health Policy, Director, International Health Systems Program, Harvard School of Public Health
Collaborator: Dr. Jorge Jimenez, former Minister of Health
Collaborative Institutions: Global Health Internship Program at HIGH, Ministry of Health, Chile; Universidad Católica, Chile; and Universidad de Chile, Chile
State Capacity, Private Insurance and Private Providers in the Policy Process of Health Policy in Colombia and Chile
Numerous countries around the globe have introduced health reforms promoting the development of a competitive private health provider and insurance markets. In many respects these reforms have not achieved all of their intended objectives. A major problem faced by countries that have experimented with private health providers and insurance is that once they are established they have been hard to regulate. Drawing on a political economy perspective, this paper argues that state capacity to regulate the private health sector shapes the implementation patterns and outcomes of the reforms. The study examines two similar middle income countries, Chile and Colombia, which implemented similar health reforms to expand the role of private insurance and private provision of health services. While there were significant achievements in both countries, the Colombian reform experienced major problems that were not experienced in Chile, especially a financial crisis that threatened the sustainability of the reforms and a significant weakening of the public sector insurance and delivery system. This study examines the concepts of the political economy literature on state capacity to assess the role that the differences in state capacity between Chile and Colombia might play in explaining the differences in health reform implementation and outcomes. The research is funded by a faculty research grant by the David Rockefeller Center for Latin American Studies.
Participating Harvard faculty: Thomas Bossert, Lecturer on International Health Policy, Harvard School of Public Health
Collaborating Institutions: Research teams in Colombia and Chile, including former vice ministers of the two countries and academics in the Universidad de los Andes in Colombia and Universidad Catolica in Chile.