Healthcare in Chile

Chile was one of the first Latin American countries introducing health care for the middle class funded through mandatory deductions from the salary, as in the Bismarckian welfare state. In the 1950s it introduced a national health care system, headed by the agency Fondo Nacional de Salud (FONASA). During the last decade of the military dictatorship a two tier system developed as people could opt out and buy private health insurance from private insurance companies called Instituciones de Salud Previsional (ISAPREs) for care by private providers at private clinics and private hospitals, which cost up to twice as much.[1]

Starting in 1990, the civilian government increased public funding, especially for hospitals, without further reform for more than a decade. In the early 2000s, President Ricardo Lagos strengthened the public-sector. Private health care became more and more expensive and as of 2015 covers only 19% of the population, down from a peak of 26%.

The so-called "Explicit Guarantee System (Acceso Universal con Garantías Explícitas, or AUGE), developed several guarantees for 56 health problems for the insured. It prescribed clinical guidelines and "no longer wait than preset periods for diagnosis, treatment, or follow-up", a maximum of out-of-pocket expense cap and a maximum designated waiting time, after which private providers for the services were an option. [1] The Lagos reform had earlier succeeded to reduce mortality rates especially with communicable diseases and mortality, even myocardial infarction it did so at the expense of chronic diseases. In 2010, the Constitutional Court of Chile declared the private insurance system's premiums adjustments for health risk by age and gender as discriminatory, disallowed it, but did not suggest an alternative mechanism. Health care consumer satisfaction has been decreasing since 2007 to its lowest point in 2014.[1]

All workers and pensioners are mandated to pay 7% of income for health insurance (the poorest pensioners are exempt from this payment). Workers choosing not to join an Isapre are covered by Fonasa. Fonasa also covers those receiving unemployment benefits, uninsured pregnant women, the dependent family of insured workers, those with mental or physical disabilities, and the poor or indigent.

FONASA beneficiaries may use public or private health facilities if the private health facility or health professional is associated with Fonasa in one of three pricing levels. When choosing public health facilities the cost is free for people older than 60, people without income or with disabilities and for workers earning less than one minimum wage (MW), or less than 1.46 MW if they have three or more dependents to take care of. Workers earning between one and 1.46 MW and having less than two dependents, or earning more than 1.46 MW and having three or more dependents, pay 10% of costs. Workers earning more than 1.46 MW pay 20% of costs if they have two or fewer dependents.[2]

The level of protection offered by ISAPREs depends on the worker's income and medical risk, estimated by age, sex, family medical history, etc. (In August 2010 Chile's Constitutional Court declared risk determination based on sex and age to be unconstitutional.[3]) This may force an affiliate to seek treatment under Fonasa when a particular service or health condition is not covered by their Isapre.[4] Isapre participants pay on average 9.2% of their income toward health insurance. The additional paid over the required 7% is voluntary and is paid to increase the benefits available. Almost 60% of payers are in the top two quintiles of income, while only 7% are in the bottom quintile. Isapres often use networks of providers to offer discounted benefits. They also offer shorter time waiting for services. Fonasa, on the other hand, uses lower cost public hospitals, and can include a broader benefit package for the same cost. The trade-off is accessibility as the waiting time for services can be substantial.[5]

Over 50% of the public sector health budget is raised through taxation — this goes to the public social security system and the Fonasa plans to help cover expenses. Isapres cover all expenses using only the contributions of members.

There are a number of high-mortality pathological conditions (currently 80[6]) that have special guarantees for both Isapre and Fonasa affiliates. The Auge (from the Spanish Acceso Universal con Garantías Explícitas, "Universal Access with Explicit Guarantees") or Ges (Garantías Explícitas en Salud, "Explicit Guarantees in Healthcare") plan includes four guarantees in relation to these illnesses:[5]

• Access: individuals will be able to get attention from a network of providers near their place of residence,
• Opportunity: there is a maximum pre-established time limit to get attention (both initial attention and after the diagnosis),
• Quality (to become enforceable from 1 July 2013[7]): services will follow technical requirement standards that will be established based on medical evidence, and
• Financial coverage: payment to providers cannot be an obstacle to attention. There will be a maximum copayment of 20% of the cost, with the total not to exceed one month of income for the family in a year.

As of December 22, 2014, there were 425 hospitals registered with the Ministry of Health.[8]

Hospitals fall into one of two administrative spheres - the Regional Ministry of Chile (SEREMI Secretaria Regional Ministerial de Chile) and the National Health Care System (Sistema Nacional de Servicios de Salud). The SEREMI accounts for 54% of hospitals (230) while the National Health Care System accounts for the remaining 46% of hospitals (195).[9]

Santiago, the capital city and most populous region of the country, accounts for 36% of the population and 30% of the country's hospitals (127 hospitals).

Beneficiaries as of 2017.[10][11][12]

• Ministry of Health (Chile)
• List of hospitals in Chile
• Chilean pharmaceutical policy
• Water supply and sanitation in Chile

• World Health Organization: Chile