Abstract

Introduction

Chile is an upper-middle-income country and a forerunner in the adoption of neoliberal reforms in Latin America. From 1973 and 1990, during the dictatorship, structural changes were introduced in the Chilean economic, political, and social systems that exacerbated the country’s inequalities, characterized by emphasis on the private sector in the provision of public services, market liberalization, and deregulation of the economy ¹1. Teichman J. The politics of freeing markets in Latin America: Chile, Argentina and Mexico. Chapel Hill: University of North Carolina Press; 2001..

The period from 1920 to 1950 had been marked by the development of an occupation-based protection system according to the social security model. The creation of the Servicio Nacional de Salud (SNS) or National Health Service in 1952, inspired by the English NHS, allowed a new institutional arrangement and resulted in the expansion of health services to more vulnerable segments of the population ²2. Bustos CAM. Institucionalidad sanitária chilena: 1889-1989. Santiago de Chile: LOM Ediciones; 2010.. Although the universalization of the SNS was interrupted by the military coup in 1973, actions developed until that point allowed building a public institutional legacy and a broad network of government health services ³3. Labra ME. Política e saúde no Chile e no Brasil. Contribuições para uma comparação. Ciênc Saúde Colet 2001; 6:361-76.^,44. Becerril Montekio V. Sistema de salud de Chile. Salud Pública Méx 2011; 53 Suppl 2:S132-43.. The military dictatorship reconfigured the Chilean health system by establishing a dual model that consolidated the segmentation and broke with the solidarity between the public and private systems ⁵5. Soto RA, Leal MCH, Zelada LG. El derecho a la salud y su (des)protección en el estado subsidiario. Estudios Constitucionales 2016; 14:95-138..

In the last three decades, health reforms were implemented in the context of democratization. This article analyzes Chile’s national health policies from 2000 to 2018, addressing the follow questions: to what extent have the reforms led to structural changes in the health system? Were there significant differences between the agendas and strategies adopted by the successive governments?

The study’s goal was to analyze the changes implemented by the democratic governments that aimed to reform the configuration of the health system built during the military dictatorship, as well as the continuities and changes in the policies’ trajectory and their conditioning factors.

Methodology

The theoretical reference was historical institutionalism, which values the time dimension, the sequence of choices and events, and the institutional legacy in the policies’ trajectory ⁶6. Pierson P. Politics in time: history, institutions and social analysis. Princeton: Princeton University Press; 2004.. From this perspective, radical changes in critical scenarios generate a “path dependence”, reinforcing previous choices and hindering comprehensive changes in subsequent scenarios. In addition to radical reforms in critical scenarios, Mahoney & Thelen ⁷7. Mahoney J, Thelen K. A theory of gradual institutional change. In: Mahoney J , Thelen K, editores. Explaining institutional change: ambiguity, agency and power. Cambridge: Cambridge University Press; 2010. p. 1-37. highlight that incremental and gradual changes in policies can, over time, result in relevant transformations.

In this study, the analysis of the trajectory of health policies from 2000 to 2018 considered three basic lines: (i) the political-institutional context, which refers to social policies’ political, economic, and legislative scenario; (ii) the governments’ agenda, constituting a set of health priorities announced by government officials, policymakers, and official documents; and (iii) the strategies that are adopted, concerning the set of health policy measures and actions.

The study focused on the following presidential terms: Ricardo Lagos (2000-2006); Michelle Bachelet (2006-2010); Sebastián Piñera (2010-2014); and Michelle Bachelet (2014-2018). Since the theoretical reference of historical institutionalism values the time dimension, we briefly contextualize the previous health policy history in Chile, based on a literature review.

The search involved various methodological strategies, featuring an analysis of official documents from 1999 to 2018, such as: legislation, government programs, reports, and resolutions. In addition, 14 interviews were held with individuals that occupied key positions during the four governments. Four of these individuals also participated in the Presidential Advisory Commissions for health sector reform in the Piñera (2010-2014) and/or Bachelet Administrations (2014-2018). The interviews, held in 2019 and lasting approximately one hour each, were recorded and transcribed. We then proceeded to an analysis of the thematic content of the documents and interviews using the Nvivo Pro Student software (https://www.qsrinternational.com/nvivo/home), according to the study’s analytical lines.

In the presentation of the results, to ensure the interviewees’ anonymity, the interviews were coded in parentheses, as shown in Box 1.

The study was approved by the respective Institutional Review Board (CAAE n. 79979317.3.0000.5240).

Trajectory of the health policies

The military dictatorship and radical health sector reform (1973-1989)

The pioneering and radical nature of the Chilean case in the adoption of liberal policies during the dictatorial period altered the direction of the country’s economic and social policies ¹1. Teichman J. The politics of freeing markets in Latin America: Chile, Argentina and Mexico. Chapel Hill: University of North Carolina Press; 2001.^,33. Labra ME. Política e saúde no Chile e no Brasil. Contribuições para uma comparação. Ciênc Saúde Colet 2001; 6:361-76.^,88. Mesa-Lago C. Protección social en Chile: reformas para mejorar la equidad. Revista Internacional del Trabajo 2008; 127:462-80.^,99. Rotarou ES, Sakellariou D. Neoliberal reforms in health systems and the construction of long-lasting inequalities in health care: a case study from Chile. Health Policy 2017; 121:495-503.. The reforms under the military regime in the 1970s were characterized by fiscal adjustment, privatizations, market opening, and containment of public spending to an unprecedented degree in Latin America ¹⁰10. Fleury S. Universal, dual o plural? Modelos y dilemas de atención de la salud en América Latina. Rio de Janeiro: Fundação Getulio Vargas; 2002..

The radical reforms in the health sector aimed to decentralize the public system and strengthen the private sector. A dual health system was created in which the public and private segments functioned simultaneously with distinct logics in their financing, entitlement, and services provision. The public sector, represented by the Fondo Nacional de Salud (Fonasa) or National Health Fund, was based on the occupational social security model, with sharing of services provisions and the promotion of solidarity based on distribution of the risks among beneficiaries. Meanwhile, the Instituciones de Salud Previsional (Isapre), or Health Insurance Institutions, furnished supplementary health plans and copayments based the person’s sex, age, individual risks, and purchasing power ¹¹11. Unger JP, De Paepe P, Cantuarias GS, Herrera OA. Chile's neoliberal health reform: an assessment and a critique. PLoS Med 2008; 5:e79..

In 1985, based on socioeconomic criteria, four groups were established in the public sector (A, B, C, and D), in addition to two modalities of care. In the institutional care modality (MAI, in Spanish), targeted to the population that could not afford to make regular payments (group A), medical care was provided in the public health services network. In the free choice modality (MLE, in Spanish), reserved for the other Fonasa groups, individuals were allowed to choose the health professional or service from the private sector to provide the services ¹²12. Tetelboin C. Tendencias y contratendencias en el sistema de salud de Chile en el marco de la situación regional. In: Tetelboin C, Laurell C, editores. O direito universal à saúde: uma análise da agenda latino-americana e controle. Buenos Aires: Conselho Latino-americano de Ciências Sociais; 2015. p. 75-97.. The institutionalization of MLE expanded the free choice system created in 1968, which served a small portion of the population.

The democratic transition began in 1990 after Patricio Aylwin of the Christian Democratic Party won the presidential elections, supported by a broad political coalition.

First governments of the Concertación: health takes back stage (1990-2000)

The Concertación de Partidos por la Democracia, or Coalition of Parties for Democracy, which supported Aylwin’s candidacy, was formed in 1988 with 17 political parties. Established to confront the rightwing candidate supported by Pinochet, Büchi Buc, the coalition was characterized by its political diversity. The Aylwin Government’s main objectives were the creation of macroeconomic protection, economic growth, employment, investment in human capital, and decreasing poverty ¹³13. Huber E, Pribble J, Stephens J. The Chilean left in power: achievements, failures, and omissions. In: Weyland K, Madrid R, Hunter W, editores. Leftist governments in Latin America: successes and shortcomings. New York: Cambridge University Press; 2010. p. 77-97.. The priorities in the political field were stability and strengthening of democracy.

President-elect Aylwin faced several roadblocks when he took office, especially due to the presence of Pinochet, who maintained political, military, and institutional influence as Commander of the Army until 1998 and later as senator for life ¹⁴14. Olavarría MO, editor. ¿Cómo se formulan las políticas públicas en Chile? Tomo 2: el plan AUGE y la reforma de la salud. Santiago de Chile: Universitaria; 2012..

Some of the obstacles in the health sector were the deterioration of the public infrastructure and the poor quality of services, resulting from dwindling investment under the military dictatorship ¹⁵15. Ministerio de Salud. Ley nº 19.378. Establece Estatuto de Atención Primaria de Salud Municipal. https://www.leychile.cl/Navegar?idNorma=30745 (acessado em 15/Ago/2019).
https://www.leychile.cl/Navegar?idNorma=... . The strategies for dealing with these problems under the governments of Patricio Aylwin and his successor Eduardo Frei Ruiz-Tagle aimed to recover public investment in health services and intensify the decentralization under the military regimen in order to overcome the regional inequalities.

Innovations were introduced in the health system, such as the creation of the per capita payment system for persons enrolled in the primary care centers and the implementation of the Primary Care Statute, submitted during Alwin’s Government and regulated by Frei, standardizing the rules for administration, financing, and coordination of primary healthcare (PHC) ¹⁵15. Ministerio de Salud. Ley nº 19.378. Establece Estatuto de Atención Primaria de Salud Municipal. https://www.leychile.cl/Navegar?idNorma=30745 (acessado em 15/Ago/2019).
https://www.leychile.cl/Navegar?idNorma=... .

Measures to regulate the private sector were started at the end of the dictatorship and adjusted during Chile’s re-democratization. The Superintendencia de Isapre, created in 1990 for regulation of the private sector, was amended in the Frei Government through more rigorous rules on the functioning and provision of health services by the Isapre ¹⁶16. Manuel A. The Chilean health system: 20 years of reforms. Salud Pública Méx 2002; 44:60-8.^,1717. Ossandon J. The enactment of private health insurance in Chile. London: University of London; 2008..

Despite the understanding that health reform was necessary, the priorities during the first two Concertación governments focused on other areas such as economic and political stability ¹⁴14. Olavarría MO, editor. ¿Cómo se formulan las políticas públicas en Chile? Tomo 2: el plan AUGE y la reforma de la salud. Santiago de Chile: Universitaria; 2012..

Nearly 30 years after Salvador Allende’s election and after the two governments of the Christian Democratic Party, socialist candidate Ricardo Lagos was elected President of Chile in 1999.

Ricardo Lagos Government: the incremental reform of Acceso Universal de Garantías Explícitas en Salud (2000-2006)

Lagos, the Socialist Party candidate under the Concertación, carried the 1999 presidential election, winning in a second round against Lavín Infante of the rightwing coalition Alianza por Chile (Alliance for Chile).

The Lagos Government, the third in the Concertación, was characterized by its preoccupation with macroeconomic stability, fiscal discipline, and the pursuit of growth, preserving the previous government’s economic policies ¹⁸18. Roberts KM. Chile: the left after neoliberalism. In: Levitsky S, Roberts KM, editores. The resurgence of the Latin American left. Baltimore: The John Hopkins University Press; 2011. p. 325-47.. During the first year of his term, he attempted to build a political base with the centrist parties.

Lagos’ commitments in the social area featured social policies for the poor population. Health reform entered the agenda of priorities at the beginning of his government, although there was no specific proposal for the health sector (interviewees E2; E4). One of the Lagos Government’s objectives was to conduct a reform that would guarantee health as a right protected by the State (E1).

Two important measures were launched by the Ministry of Health in 2000. The first established the health goals for the decade from 2000 to 2010 ¹⁹19. Ministerio de Salud de Chile. Objetivos sanitarios 2000-2010. Santiago de Chile: División de Rectoría y Regulación Sanitaria, Departamento de Epidemiología, Ministerio de Salud de Chile; 2002.. Four targets were set for the improvement of health indicators and services, to deal with challenges related to population aging and to decrease the country’s health inequalities. The second measure was the creation of an inter-ministerial commission to draft a health sector reform proposal ²⁰20. Lenz R. Proceso político de la reforma AUGE de salud en Chile: algunas lecciones para América Latina - una mirada desde la economía política. Santiago de Chile: Corporación de Estudios para Latinoamérica; 2007. (Serie Estudios Socio Económicos, 38)..

Michelle Bachelet of the Socialist Party was named Minister of Health and was responsible for conducting the reform, together with the Ministers of Finance and Labor and Social Security and the Chief of Cabinet. The Commission included an Executive Secretariat headed by surgeon Hernán Sandoval and a team of experts ¹⁴14. Olavarría MO, editor. ¿Cómo se formulan las políticas públicas en Chile? Tomo 2: el plan AUGE y la reforma de la salud. Santiago de Chile: Universitaria; 2012.. The broad discussion of the reform featured the National Congress and the Constitutional Court. Alternatives were debated, such as the return of the SNS and the creation of funds for guarantee of provisions (E2).

The Commission produced two reports that became bills of law. The first, submitted by Bachelet in 2001, dealt with patients’ rights and duties ²¹21. Biblioteca del Congreso Nacional de Chile. Historia de la Ley nº 20.584. https://www.bcn.cl/historiadelaley/fileadmin/file_ley/4579/HLD_4579_ae974d35083172604e6578d5ed1ede37.pdf (acessado em 22/Dez/2019).
https://www.bcn.cl/historiadelaley/filea... . This consisted of four bills of law submitted in 2002 and 2003 and the AUGE Plan, later renamed the Régimen de Garantías en Salud (GES) (Health Guarantees Regimen), which provided a list of diseases based on an epidemiological survey (E2; E5). For each disease, a clinical protocol was established for the various levels of care with guarantees of access, quality, financial protection, and timeliness ²⁰20. Lenz R. Proceso político de la reforma AUGE de salud en Chile: algunas lecciones para América Latina - una mirada desde la economía política. Santiago de Chile: Corporación de Estudios para Latinoamérica; 2007. (Serie Estudios Socio Económicos, 38)..

The GES and the four bills (Box 2) were developed by Sandoval and his team and submitted by Osvaldo Artaza, Bachelet’s alternate in the Ministry of Health. Artaza was succeeded in 2003 by Pedro García, who proceeded with the negotiations in Congress (E1; E8). In drafting the reform proposal, the experts drew on the Plan Garantizado de Beneficios de Salud, which proposed services provisions guaranteed by the State, drafted under the Eduardo Frei Government by then-Minister of Health Carlos Massad ²⁰20. Lenz R. Proceso político de la reforma AUGE de salud en Chile: algunas lecciones para América Latina - una mirada desde la economía política. Santiago de Chile: Corporación de Estudios para Latinoamérica; 2007. (Serie Estudios Socio Económicos, 38)..

Despite resistance by the Colegio Médico to the proposal to link the public and private sectors in the GES reform, splitting the proposal into separate bills facilitated approval by Congress and attenuated the clashes with the medical profession ¹⁸18. Roberts KM. Chile: the left after neoliberalism. In: Levitsky S, Roberts KM, editores. The resurgence of the Latin American left. Baltimore: The John Hopkins University Press; 2011. p. 325-47.^,2222. Dockendorff A. El Congreso Nacional y la reforma de salud en Chile. In: Olavarría M, editor. ¿Cómo se formulan las políticas públicas en Chile? Tomo 2: el plan AUGE y la reforma de la salud. Santiago de Chile: Universitaria; 2012. p. 183-205.. However, this division displeased part of the Concertación, contending that the proposal was insufficient to meet the health system’s needs (E2; E8).

Four of the five bills submitted to Congress, described in Box 2, pertaining to the reform’s financing, reorganization of the health authority’s and administration’s roles, regulation of the Isapre, and the GES Plan, were passed before the end of Lagos’ term.

The bill on patients’ rights and duties, the first submitted by then-Minister of Health Bachelet, had not been passed by the end of the Lagos Government in March 2006. Following debates with different stakeholders and social groups, the bill was redrafted and resubmitted in July 2006 by Michelle Bachelet, now as President of Chile.

The GES was negotiated with Congress, allowing political agreements for a long-term reform consistent with the population’s needs in terms of the right to health (E1; E2). Based on a pilot experience with the GES Regimen in 2002, the explicit guarantees were implemented over the course of three years in the Lagos Government. More diseases were added to the GES by subsequent governments.

In addition to the reforms implemented with the above-mentioned laws, the Lagos government carried out an important reform in the PHC model, a priority in the health policy. The Modelo de Atención Integral de Salud Familiar y Comunitario (Comprehensive Family and Community Healthcare Model) was implemented in 2005, oriented towards the renewal of PHC according to the Declaration of Alma-Ata²³23. Vega Romero R, Acosta Ramírez N. Mapeo y analisis de los modelos de atención primária en salud en los países de América del Sur. Mapeo de la APS en Chile. Rio de Janeiro: Instituto Sul-Americano de Governo em Saúde; 2014.^,2424. Almeida PF, Oliveira SC, Giovanella L. Integração de rede e coordenação do cuidado: o caso do sistema de saúde do Chile. Ciênc Saúde Colet 2018; 23:2213-28.. During the first governments of the Concertación, Chile was one of the pioneering countries in reorienting PHC, especially for Fonasa groups A and B.

Despite the strides in private sector regulation, the Lagos Government was unable to eliminate the effects of the private sector’s segmentation and discrimination. Some measures even expanded these effects, such as the authorization for the Isapre to create additional contributions to the mandatory contribution ²⁵25. Chile. Decreto con Fuerza de Ley nº 1. Fija texto refundido, coordinado y sistematizado del decreto ley nº 2.763 de 1979 y de las leyes nº 18.933 y nº 18.469. Diario Oficial 2006; 24 abr..

First Bachelet Government: strengthening the GES (2006-2010)

Michelle Bachelet of the Socialist Party, the first woman to be elected President of Chile, proceeded with the main economic and social policies of the Lagos Government. The two governments linked macroeconomic orthodoxy to redistributive social reforms, stepping up efforts in social protection, especially in health, social assistance, social security, and education ¹³13. Huber E, Pribble J, Stephens J. The Chilean left in power: achievements, failures, and omissions. In: Weyland K, Madrid R, Hunter W, editores. Leftist governments in Latin America: successes and shortcomings. New York: Cambridge University Press; 2010. p. 77-97.^,2626. Uthoff A. Aspectos institucionales de los sistemas de pensiones en América Latina. Santiago de Chile: Comisión Económica para América Latina y el Caribe; 2016. (Serie Políticas Sociales, 221).^,2727. Oliveira SC, Machado CV, Hein AA. Reformas da Previdência Social no Chile: lições para o Brasil. Cad Saúde Pública 2019; 35:e00045219..

The measures affecting the social determinants of health and social protection of Chilean families were expanded and became State policy (E12). These featured the inter-sector program Chile Crece Contigo (Chile Grows with You), under the Ministry of Social Development and the Family, dedicated to early childhood.

In the health sector, policy priorities expressed the predominance of continuities in the previous government’s agenda (E3; E4). The Office of the President and the Ministry of Health maintained the emphasis on PHC as the basis for the public healthcare model (E2). Budget funds were allocated for building the Family Health Community Centers to complement the Family Health Centers ²⁸28. Ministerio de Salud de Chile. Manual de apoyo a la implementación de centros comunitarios de salud familiar. Santiago de Chile: Subsecretaria de Redes Asistenciales, Ministerio de Salud de Chile; 2008..

The GES system was a priority strategy for planning and executing the public health sector‘s policies (E4; E6; E8), exemplified by the expansion in the number of diseases and procedures covered by the GES system (E3) and in the investments in health centers and hospital infrastructure. From 2006 to 2007, the list of diseases increased from 25 to 56 (Box 3) ²⁹29. Ministerio de Salud. Patologías garantizadas AUGE. http://www.supersalud.gob.cl/664/w3-propertyname-501.html (acessado em 12/Dez/2019).
http://www.supersalud.gob.cl/664/w3-prop... .

The series of expansions in the GES received criticisms, since many treatments were included due to lobbying by organized groups (E8). In 2009, health sector experts and the GES Advisory Board itself advised the Ministry of Health not to further increase the number of diseases covered by the GES, but to expand the basket of treatments that were covered. This advice was rejected by the Ministry of Health, which expanded the number of diseases to 69 in 2010 ³⁰30. Inostroza M, Sánchez H, editores. Construcción política del sistema de salud chileno: la importancia de la estrategia y la transición. ¿Cuáles son nuestras verdaderas posibilidades de cambio? https://www.ispandresbello.cl/wp-content/uploads/2019/08/construccion-politica-del-sistema-de-salud-chileno.pdf (acessado em 10/Out/2019).
https://www.ispandresbello.cl/wp-content... .

According to Huber et al. ¹³13. Huber E, Pribble J, Stephens J. The Chilean left in power: achievements, failures, and omissions. In: Weyland K, Madrid R, Hunter W, editores. Leftist governments in Latin America: successes and shortcomings. New York: Cambridge University Press; 2010. p. 77-97., the GES represented a turnaround in targeted and pro-market policies established under the dictatorship and a step towards more accessible medical care. However, it did not succeed in correcting the flaws in segmentation or in adjusting the unequal allocation of mandatory contributions to the health system.

During the first Bachelet Government, several key political leaders left the Socialist Party ³¹31. Biblioteca del Congreso Nacional de Chile. História política. Partidos, movimentos y coaliciones. https://www.bcn.cl/historiapolitica/partidos_politicos/wiki/Concertaci%C3%B3n_de_Partidos_por_la_Democracia#Elecciones_parlamentarias (acessado em 11/Dez/2019).
https://www.bcn.cl/historiapolitica/part... amid criticisms of ideological weakening of the Concertación parties. These breaks in political ties undermined the candidacy of former President Frei, and after 20 years, the coalition of center-left parties in the Concertación was defeated by Sebastian Piñera of the center-right alliance Coalición por el Cambio (Coalition for Change).

First Sebastián Piñera Government: the new health sector reform proposal (2010-2014)

Sebastián Piñera’s first term focused on political stability and strengthening Chile’s democracy, as in the governments of the Concertación, maintaining inflation under control and with growth of production and consumption ³²32. Grupo de Estudios del Capital. Tras las riendas del neoliberalismo: balance económico del Gobierno de Piñera. Santiago de Chile: Fundación Nodo XXI; 2014..

At the beginning of the Piñera Administration, public demonstrations, especially related to education, challenged the social foundations on which Chilean society was built and forced the government to change the social policy agenda ³³33. Avendãno OA. Las reformas políticas en el gobierno de Sebastián Piñera Chile, 2010-2013. Revista Mexicana de Ciencias Políticas y Sociales 2013; 58:167-91.. However, the main social protection strategy of the Bachelet Government, Chile Crece Contigo, suffered discontinuities and less public visibility during the Piñera Government ³⁴34. Bedregal P, Torres A, Carvalho C. Chile Crece Contigo: el desafío de la protección social a la infancia. Santiago de Chile: Programa de las Naciones Unidas para el Desarrollo - Chile; 2014..

In health, the Piñera Government’s plan determined five priorities: infrastructure improvement based on the construction of hospitals and clinics under a concessions system; modernization of health administration with the construction of self-administered hospitals; establishment of contracts with health service providers with targets and models for assessment; elimination of waiting lists for the GES diseases; and linkage between the public and private sector through the Bono de Garantía AUGE, with the objective of ensuring care for vulnerable persons in public or private institutions of their choice ³⁵35. Piñera S. Programa de gobierno para el cambio el futuro y la esperanza, Chile 2010-2014. Santiago de Chile: Coalición por el Cambio; 2009..

The Bono de Garantía AUGE aimed to include in the free choice modality approximately 3.5 million Fonasa group A beneficiaries, enrolled in the institutional care modality and that had only been accessing public healthcare establishments. This proposal was criticized by the opposition and did not materialize (E12). Another measure that faced opposition and claims of fraud was the publication of government data on the elimination of GES and non-GES waiting lists ³⁰30. Inostroza M, Sánchez H, editores. Construcción política del sistema de salud chileno: la importancia de la estrategia y la transición. ¿Cuáles son nuestras verdaderas posibilidades de cambio? https://www.ispandresbello.cl/wp-content/uploads/2019/08/construccion-politica-del-sistema-de-salud-chileno.pdf (acessado em 10/Out/2019).
https://www.ispandresbello.cl/wp-content... . An analysis by the Federal Comptroller’s Office revealed that documents on patient referrals to specialists had disappeared.

Meanwhile, there were limitations on private sector regulation, such as the unconstitutionality ruling by the Constitutional Court in 2010 as to the power of the Superintendency of Health to define risk-factor tables according sex and age in health plans. The Court ruled that this prerogative violated the principle of equality, the right to health, and social security ³⁶36. Luzuriaga MJ. Privados de la salud: las privatizaciones de los sistemas de salud en Argentina, Brasil, Chile y Colômbia. São Paulo: Hucitec Editora; 2018., and that the issue required specific legislation by Congress.

Measures related to prevention and health promotion were implemented during this period, featuring the program called Elige Vivir Sano (Choosing to Live Healthy). The Tobacco Control Law, one of the program’s nine goals for 2011-2020, set restrictions on tobacco consumption, sales, and advertising (E9).

This period also featured the creation of the Agencia Nacional de Medicamentos (AnaMed) (the National Drug Agency) and the regulation of the New Drug Law, previously not addressed by governments of the Concertación, and considered a successful policy under this government, since it favored guaranteeing quality medicines for the Chilean population (E11; E8). In addition, after 11 years of review, Law n. 20,584 of 2012 was regulated, establishing patients’ rights and duties.

The first rightist government since the dictatorial period continued the implementation of the GES. The list of diseases implemented by Bachelet in 2010 was maintained, and the number of diseases was expanded from 69 to 80 in 2013, corresponding to the protection of 60% of the burden of diseases in the Chilean population ³⁷37. Ministerio de Salud. En salud, Chile avanza con todos (2010-2014). Santiago de Chile: Gobierno de Chile; 2013., as shown in Box 3. However, the expansion of the GES list led to underfinancing of the public system, since the funds were not adjusted or expanded proportionally to the coverage ³⁰30. Inostroza M, Sánchez H, editores. Construcción política del sistema de salud chileno: la importancia de la estrategia y la transición. ¿Cuáles son nuestras verdaderas posibilidades de cambio? https://www.ispandresbello.cl/wp-content/uploads/2019/08/construccion-politica-del-sistema-de-salud-chileno.pdf (acessado em 10/Out/2019).
https://www.ispandresbello.cl/wp-content... .

Health sector reform was on the policy agenda in the Piñera Government, but its repercussions were limited. In the first year of Piñeras’s term, a Presidential Commission was assembled with 13 public health experts and which submitted two reform proposals. The first, supported by a majority of the commission, proposed a structural reform based on a multi-insurance system with a risk compensation fund between the public and private sectors. The second, by a minority of the commission, only referred to the private sector and to the introduction of public subsidy portability (E8). The first proposal was rejected by the Ministry of Health, which set up a new commission. In 2011, this commission in turn presented a report to Congress that only referred to the Isapre (E8). Since it failed to meet the interests of the Executive, Congress, and other groups, the draft remained in Congress awaiting an alternative proposal (E10; E8), which only came in 2019 during Piñera’s second term.

In the 2013 elections, nine candidates ran for President, and Michelle Bachelet was elected to her second term.

Second Bachelet Government: health reform obstructed (2014-2018)

Michelle Bachelet ran in the 2013 elections with the support of the Nueva Mayoría (New Majority) party coalition, proposing to implement three structural changes: educational, fiscal, and constitutional ³⁸38. Garretón MA. El proyecto de transformación y la crisis político-institucional de la sociedad chilena: el gobierno de Bachelet entre 2014-2016. In: Arqueros C, Iriarte A, editores. Chile y América Latina: crisis de las izquierdas del siglo XXI. Santiago de Chile: Instituto Res Publica, Universidad del Desarrollo; 2017. p. 209-44.. Her government’s program included important changes in relation to her first term. The renewal of the foundations for democracy, with the introduction of politically progressive proposals, indicated a change in the political, economic, and institutional structure inherited from the dictatorial period ³⁹39. Bachelet M. 50 compromisos para los primeros 100 días de gobierno. http://www.desarrollosocialyfamilia.gob.cl/btca/txtcompleto/50medidasMB.pdf (acessado em 14/Out/2019).
http://www.desarrollosocialyfamilia.gob.... .

Besides prioritization of the three reforms, the program included 50 measures from different sectors to be implemented in the government’s first 100 days. By the end of this period, 91% of the measures had been implemented, including: the creation of the Presidential Advisory Commission to analyze and propose a new legal regimen for the private health system and the delivery of the National Plan for Public Health Investments, 2014-2018 ³⁸38. Garretón MA. El proyecto de transformación y la crisis político-institucional de la sociedad chilena: el gobierno de Bachelet entre 2014-2016. In: Arqueros C, Iriarte A, editores. Chile y América Latina: crisis de las izquierdas del siglo XXI. Santiago de Chile: Instituto Res Publica, Universidad del Desarrollo; 2017. p. 209-44..

Other commitments by the government involved building and equipping urgency primary care services, agreements with municipalities for dispensing free medications to chronic patients, hospital construction, and funding for hiring specialists ³⁹39. Bachelet M. 50 compromisos para los primeros 100 días de gobierno. http://www.desarrollosocialyfamilia.gob.cl/btca/txtcompleto/50medidasMB.pdf (acessado em 14/Out/2019).
http://www.desarrollosocialyfamilia.gob.... .

Priorities of previous governments were maintained, such as strengthening PHC, restructuring hospital infrastructure, regulation of food labelling, and decreases in waiting times, especially for specialists (E6; E7; E12).

One of the government’s first measures for the health sector was the creation of an “Advisory Commission for the Study and Proposal of a New Model and Legal Framework for the Private Health System” ⁴⁰40. Chile. Informe estudio y propuesta de un nuevo marco jurídico para el sistema privado de salud. Santiago de Chile: Comisión Asesora Presidencial para el Estudio y Propuesta de un Nuevo Marco Jurídico para el Sistema Privado de Salud; 2014.. The commission, consisting of 18 specialists and led by economist Camilo Pedraza, drafted a proposal in 2014 for radical health sector reform ⁴¹41. Uthoff A, Cid C. La necesaria transformación del sistema de salud en Chile propuesta por la Comisión Cid. Cuad Méd Soc (Santiago de Chile) 2018; 58:41-8.. As short-term measures, mechanisms were established to eliminate payments associated with individual risks, including the same prices for premiums, regardless of sex and age. Long-term measures included the creation of a Single Fund for National Health Insurance and the preservation of voluntary complementary private insurance ⁴⁰40. Chile. Informe estudio y propuesta de un nuevo marco jurídico para el sistema privado de salud. Santiago de Chile: Comisión Asesora Presidencial para el Estudio y Propuesta de un Nuevo Marco Jurídico para el Sistema Privado de Salud; 2014.. Box 4 compares the reform proposals presented by the Presidential Commissions of 2010 and 2014, emphasizing aspects pertaining to financing, services provision, and regulation.

The proposal by the Presidential Advisory Commission, considered a radical and structural project, met with criticism by sectors connected to the Isapre (E14). Besides, the second Bachelet Government was marked by the introduction of reforms in various areas such as taxes and education in addition to the proposal for a new Constitution. The contextual analysis by the President and the Ministry of Health concluded that the political conditions were insufficient for implementing another radical reform such as that idealized by the Commission (E12; E13; E14). There were also reports of corruption involving Bachelet’s son in the second year of her term, exacerbating the political weaknesses and fueling clashes that jeopardized negotiations over the reforms, including the health reform (E7; E12).

As for incremental changes, in 2015, following widespread popular mobilization, the Ricarte Soto Law was passed, granting coverage for high-cost diseases for individuals enrolled in the public and private systems. As of late 2019, 27 high-cost diseases were covered, and as with the GES system, various groups were lobbying to incorporate new diseases.

In the last year of the Bachelet Government, another controversial topic was prioritized, namely the decriminalization of voluntary termination of pregnancy (E12). Despite resistance by conservative sectors of Congress and criticism by religious institutions, in 2017 the government regulated the law on decriminalization in three situations: risk to the mother’s life, pregnancy resulting from rape, and fatal fetal impairment. Passage of the law was one of the last important health measures by the Bachelet Government (E12).

Box 5 summarizes the principal characteristics of the institutional political context, agenda, and strategies for the health sector in the governments analyzed here.

Conditioning factors in the health system’s configuration

The analysis of the trajectory of health policies in Chile reveals three groups of conditioning factors in the relations between State and market and in the health system’s configuration during this period, namely structural, institutional, and political conditioning factors.

The structural conditioning factors involve the characteristic capitalist model of peripheral economies that reinforces social inequalities and the historical nature of social protection systems that reiterates the segmentation by social groups, as observed in the majority of Latin American countries ⁸8. Mesa-Lago C. Protección social en Chile: reformas para mejorar la equidad. Revista Internacional del Trabajo 2008; 127:462-80..

One structural conditioning factor concerns the radical reform implemented by Pinochet’s authoritarian government, which transformed State-market relations in health. A dual system was established with strong private participation and that gained a solid institutional basis and mobilized the interests of various political and economic organizations and actors ²2. Bustos CAM. Institucionalidad sanitária chilena: 1889-1989. Santiago de Chile: LOM Ediciones; 2010.. The free choice system, expanded under the military regimen, ensured the presence of the middle class in the public sector, but represented a central element in the private sector’s predominance in services provision ³⁶36. Luzuriaga MJ. Privados de la salud: las privatizaciones de los sistemas de salud en Argentina, Brasil, Chile y Colômbia. São Paulo: Hucitec Editora; 2018.^,4242. Goyenechea M, Sinclaire D. La privatización de la salud en Chile. Revista Políticas Públicas 2013; 6:35-52.. Workers’ compulsory contributions to the private sector in the free choice modality became part of the health system’s institutional arrangement. These factors raised obstacles to proposals for comprehensive structural transformations of the health system during the democratic period.

The dictatorship’s tactic for breaking with the mechanisms of solidarity between the public and private systems created, as an institutional legacy, a radical segmentation that persisted as a characteristic of the Chilean health system ³3. Labra ME. Política e saúde no Chile e no Brasil. Contribuições para uma comparação. Ciênc Saúde Colet 2001; 6:361-76.. The rules defining the dual structure and their respective interests hindered the introduction of radical changes in the health system, even with the proposals by the democratic governments. The current study corroborates the analysis by Labra ³3. Labra ME. Política e saúde no Chile e no Brasil. Contribuições para uma comparação. Ciênc Saúde Colet 2001; 6:361-76. that identified the difficulty in the introduction of structural changes in health systems after the historical consolidation of a given institutional format. The Chilean case illustrates a situation of “path dependence”, since governments with different political positions were unable to implement reform proposals, while the structural configuration of the health system adopted by Pinochet was maintained.

The implementation of incremental reforms such as GES have generated another segmentation in the system, aggravating the difference in access and waiting times between Chileans without and without GES coverage ¹²12. Tetelboin C. Tendencias y contratendencias en el sistema de salud de Chile en el marco de la situación regional. In: Tetelboin C, Laurell C, editores. O direito universal à saúde: uma análise da agenda latino-americana e controle. Buenos Aires: Conselho Latino-americano de Ciências Sociais; 2015. p. 75-97.^,2424. Almeida PF, Oliveira SC, Giovanella L. Integração de rede e coordenação do cuidado: o caso do sistema de saúde do Chile. Ciênc Saúde Colet 2018; 23:2213-28.^,3636. Luzuriaga MJ. Privados de la salud: las privatizaciones de los sistemas de salud en Argentina, Brasil, Chile y Colômbia. São Paulo: Hucitec Editora; 2018.. GES is financed by a regressive tax, and the system is limited by the demand for services that exceeds the public capacity to supply them.

Despite the contradictions produced by the GES reform, its continuity has been a priority healthcare strategy in governments of different political positions, with incremental adjustments (Box 3), in addition to its relevance for the improvement of conditions in healthcare access by the population in the public and private sectors, suggesting the importance of gradual institutional changes for achieving significant transformations in times of stability ⁷7. Mahoney J, Thelen K. A theory of gradual institutional change. In: Mahoney J , Thelen K, editores. Explaining institutional change: ambiguity, agency and power. Cambridge: Cambridge University Press; 2010. p. 1-37.. The Health Authority and Management Law, regulated in 2004, which reorganized the roles of health oversight, management, regulation, and provision, can be an important strategy from this perspective (Box 2).

Finally, in relation to political conditioning factors, proposals for health sector reform remained on the agendas of two consecutive governments after the implementation of GES. Still, the Piñera Government’s reform proposal ⁴³43. Chile. Informe Comisión Asesora Presidencial para el Estudio y Propuesta el Sistema Privado de Salud. Santiago de Chile: Comisión Asesora Presidencial para el Estudio y Propuesta el Sistema Privado de Salud; 2010., more limited to the private sector, stalled in Congress. Meanwhile, the proposal drafted in the second Bachelet Government ¹⁹19. Ministerio de Salud de Chile. Objetivos sanitarios 2000-2010. Santiago de Chile: División de Rectoría y Regulación Sanitaria, Departamento de Epidemiología, Ministerio de Salud de Chile; 2002., more radical, was not even submitted to Congress (Box 4), since resistance to it had been identified and other conflicting reform bills were being negotiated at the same time, such as the educational reform bill.

In addition, the heterogeneous and pluralist nature of the center-left parties comprising the Concertación and later the Nueva Mayoría created obstacles, especially in the governments of Michelle Bachelet, affiliated with the Socialist Party, with a reformist profile ³⁸38. Garretón MA. El proyecto de transformación y la crisis político-institucional de la sociedad chilena: el gobierno de Bachelet entre 2014-2016. In: Arqueros C, Iriarte A, editores. Chile y América Latina: crisis de las izquierdas del siglo XXI. Santiago de Chile: Instituto Res Publica, Universidad del Desarrollo; 2017. p. 209-44..

In the second Bachelet Government, the existence of structural reform proposals in different areas and the President’s dwindling political support base jeopardized negotiating a reform focused on reorientation of the health system from a more comprehensive social welfare perspective.

Conclusion

In Chile, following re-democratization, the reform proposals that aimed to alter the health system’s structure to regulate the private sector and strengthen the public sector, especially those presented by center-left governments, encountered structural, institutional, and political limits, creating an example of path dependence on the structural reform carried out under the military dictatorship.

There were elements of continuities and changes throughout the governments of different political positions. In terms of continuities, the democratic governments were unable to implement sweeping health reforms, but they did adopt incremental changes that expanded health services access and provision, such as the incremental changes in PHC and the GES strategy.

The reform agendas under governments of various political positions differed from each other in some ways. Despite the limited effects of the proposals’ materialization, the agendas generally featured initiatives to strengthen the public sector on the agenda of center-left governments and a focus on the private sector in the agenda of the center-right government.

The study prioritized the analysis of official documents and interviews with policymakers that worked in the National Executive, but did not include other government officials or nongovernment actors. Further studies are need for a more in-depth analysis of public-private relations in the organization, financing, and provision of health services, as well as their effects on the health system’s results.

In Latin America, the Chilean model inspired reforms focusing on greater private sector participation in health. Still, this model showed signs of exhaustion, expressed in late 2019 in the wave of protests that culminated in the promise of a new National Constitution and that refueled the debate on health sector reform in academia, professional societies, and civil society. The new scenario has opened possibilities for redirecting health policies in Chile. It remains to be seen whether the Chilean people’s aspirations will win out over the interests of economic and political groups that have benefited from the Chilean health system’s dual structure.

Acknowledgments

S. C. Oliveira holds a scholarship from the Brazilian Graduate Studies Coordinating Board (CAPES/PDSE/case n. 88881.189908/2018-01) and C. V. Machado holds a research grant from the Brazilian National Research Council (CNPq). The authors also wish to acknowledge the PROEX-CAPES-ENSP Call for Projects-2018 for the financial support.

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