UHC in Latin America: Learning from the Past, Planning for the Future

Last week I participated in the launch of a new Lancet series on universal health coverage (UHC) in Latin America, which aims to showcase and contextualize how the UHC experience has played out to date in the region.  And there is a lot to showcase: convergence –as advocated by Larry Summers and colleagues in the Global Health 2035 report – is almost complete in the region, with infant mortality and under-5 mortality similar across many countries with economies of very different sizes. Still, in spite of large increases in public spending, within-country inequalities are still pronounced and out-of-pocket spending remains stubbornly high[1], even in public health success stories like Brazil. Participants at the event highlighted obstacles to faster progress in these areas, including the fragmentation of risk pools and payment arrangements. Further, citizens’ perceived satisfaction with health systems has remained flat over time, and new pressures associated with growing economies and expectations are increasingly in play.

While the series looks to the past for lessons, I am increasingly worried about the future. The choices made today about what health benefits to cover with public monies will have implications for well-being and spending tomorrow. In a paper released last week, Juan Ignacio Zoloa and I explore what past levels and patterns of aging, risk factors, service utilization, and spending in Brazil, Chile and Mexico might mean for future public spending requirements. Without reforms aimed at expanding policies and programs to prevent disease and enhance the efficiency of health systems, we find that health spending will likely grow considerably in the not-distant future without necessarily improving health access or outcomes. We use long-term fiscal projection techniques employed by the OECD and the Congressional Budget Office to model future spending requirements in the US and Europe, techniques not commonly used in low- and middle-income countries.

The Pan American Health Organization’s Directing Council recently passed a resolution on UHC after weeks of tough debate.  The resolution sets out a vision for UHC in the Americas, finally going beyond the “basics” of maternal and child health care which have been the focus of many health systems in the region for decades. But the goals are ambitious: greater access to a “comprehensive, universal package of legally guaranteed services to be progressively expanded in accordance with health needs, system capacities and national context” and elimination of out-of-pocket spending on health, among others. Is the region set for an order of magnitude increase in public spending on health? What reforms need to be undertaken to assure that coverage expansions are high impact on health and fiscally sustainable?  What we decide today will play out tomorrow.