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Violent protests in Chile linked to health-care inequities

Many grievances are driving civil unrest in Chile, but inequities in the health-care system are a key one. Barbara Fraser reports.

Latin Americans were shocked to see Chile erupt in street demonstrations and looting, followed by a violent crackdown by security forces, after the government announced a transit fare increase of 30 pesos, equivalent to US$0·04, in October.

Slogans chanted by protesters—including “It’s not 30 pesos, it’s 30 years” and “Chile awoke”—hinted at long-standing discontent behind the apparently sudden upheaval. The fare hike “was just the trigger”, said economist Guillermo Paraje of Adolfo Ibáñez University in Santiago. “If it wasn’t that, it would have been something else.”

The protests, which began in Santiago and spread throughout the country, stripped away Chile’s veneer of tranquillity, exposing discontent over deep inequalities that has been building since the military government of Augusto Pinochet instituted neoliberal reforms in the 1980s.

Chile and Mexico, the only Latin American countries in the Organisation for Economic Co-operation and Development (OECD), are also among the most unequal, with the income of the wealthiest people more than 25 times that of the poorest.

Chilean officials set an insensitive tone at first, with President Sebastián Piñera saying the government was “at war” with the protesters and the economy minister suggesting that commuters who wanted to avoid the fare increase should leave for work earlier, when transit fares were lower. The minister later apologised.

As the protests continued into a third week, Piñera suspended a November meeting of the leaders of Pacific Rim countries and an international climate summit scheduled for December.

The fare hike had been announced days before the unrest began. On Oct 17, students began jumping subway turnstiles. Wider protests the next day turned violent, with demonstrators looting and setting subway stations, vehicles, and some public buildings ablaze.

On Oct 19, Piñera declared a state of emergency in Santiago and several smaller cities, sending the police and military into the streets in a show of force that was strange to young Chileans, but all too familiar to older residents who remember human rights violations during the Pinochet years, said Alejandra Vives, associate professor of public health at the Pontifical Catholic University of Chile in Santiago.

At least 18 people were killed during the protests, according to the Interior Ministry. More than 1000 were injured and at least 3500 were arrested, according to the National Institute of Human Rights, which also filed legal complaints about cases of rape and torture by security forces.

The grievances that drove hundreds of thousands of Chileans—estimates reached nearly 1 million on Oct 25—into the streets included costs associated with health care and education and long-standing anger about the private pension system.

Underlying all of these grievances are the frustrated expectations of middle-class Chileans, half of whom earn less than about $600 a month. Polls show dissatisfaction with jobs and wages that do not stretch to cover expenses, including health care.

Health indicators such as infant and maternal mortality have improved considerably in recent years, although they are still among the highest in the OECD. Under-5 mortality has fallen from 19·1 deaths per 1000 livebirths in 1990, to 10·9 in 2000, and 7·4 in 2017. Similarly, maternal mortality dropped from 57 deaths per 100 000 livebirths in 1990, to 22 in 2015.

Nevertheless, people still feel “a sense of uncertainty, of anxiety, of what will happen if someone gets sick—that the system won’t respond if needed”, Paraje said.

Technically, Chile has universal health care, with everyone covered under the public National Health Fund. However, the country has a two-tier system, in which the public system covers about 78% of the population and private insurers cover about 17%. The small remainder is covered by the police or military systems.

The public system is chronically underfunded, with a deficit of $1·15 billion in 2018. According to Antonio Infante, who has administered one of Santiago’s largest municipal systems and served as undersecretary in Chile’s Health Ministry, one effect of the budget shortfall is long waiting lists for certain surgeries. Although the Health Ministry has made efforts to clear waiting lists, long delays persist, especially for conditions not included under the mandatory coverage plan. In 2016, the OECD warned that “the public system overwhelmingly covers the poorest while competing private insurers select good risks and apply different premiums, sometimes penalising those with greater needs”. “There is room for improving the system by moving towards a unified, equitable social security system for the entire population.”

Under a 2005 law, both the public and private systems are required to cover 56 medical conditions, including many chronic conditions. This system of “explicit health guarantees”, which has since been expanded to more than 80 conditions, has reduced inequalities between the two systems but has not eliminated them, said Cristian Herrera, a Chilean health policy analyst at the OECD.

In the public system, primary care is funded by the state but managed by municipal governments. As a result, the efficiency of the primary care system varies from one municipality to another, and there can be high management turnover, as administrators are often replaced when a new mayor takes office, said Infante. Where primary care is inefficient and wait times long, many Chileans go straight to hospital emergency rooms instead. Chile’s out-of-pocket expenditures as a proportion of total health expenditures are also among the highest in the OECD, at 33%. Nearly a third of that amount is due to drug expenditures, with another 30% divided between dental costs and doctor visits, according to a study by public health expert Pablo Villalobos of the University of Santiago. The OECD has made various recommendations, including better regulation of the private insurance market and lower copayments for medicines.

On Oct 23, Piñera announced a series of measures that include a pension increase, a guaranteed minimum wage of about $460 a month, electricity rate controls, higher taxes on those earning more than about $10 700 a month, and more equitable financing of public services, including health, to reduce the gap between wealthier and less wealthy municipalities.

Specific health-related proposals included a ceiling on families’ out-of-pocket expenses for catastrophic illnesses, creation of an insurance plan to cover drug costs not covered under existing plans, and expansion of an agreement between the public health service and private pharmacy chains to reduce the cost of medicines for users of the public system.

But these are technical fixes to a problem that needs a political decision about what role, if any, the private sector should play, Villalobos said.

There have been various attempts at health reform over the past two decades, but much remains to be done, according to the OECD report and Chilean experts. Most recently, a commission formed in 2014 by then-President Michelle Bachelet to propose changes to the private insurance system failed to reach consensus and never submitted a proposal to the legislature.

There is growing pressure to eliminate the private insurance system, said Paraje, who served on that commission, but private insurers have resisted that suggestion. Health-care reform should be accompanied by changes in the pension system, he said, because retirees are hit even harder by the cost of medicines and by out-of-pocket expenses if they seek care in the private system.

The right to “free and egalitarian access” to health care is enshrined in Chile’s constitution. The constitution also guarantees that “each person has the right to choose the health system they wish to join, either state or private”. Because of that language, elimination of the private system could require a change to the constitution, said Cristian Montenegro, a sociologist at the Pontifical Catholic University of Chile. Although there have been some calls for a revamping of the constitution, that would be a long process requiring a constituent assembly, and is not likely in the near future, he said.

As the protests continue, it is not clear how the government will address the multiple, dispersed demands. A cabinet shake-up on Oct 28 failed to stem the protests, and calls have mounted for Piñera’s resignation.

Chile’s upheaval is a cautionary tale for other Latin American countries that have wide income gaps and that still depend largely on revenues from exports of raw materials, placing them at the mercy of global market forces. Income inequality is greater in Latin America than in any other region in the world. “In many rankings, [Chile] has done well in the region”, Montenegro said. “It seemed to be economically and institutionally stable. But the price of this progress was the inequality it created.”

Source: www.thelancet.com

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