Chile: New Constitution and the possibility of reforming the health system

Camilo Bass* and David Debrott Sanchez**

After more than 45 years, with Chilean society walking the path of neoliberalism, on Friday, October 18, 2019, the Chilean people rose up, the most immediate cause being a public transportation fare increase, to say enough is enough to the prevailing inequality and exclusion. As a consequence of the social uprising, the Chilean political class launched an operation to both close down and salvage the established power structure through a Constitutional Convention that would channel, via institutional means, a process of impeachment that would lead to the fall of President Piñera and his government, which had become a violator of human rights.

Within this institutional framework negotiated by the political class, the plebiscite held in October 2020 showed that almost 80% of voters decided to change the Constitution inherited from the dictatorship, and expressed their desire to exclude members of Parliament from the drafting of the new Magna Carta, opting for a Convention entirely elected by popular vote and with the participation of independent lists.

Subsequently, the election of delegates was extraordinary, favoring representatives of social movements, as opposed to the traditional political parties that have administered the post-dictatorial stage.

However, the process has not been without problems, tensions, and critical stumbling blocks, with the onslaught of classic traditional politics threatening to hijack the new Constitution or simply reject all the work.

The role assumed by the socialist collective and the Broad Front in systematically boycotting proposals for deeper transformation, especially in economic matters, led by the former People's List, social movements, the Communist Party, and independents, has been denounced in various publications and national debates. (1)

The process of democratic and pluralistic debate surrounding the New Constitution has been very complex, since the fraudulent current constitution produced radical changes with a legal framework in our society as a consequence of its neoliberal reforms, privatizing social security, the (former) national health service through the modulation of a model of for-profit financial insurers such as the Private Health Insurance Institutions (ISAPRE) and also pensions through the Pension Fund Administrators (AFP). (2)

Due to the above, the Health System is currently in a serious crisis. Composed of several fragmented and segmented systems, it produces segregation of the population in access to healthcare and a complete lack of capacity for comprehensive health care, establishing one healthcare system for the poor and sick and another for the rich and healthy. The public sector is chronically underfunded and losing capacity, while the private insurance sector discriminates based on economic status, health condition, sex, age, and other arbitrary factors, lacking solidarity, efficiency, and effectiveness. This situation is associated with high out-of-pocket expenses for families, which account for at least 32% of total health expenditure (according to the World Health Organization, out-of-pocket expenses in countries with recognized high-performing health systems do not exceed 10 to 15% of total health expenditure). (3)

Furthermore, as a result of the last health reform process (2005) under the Concertación coalition, which did not produce significant changes in the system's structure, the Explicit Health Guarantees (GES) program was implemented, with a current list of 85 diseases or conditions that provide access to specific health interventions under certain conditions. Its positive effects have been more limited than has been portrayed since the [unclear - possibly "the GES"]. health establishment of functional public health, They must not hide their significant problems: excessive bureaucracy, discrimination against all other non-GES pathologies, significant diversion of public resources to the private for-profit healthcare system, and a rationale that has strengthened the curative, medicalized, and hospital-centric logic. (4)

In the current constitutional proposal, from a broad and intercultural political and social perspective, there are significant advances in favor of the majority of Chilean society. However, in the field of Health, as well as in other areas such as pensions, the consensus reached leaves the door open to an institutional reconfiguration with a different face, a cosmetic change, but mediated by the market and companies that seek profit as their main motivation. (5)

Due to the above, during the constituent process, three popular legislative initiatives, which garnered over fifteen thousand signatures of citizen support, presented by the National Confederation of Municipal Health (Confusam) (6), the National Confederation of University Professionals in Health Services (Confederación Fenpruss) (7), and the Health as a Right Assembly (8), after a process of systematization, managed to draft a single proposal that synthesized the common elements, characterized by a broad and comprehensive vision of health, considered a fundamental human right, of a collective nature and embedded in social security, reinforcing the concept of the social construction and determination of health. Mandating the State to establish a single and universal public health system, financed through general taxes and with the intention of moving towards the complete free provision of care and, therefore, the elimination of out-of-pocket expenses and costs related to health problems. (9 and 10)

Undoubtedly, the most relevant aspect of this proposal was to end the dual nature of the Chilean healthcare system, which has been widely documented and criticized internationally. This dual nature is inspired by neoliberal logic, in which the right to health (referred to by the World Bank as the right to social protection of health) is individual and where the State guarantees the “freedom to choose” between a public and a private system. This neoliberal fallacy is based on the idealization of the abstract and theoretically identical individual, obscuring the enormous inequality in health conditions (risks) and, particularly, the inequality in economic conditions (income). (11)

The finally approved proposal emphasizes the nature of a national health system; removes freedom of choice as the primary right; and considers the health of Indigenous peoples. Unfortunately, it failed to address some relevant aspects of popular initiatives, stripping the right to health of its social component, since the current wording of the law is clearly interpretable as an individual right. Furthermore, it perpetuates the continued presence of for-profit private providers at the heart of the healthcare system, thus maintaining a market based on the suffering caused by illness.

Despite these weaknesses, once the exit plebiscite is over, it would be appropriate to maintain the mobilization of social organizations to advance towards the refounding of a single, universal healthcare system. However, those who failed to foresee the social uprising are now attempting to force opportunistic agreements that obscure the structural transformations proposed for the collective rights of the majority.

Regarding pensions, it is unusual that parties within the current government support maintaining individual capitalization without mentioning solidarity, pay-as-you-go systems, or defined benefits. As for the healthcare system, the government is conditioning its support for the "Approve" option on transforming the system into a "Single Health Insurance" that protects the "freedom to choose" providers, once again using as its roadmap the current proposals from international organizations such as ECLAC, the World Bank, and PAHO/WHO for "single insurance" systems to redistribute "risks" and a fund to modulate coverage.

Absolutely contrary to what the New Constitution proposes, which does not refer to the existence of “insurance” (which is always “unsafe”), expressly stating that the health system will be based on primary care, which implies a concrete way of satisfying the needs for comprehensive care, which cannot be interpreted under the “commodified” and “neoliberal” logic of the fallacious “freedom of choice”, nor to modulate coverage with insurance, which is the basis of the current Constitution of the dictatorship. (12)

Therefore, we face a new problem related to pro-market versus socio-health proposals, because the differences between having a single health insurance system and moving towards a National Health System (National Health Service) are very significant. The current Ministry of Public Health in Chile has reduced this tension and roadmap by simply calling the “single health insurance” (that is, an insurance-based system) a “Universal Health System.” This is obviously done without understanding or studying in depth, and grotesquely simplifying the epidemiological, demographic, health, and intercultural implications and challenges of building Universal and Intercultural Health Systems in the 21st century.

The disadvantages of relying solely on a single insurance system, which would further expand the banks' "universal insurance" model, are significant. This perpetuates the logic of individual insurance, demand-side subsidies, the commodification of healthcare and profit-making using public resources, the separation of functions, bundled services and coverage for specific conditions, and the manipulation of a state that functions in conjunction with the market. It also weakens the public healthcare system, as the external purchase of private services could be carried out without regard for health criteria, among other issues.

Quite different is the idea of ​​re-establishing a National Health Service or System, characterized by funding through progressive general taxes. Rethinking a Unified System in the 21st century, in addition to being nationally funded and seeking comprehensive responses (without discrimination based on age, sex, or illness), requires a robust public provider system (private providers should be only complementary and non-profit), with a strategy centered on comprehensive health care and well-being. This approach highlights the importance of territory and the territoriality of collective ways of life, fostering a respectful dialogue between allopathic care and ancestral and popular knowledge, aiming to create synergy within a universal and intercultural system. Furthermore, it strengthens the autonomy and ecological knowledge of communities in generating care processes aligned with the dynamics of their own territories, as well as co-management at all levels of public health facilities with community participation.

This is no longer about reforming the reform, but about creating a strategy conceptualized as a Universal and Unified Health System. This system utilizes the most equitable financing possible, promoting justice in the source of resources and in health outcomes, and building a network of responses with comprehensiveness and interdependence. It places interculturality at the center of care strategies. Furthermore, it is guided by the principles of universality, comprehensiveness, and democratization, promoting responses to the health needs, problems, and priorities of everyone. This involves a holistic understanding of the health-disease-care process at a collective (not just individual) level, making it more feasible to end the commodification of health and the profiteering from public resources.

That is why it is so important to join forces from trade unions, social organizations and the health sector, users and citizens around these common axes, valuing the effort and generosity of the organizations and leaders who have put the common good and collective health above other legitimate interests and demands. 

Likewise, it is essential to organize work and social control in perspective of the debate that will open around the laws that will interpret and implement the New Constitution, immediately after September 4, where we hope with deep conviction for a new triumph of the people and dignity.

* Chilean public health specialist and researcher with the Working Group CLACSO International Health and Health Sovereignty
** Chilean economist.

This text expresses the position of the CLACSO Working Group on International Health and Health Sovereignty.

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References:

1. https://www.ciperchile.cl/2022/08/19/por-que-tanta-neofobia-asimetrias-constitucionales-y-pequeneces-partidarias/
   https://www.clacso.org/boletin-70-nuestra-america-xxi-desafios-y-alternativas/
   https://www.revistadefrente.cl/unidos-y-unidas-para-aprobar-una-nueva-constitucion-reacciones-y-balance/
2. Tetelboin, C. (2009). Evaluation of health and social security reforms in Latin America. XXVII Congress of the Latin American Sociological Association. VIII Sociology Conference of the University of Buenos Aires. July 30, 2019, Latin American Sociological Association, Buenos Aires. Accessed August 26, 2022, available at: http://cdsa.aacademica.org/000-062/1495.pdf
3. Benítez, A., Hernando, A., Velasco, C. (2018). Snapshot of out-of-pocket health spending in Chile: Analysis of the change in spending between 2012 and 2016. Reference Points MR, Digital Edition. No. 491, Center for Public Studies. Reviewed on 08/26/2022, available at: https://www.cepchile.cl/cep/site/docs/20181023/20181023161058/pder491_abenitez.pdf
4. Basile, G. and Hernández Reyes, A. (2021). Refounding health systems in Latin America and the Caribbean: decolonizing theories and policies. 1st ed. Autonomous City of Buenos Aires. CLACSO Working Group on International Health and Health Sovereignty. Reviewed on 26/08/2022, available at: https://www.clacso.org/refundacion-de-los-sistemas-de-salud-en-america-latina-y-el-caribe/
5. Constitutional Convention. (2022). Proposed Political Constitution. Retrieved 26/08/2022, available at: https://www.chileconvencion.cl/wp-content/uploads/2022/08/Texto-CPR-2022-entregado-al-Pdte-y-publicado-en-la-web-el-4-de-julio.pdf
6. Confusam. (2022). Proposal for a Popular Initiative for a Constitutional Norm. National Confederation of Municipal Health. Reviewed on 08/26/2022, available at: https://confusam.cl/web/wp-content/uploads/2022/01/Propuesta-Iniciativa-Popular-de-Norma-Salud.pdf
7. Fenpruss. (2022). Popular Initiative for a Law on the Right to Health No. 4.126. National Confederation of University Professionals in Health Services. Reviewed on 08/26/2022, available at: https://fenpruss.cl/?p=12212
8. Cabildo Health a Right. (2022). Popular Initiative for a Law on the Right to Health No. 9.026. Reviewed on 08/26/2022, available at: https://www.elciudadano.com/chile/iniciativa-popular-de-norma-para-un-sistema-unico-de-salud-entre-las-mas-votadas-en-la-convencion-constitucional/01/07/
9. Health as a Right Council, CONFUSAM, FENPRUSS. (2022) Common Axes Constitutional Proposal: Right to Health – Single and Universal Health System. Reviewed on 08/26/2022, available at: https://drive.google.com/file/d/1BizfiKz–5urWyEIezYWvl8NQWtYjKi7/view
10. Debrott, D. (2022). Right to health in collective reformulation. Reviewed on 26/08/2022, available at: https://www.ciperchile.cl/2022/03/02/derecho-a-la-salud-en-reformulacion-colectiva/
11. Confusam (2022). Constitutional Convention: The right to health in the final stretch. Reviewed on 26/08/2022, available at: https://confusam.cl/infusam-18/convencion-constitucional-el-derecho-a-la-salud-en-la-recta-final/
12. https://www.change.org/p/carta-abierta-por-el-apruebo-sin-apellidos-ni-condiciones