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Latin America Upper-middle-income countries

Achieving universal health coverage in Costa Rica

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The last of GNHE’s country assessments was published today. Written by Pablo Slon, it examines the progress of Costa Rica towards universal health coverage.

As Pablo Slon writes, one of the main features of the Costa Rican health system is the existence of a single health insurance fund, just as in the United Kingdom, France and Canada. Prepayment is mandatory for the whole working population and employers, and health insurance coverage in 2011 was 86%. Health services are provided mainly by this health insurance fund, with the coexistence of private sector provision. Health services are free at the point of access.

There is equal access to public health services because there is high coverage in terms of provision. There is also equality of financial risk protection.. The factors explaining these achievements include various institutional factors and health system characteristics.

One of the explanatory factors is the fact that Costa Rica ‘started small’ with an early political agreement to develop a Bismarck-style insurance system for the working class. A gradual process of including progressively more groups into this insurance system played a major role.

The existence of a tripartite financing scheme – involving employers, employees and the state in contributing to a common fund – creates cross-subsidies that allow access to health care across different population groups. Having a single risk pool is also a key factor. The existence of a private sector that complements the public sector allows those who do not want to use public services to reduce the demand on the public system. Last, but not least, low income-inequality and poverty within the country helps to reduce economic barriers to accessing health services. Democratic institutions and the rule of law support the performance of the health system through accountability, supervision, law enforcement and regulation.

However, the fact that the public health insurance fund is the main revenue collector, purchaser and provider creates some conflict of interests from the perspective of regulation. This is because the lack of separation of functions weakens the allocation process and oversight of performance. It also gives the fund enormous economic and political power, constraining the stewardship role that should be played by the Ministry of Health.

A future challenge is to ensure the financial sustainability of the National Health System in the face of demographic changes, with the proportion of elderly people growing. There is also an epidemiological challenge because chronic diseases are becoming more prevalent. Finally, there is a portion (14%) of the population that is not insured. Although they can access care if they require services, they have to pay fees for these services, which can impoverish them as they could incur into catastrophic expenditures. An additional problem is that this segment of the population mainly accesses emergency services, and they are not able to get appointments for outpatient services. Insuring this remaining portion of the population and charging for services properly after they have been used are important challenges.

Finally, more data are needed to understand whether the Costa Rican health care system is closing the gap between health care needs and health care provision, especially across all socio-economic groups. There are some indications that there are remaining differentials in actual and perceived health status across different income quintiles, and that waiting lists prevent some patients receiving prompt attention.


Pablo Slon. 2017. Universal health coverage assessment: Costa Rica. Global Network for Health Equity. 

Latin America Lower-middle-income countries

Achieving universal health coverage in Bolivia

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To celebrate the start of a new year, GNHE has published an assessment of progress towards universal health coverage in another country – Bolivia.

You can read the full assessment here.

The author is Cecilia Vidal Fuertes and her main conclusions are:


Bolivia has recently made important progress towards the goal of universal coverage by injecting additional funds (mainly from general revenues) into the health system and pooling them more effectively to spread financial risks. Total health expenditure as a percentage of GDP and total per capita health expenditure have also risen considerably over the past decade.

There have also been efforts to reduce financial barriers to access and the financial risks of illness. Over the past two decades, large inequalities in health outcomes and health service utilisation motivated the implementation and expansion of public insurance schemes, which covered vulnerable populations (pregnant woman, children and the elderly), providing access to government-financed services and eliminating fees for selected health services. As a result, general government expenditure on health as a percentage of total health expenditure rose to 78% in 2013, while out-of-pocket payments fell to 20%.

Despite this progress, there are several challenges in terms of risk pooling and strategic purchasing. In spite of more funds flowing into the system, risk pooling in Bolivia remains very fragmented. There are separate pools at the municipal level to finance national public health insurance schemes, as well as independent pools among social security managerial entities. This affects the efficiency and equity of the overall system and, more specifically, reduces its capacity to provide cross-subsidies between different income groups and health risks.

In terms of purchasing, different mechanisms apply to the national public health delivery system, public insurance schemes and social security. There is a need to analyse and implement the most efficient payment mechanisms in order to achieve strategic purchasing in support of universal health coverage.

In assessing progress towards universal health coverage, the most direct indicators of financial protection are the extent of catastrophic health expenditure and impoverishment due to health care spending. Both indicators for Bolivia are relatively low compared to other countries, suggesting improvements in financial protection. This result is consistent with decreasing levels of out-of-pocket payments. However, these indicators do not capture those people who cannot afford to pay for any care (even subsidised health care in public health facilities) and are still not covered by public insurance.

The question of who pays for health care is addressed through a progressivity analysis of multiple financing mechanisms. There is evidence that resources from general taxation are regressive, as well as employers’ contributions to mandatory social security. By contrast, there is evidence that out-of-pocket payments in Bolivia, which constitute the largest fraction of private spending, are progressive, as it is the more affluent population groups that incur higher payments. The net effect is probably a slightly regressive health financing system, however.

The analysis of equity in health care utilisation relative to need is important for the assessment of the health system in relation to the goal of universal health coverage. In Bolivia, the positive value of the concentration index for overall health service utilisation indicates that utilisation is still concentrated amongst the better-off. Although services provided in public facilities seem to be equally distributed across socioeconomic groups, those provided by social security and private for-profit facilities are highly pro-rich. Hospital health services, regardless of type of provider, tend to be more concentrated among the higher socioeconomic groups.

In terms of coverage, Bolivia still faces important challenges to securing financial protection for its whole population. Overall, health insurance coverage is still low. Public health insurance is heavily concentrated on specific vulnerable populations, and social security only reaches around one third of the population. It is a big challenge to find ways to expand financial protection to the self-employed and those in the informal sector using innovative schemes.

Another key challenge is equalising or universalising the benefits covered by all of these schemes. Only a small fraction of the population has access to a comprehensive set of services and is partially protected from severe financial risk (that is, those people belonging to social security affiliates). Services covered by public health insurance are limited in terms of scope, with only partial coverage for catastrophic conditions.

Finally, another main challenge that lies ahead is improving the overall efficiency and quality of the health service network, including expanding and improving health infrastructure to make services available to all. Distributing human resources efficiently and equitably is part of this challenge.

Further analysis is required to monitor and assess the health financing system in Bolivia comprehensively, to explore catastrophic health spending and impoverishment in vulnerable populations, and to evaluate the progressivity of health expenditure. For this task, updated National Health Accounts information and timely micro-level data from household surveys are a priority.


Fuertes, CV. 2016. Universal health coverage: Bolivia. Global Network for Health Equity (GNHE). Available at:

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Measuring progress towards UHC

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If you missed our posts last year, remember to read GNHE’s perspective on practical approaches countries can take to measuring their progress towards UHC.

A summary of key messages on this topic is available here.

Two policy briefs that provide more details on how to measure progress towards access and financial risk protection, respectively, are available here.

Africa High-income countries Latin America Low-income countries Lower-middle-income countries South-East Asia Upper-middle-income countries

Key messages on UHC measurement

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With the inclusion of universal health coverage (UHC) in the Sustainable Development Goals (SDGs), there is considerable discussion on how best to measure progress to UHC. This note summarises the perspective of the Global Network for Health Equity (GNHE), a network that brings together the views and experience of a diverse network of researchers based at country level in Africa, Asia and Latin America.


Guiding principles

  • Our concern is with UHC as defined according to outcomes, namely access to needed health services of sufficient quality to be effective, and financial risk protection for all. Within this context, measurement of these outcomes must be independent of the structure of financing and provision in a health system.
  • In order to allow comparison across all countries irrespective of their income level, UHC measures must use data that are likely to be available across a diverse range of health systems, or for which there are reasonable substitutes.
  • GNHE supports the use of a small number of key indicators rather than a single composite UHC indicator, which obscures the multi-dimensionality of UHC as a concept. However, indicators of the two key elements of UHC should be assessed and interpreted together.
  • Monitoring of progress towards UHC should not only be measured in terms of each indicator’s overall average, but also the narrowing of differentials across socio-economic groups to take account of equity.


UHC goal of access to health services for all

  • Due to the complexity of measuring access directly, we propose measuring actual use of services.
  • Instead of focusing on a few services (such as antenatal care and immunisations), GNHE proposes assessing the adequacy and equity of overall service utilisation.
  • We recommend a minimum average utilisation rate of 4 outpatient visits per person per year; utilisation rates below this threshold suggest that a country is unlikely to have adequate access to services.
  • For inpatient services, a minimum threshold of 100 inpatient discharges per 1,000 population per year is recommended.
  • To assess equity, these minimum thresholds should be achieved in all socio-economic groups. Given that service utilisation should be according to need, the difficulty of accurately measuring need for health care and the generally greater burden of ill health among lower-income groups, utilisation rates should be at least equal across socio-economic groups.
  • Further work is required to develop an appropriate means of assessing quality and effectiveness of services used.


UHC goal of financial risk protection

  • Indicators of catastrophic levels of out-of-pocket health expenditure and impoverishment from making out-of-pocket payments for health services should be used to assess financial risk protection.
  • Constraints on currently available data limit refinements to these existing measures. Priorities for improved data collection and future refinement of these measures include:
    • Including all direct costs related to using health services when needed (e.g. costs of transport to the health care provider) and possibly also health insurance contributions
    • Developing a common methodology to measure country-specific basic needs’ thresholds for use in impoverishment analyses instead of the global, minimalistic poverty lines (e.g. $1 per day)
  • It is important to recognise that these measures only reflect the proportion of the population who actually use health services and are impoverished or face financial catastrophe as a result. They do not take account of those who do not use health services due to a lack of financial resources. It is for this reason that measures of financial risk protection must be assessed together with measures of service utilisation; where utilisation rates are below the minimum threshold, this is likely to reflect the existence of unmet need.
High-income countries Low-income countries Lower-middle-income countries Upper-middle-income countries

Improving the measurement of financial risk protection

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To celebrate international UHC Day on 12 December, GNHE has just published a policy brief on how to improve the measurement of financial risk protection.

This is a companion piece to a similar brief on improving the measurement of health care use (available here).

If you want to read the full financial risk protection brief, click here.


The key messages of the financial risk protection brief are:

  • A key element of Universal Health Coverage (UHC) is financial risk protection (FRP) for all
  • Equitable financial protection means that everyone, irrespective of their level of income, is free from financial hardship caused by using needed health services
  • FRP must be measured alongside, and in addition to, the other dimension of UHC, which is access to needed health services: this is because UHC can only be achieved when both dimensions are addressed
  • Assessment of FRP should go beyond the conventional measures of financial catastrophe and impoverishment from out-of-pocket spending, because these under-estimate the level of financial risk
  • Measurement should seek to be inclusive and comprehensive, covering the whole population (both those who use health services and those who are unable to afford the use of health services when needed)
  • If the traditional measures are used, they should be interpreted accordingly – as simply the proportion of the population who use health services and are consequently impoverished or face financial catastrophe


Ataguba JE, Lu JR, Muiser J, Knaul FM. Assessing progress to UHC – the GNHE perspective: Financial risk protection. Available at:


Latin America Upper-middle-income countries

Important strides to universal health coverage in Colombia

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Ramiro Guerrero, and others from the Centro de Estudios en Protección Social y Economía de la Salud in Colombia, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

Colombia has made big efforts to fulfil the goal of universal health coverage:

  • since 2000, health expenditure as a percentage of GDP has been around 6.8%
  • government health expenditure as a percentage of total health expenditure is almost 80%
  • in 2010 all health system financial sources were progressive, meaning that higher-income individuals contributed relatively more towards the health system
  • in 2013 the contributory and subsidised regimes covered approximately 96% of Colombia’s population, and more than half the population was completely subsidised
  • there is a common mandatory benefit package
  • The Colombian health system has two major health insurance schemes:
    • the contributory regime is mandatory for formal workers and other people with the capacity to pay
    • the subsidised regime is for the unemployed, informal sector workers and the poor
  • The structure of the health system pools all resources into a common fund that is distributed on a risk-adjusted, capitation basis to a range of public and private health maintenance organisations. People are allowed to choose their health maintenance organisation, and health maintenance organisations are able to choose the providers with which they contract.
  • However, 4.6% of households in 2010 incurred catastrophic expenditure (measured using a 40% threshold of non-food household expenditure). Although this was an improvement from 2008, the intensity of catastrophic expenditures is still concentrated in low-income people. Data also suggest that the households that became poor after a financial shock were predominantly those in the subsidized regime and the uninsured.
  • In summary, Colombia has made important progress towards universal health coverage but attention still needs to be paid to the differences in access to health care for those with lower incomes and living in rural areas.


Read more in: Guerrero R et al. 2015. Universal health coverage assessment: Colombia. Global Network for Health Equity (GNHE). Available at:



Upper-middle-income countries

Achieving universal health coverage in Peru

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Janice Seinfeld and Nicolas Besich, of Videnza Consultores in Peru, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ concluding points are:

  • The health sector in Peru is fragmented, consisting of a non-integrated set of sub-systems aimed at serving different segments of the population.
  • Over a third of the population remains uncovered and out-of-pocket payments account for over a third of health care financing.
  • More than 75,000 households are impoverished annually as a result of health care payments.
  • One of the most neglected segments of the population in terms of health insurance is the one including lower-middle and low-income individuals. This segment is not classified as poor and thus cannot access subsidized insurance through the publicly financed SIS. At the same time, they mostly work in the informal sector and therefore are not able to access the mandatory insurance scheme for formal sector workers, EsSalud.
  • There are several problems that account for this state of affairs:
    • the large informal labour market
    • the fragmentation of the health system
    • fragmented and inadequate funding for the public sector
    • the poor responsiveness of health services (especially in the public sector)
    • bottlenecks associated with the integration of the purchasing and provision functions of EsSalud
    • difficulties in implementing strategic purchasing
    • the absence of a risk-pooling mechanism for different insurance plans
    • the inefficient and inequitable distribution of human resources
  • In response to these problems, in 2013 the Ministry of Health announced a comprehensive reform of the public health sector:
    • reorganisation of the sector and public agencies
    • strengthening the funding of SIS and EsSalud
    • the modernisation of the management of public investments in the sector
    • the modernisation of the national health system (e.g. to shift the focus to promotion, prevention and early detection)
    • a comprehensive reimbursement policy
  • The impact of these reforms is not yet known.
  • Some important areas that need attention with respect to promoting financial protection are:
    • the definition of an explicit benefit package and actuarial projections about its costs
    • improving the efficiency of available resource use
  • Any budgetary increase must be justified by the increased ability of the government to attain its health objectives.


Read more in: Seinfeld J, Besich N. 2014. Universal health coverage assessment: Peru. Global Network for Health Equity (GNHE). Available at: