public sector financed health care
and all citizens could receive free
care. But under the rule of General
Augusto Pinochet (1974–1990) the
national system was replaced with
a public-private approach, opening medical care delivery to the
private sector and decentralizing
it to the municipal level. This system—criticized for benefiting the
wealthy at the expense of other
social groups—continues despite
changes introduced since the country’s return to democracy.
In Cuba, a government-run
health system provides free, universal coverage, which has brought
major improvements in the quality of care. But it lacks productivity
and efficiency and needed management improvements.
Colombia’s health reform,
launched in 1993, offers yet a third
model. It dismantled the social security and public-sector services
system common throughout much
of the region, and replaced it with
a system based on neoliberal principles, in which private and public
providers compete for clients. Insurance premiums are paid by employers, with the government covering those for the needy. But high
co-payments have prevented the
poor from gaining access to the system. The results are typically unimpressive: skyrocketing total health
expenditures without visible improvements in equity. Studies also
indicate that efficiency and quality
have deteriorated. On the delivery
side, insurance companies report
large profits and high administrative expenditures while many hospitals have gone bankrupt.
Ministry of Health. In effect, it is
a single-payer model managed by
Caja and financed by the employers, employees and the government, with the government subsidizing care for the poor.
The results have been impressive: 86 percent of the population
has equal access to quality, comprehensive care. Medical services, including transplants, are free as are
prescribed pharmaceuticals. The
14 percent not served by Caja are
mostly the wealthy and the self-employed who prefer to pay as you go.
According to the World Health Organization, life expectancy is now
the longest in Latin America: 75
years for men and 80 for women.
But Costa Rica didn’t get to this
point without some trial and error.
In the 1980s Caja organized a
handful of health cooperatives
and a capitation system (where a
set amount is paid for each person in a health plan assigned to a
specific provider) that failed to improve the efficiency or coverage
of health care. Other experiments
have proved to be more successful.
In 1974 factories were permitted to
hire physicians to work on-site, providing workers with easier access
to care. Lab and diagnostic tests,
hospitalization, specialty care, and
drug provision continue at Caja locations. A similar program has allowed patients to pay low fees and
be treated by private physicians of
their choosing while still receiving
other Caja services.
There is no perfect health system,
and Costa Rica has experienced its
share of problems. There has been
corruption at high administrative
levels, and physicians have found
ways to take advantage of the system by reducing work load or using
public resources for personal gain.
But overall many experts consider
Costa Rica to have the region’s most
efficient, comprehensive, equitable,
and affordable health system.
Antonio Ugalde is Professor
Emeritus at the University
of Texas at Austin and Núria
Homedes is director of global
health at the University of Texas-
Houston School of Public Health.
Three Years After
In 2006, high-school students in Chile took to the streets to pro- test the country’s education
system, sparking President Mi-
chelle Bachelet’s first major cri-
sis. Known as the Penguin Revo-
lution (a term that refers to the
students’ white and black uni-
forms), the protests accomplished
what decades of public debate had
failed to do: force a political agree-
ment to reform institutional prac-
tices in place since the 1980s. The
student movement—perhaps the
most successful in the country’s
history—responded to widespread
complaints that despite public
education funding, the system’s
guiding principles perpetuate so-
As a result, needed change has
come to Chilean education. But
there is still much work to be done.
In practice, Chilean schools are
segregated by socioeconomic lev-
els. The Education Ministry classi-
fies them into five groups using a
methodology that combines infor-
THE COSTA RICAN
A fourth, and more promising,
model of care has existed in Costa
Rica since 1974. It involves inte-
gration of the social security pro-
gram—the Caja Costarricense de
Séguro Social (CCSS or Caja)—with
the medical services offered by the