the Five cs of universal Health care pHILIp musgrOve
Rapid technological progress
has driven up total health
expenditure and led to public
underfunding of care.
Because the government of Cuba exercises much
greater control over the economy than any of the other
countries, it is difficult to compare its path to universal
coverage with that taken elsewhere. The political pressures that shaped the Colombian reform or the movement away from, and then back toward, a more public
health system in Chile are absent; and relative prices
and costs are quite different.
What Cuba’s experience demonstrates, however, is
that a single, publicly funded and managed system can
achieve universal coverage. It does not necessarily suffer the limitations that have plagued such attempts in
much of Latin America and that have led to the more
typical mixed public and private systems. One result
is that, except for the prohibition on private practice
and the management by provinces, the Cuban system
resembles that of Canada more than that of any of the
other “C” countries.
lessons from the “Cs”
At the most basic level, universal coverage im- plies that every citizen of a country, or every resident, should have legal and physical ac- cess to health care services. Historically, this was the goal of all the ministries of health in
Latin America and the Caribbean, to be achieved either
by providing care directly through providers who are
public employees, or indirectly by purchasing services
from private providers. Ideally, in this model there is no
need for health insurance. Health care is financed by
taxes with some minor contribution from out-of-pocket
spending by patients. One might call this implicit insurance: people are guaranteed access to care when they
need it, but there is nothing corresponding to an insurance policy identifying the individual and specifying
what he or she has a right to receive or a duty to pay.
Of the “C” countries mentioned, only Cuba operates
a health system of this type. But Chile, Colombia and
Costa Rica all tried to implement such a model, starting
in the first half of the twentieth century, maintaining elements of it well into the second half of
the century. However, care assured by the government generally failed to achieve truly universal
coverage, even though, formally, every existing
ministry of health legally has that responsibility. (Canada is an exception, as described above.)
Three different factors undermined countries’
Second, social security institutions in most countries
began to offer their own coverage of health care, either
through their own clinics or by contract with private
providers. Since social security coverage was tied to formal employment, this created a health care distinction
bet ween more organized, better-paid workers and those
in informal, generally lower-income activities. Third,
where private health insurance was legal, it attracted
still higher-income customers who could pay for it out
–of–pocket or through their employment.
Together, this led to the tripartite model of paying for
and providing health care that is common throughout
Latin America. This model was not followed in North
America, where social security (in the U.S.) and social
insurance (in Canada) remain mechanisms for partly financing retirement benefits and subsidies to some disabled persons, not for health care.
These developments do not mean that universal coverage cannot be achieved. Rather it suggests that everyone can get access to health care, but from different
funders and/or providers.
If a ministry of health provides for everyone not covered by social security or private insurance, no one is
left out—and that is precisely how ministers of health
have traditionally seen their task. However, having several different forms of coverage does affect what universal coverage means. It implies unequal coverage, with
some people having the right to more or different health
services than others, or with providers and facilities of
different quality. It means that people are exposed to
different degrees of financial risk: some may have to pay
out–of–pocket for care that others get for free.