Chile's Neoliberal Health Reform: An Assessment and a Critique

Policy Forum T he Chilean health system has been studied extensively [1]. Its current form is the result of a major reform undertaken by the Pinochet government following the coup d'état in 1973. Pinochet's reform established competition between public and private health insurers and promoted private health services, following neoliberal principles. Neoliberalism is an economic and political movement that gained consensus in the 1980s among international organisations like the International Monetary Fund and the World Bank. This movement demands reforms such as free trade, privatisation of previously public-owned enterprises, goods, and services, undistorted market prices, and limited government intervention. After the publication of the World Bank's 1993 report, " Investing in Health " [2], Chile became a model for neoliberal reforms to health services. In this Policy Forum, we assess the effects of the Chilean reform from Pinochet until 2005, and including the transition to democracy in 1990. We suggest that the use of Chile as a model for other countries of the health benefits of neoliberalism is seriously misguided. We stress the dominant role of the public health system in Chile, while most other studies have assessed the introduction of a private insurance sector as part of the neoliberal reform. Revisiting the Chilean health reform after 25 years, we come to new conclusions that could be important for countries such as Ecuador and Bolivia, which are preparing health reforms, and even for the United States, with its current debate on universal health insurance. Chile has been a social laboratory, having experienced democratic liberalism democratic coalition governments from 1990 to the present (see Glossary for definitions) [3]. The neoliberal reforms were not limited to the health system, but were also made to the pension system, in education, and through the privatisation of state industries. Many of the changes in the health system were later conceptualised in World Bank– supported documents [4]. In 1979, after having brutally repressed opposition to the 1973 coup against socialist president Salvador Allende, the Pinochet regime embarked on a sweeping health sector reform, based on neoliberal doctrines [5–7]. A private health insurance system, ISAPRES, was developed alongside the state system and was intended to be the dominant one. The two systems followed completely different rationales: the public system, a traditional " Bismarckian " social security system (members contribute a proportion of their wages to receive health services according to their need), promoted solidarity via risk-sharing and …