Latin America: priorities for universal health coverage.

www.thelancet.com Vol 385 April 4, 2015 e31 To achieve universal health coverage, a defi nition of what coverage everybody is guaranteed is needed. In view of the gap between what is medically possible and what is fi nancially feasible, some type of rationing is inevitable in all societies. So the decision is not about whether to prioritise, but how best to achieve this. However, this issue is often neglected or is an afterthought in the debate about universal health coverage. This situation arises because explicit priority setting is contentious, politically charged, and technically challenging, and it is rarely studied and poorly understood. Thus, lessons from Latin America are especially relevant. More than any other part of the world, countries in this region have introduced explicit priority setting to defi ne their health benefi t plans. Advocates argue that the results are potentially more eff ective, equitable, transparent, and effi cient than are implicit rationing practices, which include waiting lists, quality adjustments, or user fees. The fi rst lesson is that benefi t plans take diff erent shapes and sizes, and are not restricted to a list of essential services for societies with severe resource constraints. Giedion and colleagues highlight the heterogeneity of approaches used by Latin American countries to establish priorities and to design and deliver benefi t plans. The scope ranges from broad to narrow, in terms of types of technologies used, disease control priorities, and eligible populations. For example, Uruguay’s Plan Integral de Atención en Salud (PIAS) is comprehensive for everybody and provides integral universal care for health disorders throughout the life cycle, mainly at primary care level, and an extensive catalogue of more complex diagnostic and therapeutic services, independent of provider. Chile’s Acceso Universal con Garantías Explícitas (AUGE) plan includes legally enforceable entitlements to a comprehensive set of services for a prioritised group of diseases, but does not deny health care for other disorders, which remain subject to waiting lists. Thus, AUGE is comprehensive for some diseases. Colombia’s Plan Obligatorio de Salud Subsidiado (POSS) selects interventions across disease groups to establish a set of health-care services guaranteed by the state, which means that all people can receive a limited set of services. Other plans are designed for eligible subpopulations. The Mexican Seguro Popular benefi t plans for people outside the social security system prioritise catastrophic coverage for complex benefi ts (Fondo de Protección contra Gastos Catastrófi cos [FPGC]) coupled with groups of interventions in Catálogo Universal de Servicios Esenciales de Salud (CAUSES). Peru’s Plan Essential de Aseguramiento en Salud (PEAS) prioritises health disorders, but provides more limited essential health-care services for specifi c groups. Plan Nacer in Argentina and Paquete Básico de Salud (PBS) in Honduras focus on health care for poor mothers and children. All of these programmes are examples of coverage of specifi c population groups with some interventions, rather than universal plans. A second lesson relates to the large institutional capacities needed to defi ne and regularly update benefi t plans. Institutions fi nd fulfi lling their promise very resource intensive; sustained political and technical leadership backed by legal underpinnings are required. Good technical processes are a sine qua non, encompassing health needs assessment and appraisal of new technologies and intervention alternatives, and planning and service delivery organisation. Politically, balancing various, at times confl icting, interests is needed. Robust regulatory measures need to be in place to keep vested interests from serving narrow parochial interests of industry, specifi c groups, or organisations, and consequently distorting national health goals. For example, by law in Chile the defi nition of AUGE requires the use of epidemiological, burden of disease, and cost-eff ectiveness studies and must consider social preferences and feasibility. Mandatory consultative Latin America: priorities for universal health coverage