Washington, D.C., 28 September 2016 (PAHO/WHO) - Since 2014, when the Member States of the Pan American Health Organization (PAHO) unanimously endorsed the goal of achieving universal access to health and universal coverage, progress for most of the region's countries has been hampered by sluggish economic growth, the rising costs of medicines, and growing demand for care due to aging populations and increases in noncommunicable diseases. 

Health leaders gathered to discuss the challenges of advancing toward universal health in this context during a special high-level forum on "Investing for Universal Health: The Role of Public Investment in Health." Organized as a side event to PAHO's 55th Directing Council, the forum featured Premier Rufus Ewing of Turks and Caicos, Minister of Health of Chile Carmen Castillo Taucher, and Minister of Health of Guatemala Lucrecia Hernandez Mack as panelists. 

National Health Insurance Plan of Turks and Caicos

Ewing described Turks and Caicos's six-year-old National Health Insurance Plan, which is financed with employer and employee contributions that are mandatory for all residents. The plan acts as a single payer and covers an extensive package of benefits for all the islands' residents, with limited out-of-pocket payments that Ewing says will eventually be eliminated altogether.

The Turks and Caicos national plan has no exclusions on pre-existing conditions and even pays for health care obtained abroad, although the latter benefit is being reconsidered due to its high costs. To improve access to care, the government has established extended-hours clinics, open until 9 or 10 p.m. for those who find it difficult to seek health care during regular working hours. Recently proposed amendments to the plan include an expansion in coverage for the unemployed from the current 90 days to up to 18 months and guaranteed health care for the children of migrant workers. "With these amendments we will approach 100% coverage," said Ewing.

Chile: expanding care "in an orderly way"

Minister of Health of Chile Carmen Castillo described recent changes to her country's universal health system, which provides coverage primarily through the public National Health Fund (FONASA) but also through private insurers known as ISAPREs. The recent changes are contained in a new law that ensures coverage for diagnostics and high-cost medicines for 11 pathologies. The new law, enacted last October, builds on the Explicit Guarantee System (AUGE), which has ensured timely treatment for a growing list of conditions since its establishment in 2005.

"AUGE gave us experience in how to expand access in an orderly way," noted Castillo. The newer law, know as the Ricarte Soto law (in honor of a Chilean journalist who died of lung cancer in 2013). Developed in consultation with patient groups, the new law was expected to benefit some 4,000 patients, but the number of beneficiaries continues to rise, said Castillo. This expansion, which is expected to cost some $66 million annually, along with some $4 billion in health infrastructure investments have been financed largely through fiscal and tax reforms under Chile's current president, Michelle Bachelet.

Guatemala's health system: a patient in critical condition

Guatemala's new health minister, Lucrecia Hernández Mack, described the challenges of assuming responsibility for a national health system that has suffered from chronic underinvestment, widespread corruption in contracting, procurement and human resources management, as well as recurring labor disputes. She described the system as a "patient who has been chronically malnourished, who then gets an infection and is now in critical condition." She said the public health services network is "40 years behind" where it should be to serve the health needs of Guatemala's more than 16 million people.

Hernández said her top priority is to strengthen the country's primary care services, with a focus on community-based care provided through puestos de salud ("health posts"). In addition to currently being far too few in number (she points to a shortage of 4,000 facilities), these posts have traditionally provided care primarily for children under 5 and women of childbearing age. Hernández's goal is to shift that focus toward providing health care for all ages, throughout the life course.

Financing these and other improvements in Guatemala's health system is a major challenge, Hernández acknowledged. A fiscal reform package proposed by the current president failed to pass in the Guatemalan Congress, and the overwhelming majority of health spending in Guatemala remains out-of-pocket.

Camilo Cid, PAHO/WHO regional advisor on financing in health economics, said countries need to adopt the policy of countercyclic investment in the health sector, that is, increasing health investments even as national economic growth stagnates or declines.