Well-functioning health systems improve population health, provide social protection, respond to legitimate expectations of citizens, contribute to economic growth,1, 2, 3, 4, 5, 6 and underpin universal health coverage.7 Political stability, committed leadership, sustained economic growth, and strong health systems are crucial for achieving universal health coverage, which is hindered by income inequalities.8
Starting in the late 1980s, many countries in Latin America began social sector reforms to alleviate poverty and reduce socioeconomic inequalities, including reforms in the 1990s to strengthen health systems and introduce universal health coverage. Latin American countries share many economic, political, social, and cultural similarities (figure 1), but are also historically, socioculturally, and politically diverse; they gained independence from their European colonisers in the 19th century, but many suffered military dictatorships with human rights abuses and have experienced some of the worst income inequalities worldwide (appendix). The rich historical, sociocultural, and political context of Latin American countries has profoundly shaped health-system reforms and the trajectory of universal health coverage underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities—a distinguishing feature of the Latin American health-system reform experience, with lessons that are relevant for countries that are progressing towards universal health coverage.
We used an analytical framework,7 and data from several sources (appendix) to explore in the study countries—Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Mexico, Peru, Uruguay, and Venezuela—how the interplay of demographic, epidemiological, economic, political, and sociocultural factors (table) has provided the impetus for these countries to strengthen their health systems and progress towards universal health coverage. We selected these countries because they have introduced health-system reforms to achieve universal health coverage and because relevant data are available. As with the other reports in the Lancet Latin America Series, we have not analysed the English-speaking countries of the Caribbean or Haiti because these countries had a different history to the Latin American countries studied. We provide a summary of the economic, demographic, population health, and health-systems indicators for these countries and compare them with the world regions and the world averages (appendix).
Key messages
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Latin American countries are characterised by sociocultural, economic, and political diversity, with wide socioeconomic and health inequalities.
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Costa Rica and Mexico established parliamentary democracies in early 20th Century, but beginning in the late 1950s revolutions in Cuba and Venezuela were followed by military dictatorships in most Latin American countries with widening socioeconomic disparities.
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In the 1980s, health emerged as a fundamental human right and entitlement in Latin America—regardless of social position or capacity to pay—and a democratic platform for reclaiming citizens' rights.
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Social movements, led by civil society, shaped heath-system reforms in most countries, while in Mexico, Costa Rica, and Colombia rapid epidemiological transition was the critical driver.
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Latin American countries have developed a distinct approach to health-system reforms, which combined demand side changes to alleviate poverty and comprehensive primary health care to extend service access. These reforms fostered inclusion, citizen empowerment, and health equity, established legal rights to health and health protection, and achieved universal health coverage.
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Social health insurance or tax based financing have been used with different health-system, organisation, governance, and service delivery approaches to introduce explicit entitlements for health benefits.
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The Latin American countries have developed country-level and regional capacity to learn from country and regional experiences, and used this capacity to refine health-system reforms to establish context-sensitive approaches to universal health coverage to improve health outcomes.
The social and political orders that emerged after independence to establish democracy were diverse in the ten study countries. Various governance, political arrangements, and governments emerged after the end of military regimes in Argentina, Brazil, Chile, Colombia, Costa Rica, Peru, Uruguay, and Venezuela; at the end of state corporatism in Mexico, and after revolutions in Cuba and Venezuela, with varying amounts of citizenship and civil rights. These experiences in governance also shaped the approaches adopted for health-system reforms and universal health coverage.
This report is organised in five sections. The introduction is followed by an analysis of the contextual challenges driving change in Latin American health systems. We next analyse health-system reforms aimed at achieving universal health coverage in the study countries. We then discuss the key achievements of health-system reforms and universal health coverage in the study countries and the lessons learned. The final section discusses the future challenges for Latin American health systems. In the Lancet Latin America Series, Cotlear and colleagues11 provide an in-depth analysis of the historical antecedents of health-system reforms and Andrade and colleagues12 describe the social determinants of health in Latin America.