World Report
Violent protests in Chile linked to health-care inequities
Many grievances are driving civil unrest in Chile, but inequities in the health-care system are a
key one. Barbara Fraser reports.
Latin Americans were shocked to see
Chile erupt in street demonstrations
and looting, followed by a violent
crackdown by security forces, after the
government announced a transit fare
increase of 30 pesos, equivalent to
US$0·04, in October.
Slogans chanted by protesters—
including “It’s not 30 pesos, it’s
30 years” and “Chile awoke”—hinted
at long-standing discontent behind
the apparently sudden upheaval.
The fare hike “was just the trigger”,
said economist Guillermo Paraje of
Adolfo Ibáñez University in Santiago.
“If it wasn’t that, it would have been
something else.”
The protests, which began in
Santiago and spread throughout the
country, stripped away Chile’s veneer
of tranquillity, exposing discontent
over deep inequalities that has been
building since the military govern­
ment of Augusto Pinochet instituted
neoliberal reforms in the 1980s.
Chile and Mexico, the only Latin
American countries in the Organisation
for Economic Co-operation and
Development (OECD), are also among
the most unequal, with the income
of the wealthiest people more than
25 times that of the poorest.
Chilean officials set an insensitive
tone at first, with President Sebastián
Piñera saying the government was
“at war” with the protesters and the
economy minister suggesting that
commuters who wanted to avoid the
fare increase should leave for work
earlier, when transit fares were lower.
The minister later apologised.
As the protests continued into a third
week, Piñera suspended a November
meeting of the leaders of Pacific Rim
countries and an international climate
summit scheduled for December.
The fare hike had been announced
days before the unrest began. On
www.thelancet.com Vol 394 November 9, 2019 1697
Oct 17, students began jumping
subway turnstiles. Wider protests
the next day turned violent, with
demonstrators looting and setting
subway stations, vehicles, and some
public buildings ablaze.
On Oct 19, Piñera declared a state
of emergency in Santiago and several
“Chile’s out-of-pocket
expenditures as a proportion of
total health expenditures are
also among the highest in the
OECD, at 33%.“
smaller cities, sending the police and
military into the streets in a show
of force that was strange to young
Chileans, but all too familiar to older
residents who remember human
rights violations during the Pinochet
years, said Alejandra Vives, associate
profes­sor of public health at the
Pontifical Catholic University of Chile
in Santiago.
At least 18 people were killed during
the protests, according to the Interior
Ministry. More than 1000 were injured
and at least 3500 were arrested,
according to the National Institute of
Human Rights, which also filed legal
complaints about cases of rape and
torture by security forces.
The grievances that drove hun­
dreds of thousands of Chileans—
estimates reached nearly 1 million
on Oct 25—into the streets included
costs associated with health care and
education and long-standing anger
about the private pension system.
Underlying all of these grievances
are the frustrated expectations of
middle-class Chileans, half of whom
earn less than about $600 a month.
Polls show dissatisfaction with
jobs and wages that do not stretch
to cover expenses, including health
care.
Health indicators such as infant and
maternal mortality have improved
considerably in recent years, although
they are still among the highest in the
OECD. Under-5 mortality has fallen
from 19·1 deaths per 1000 livebirths in
1990, to 10·9 in 2000, and 7·4 in 2017.
Similarly, maternal mortality dropped
from 57 deaths per 100 000 livebirths
in 1990, to 22 in 2015.
Nevertheless, people still feel “a
sense of uncertainty, of anxiety, of
what will happen if someone gets
sick—that the system won’t respond if
needed”, Paraje said.
Technically, Chile has universal
health care, with everyone covered
under the public National Health
Fund. However, the country has a
two-tier system, in which the public
system covers about 78% of the
population and private insurers cover
about 17%. The small remainder
is covered by the police or military
systems.
The public system is chronically
under­ f unded, with a deficit of
$1·15 billion in 2018. According to
Antonio Infante, who has admin­istered
one of Santiago’s largest municipal
systems and served as undersecretary
in Chile’s Health Ministry, one effect
Henry Romero/Reuter Pictures
A protester in Santiago waves the Chilean flag
 World Report
of the budget shortfall is long waiting
lists for certain surgeries. Although the
Health Ministry has made efforts to
clear waiting lists, long delays persist,
especially for conditions not included
under the mandatory coverage plan.
In 2016, the OECD warned that “the
public system overwhelmingly covers
the poorest while competing private
insurers select good risks and apply
different premiums, sometimes
penalising those with greater needs”.
“There is room for improving the
system by moving towards a unified,
equitable social security system for the
entire population.”
Under a 2005 law, both the public
and private systems are required
to cover 56 medical conditions,
including many chronic conditions.
This system of “explicit health
guarantees”, which has since been
expanded to more than 80 conditions,
has reduced inequalities between the
two systems but has not eliminated
them, said Cristian Herrera, a Chilean
health policy analyst at the OECD.
In the public system, primary care
is funded by the state but managed
by municipal governments. As a
result, the efficiency of the primary
care system varies from one muni­
cipality to another, and there can
be high management turnover, as
administrators are often replaced
when a new mayor takes office,
said Infante. Where primary care
is inefficient and wait times long,
Pedro Lopez/Getty Images
Chilean President Sebastián Piñera addresses the nation on Oct 26
1698 www.thelancet.com Vol 394 November 9, 2019
many Chileans go straight to hospital
emergency rooms instead. Chile’s
out-of-pocket expenditures as a pro­
portion of total health expenditures
are also among the highest in the
OECD, at 33%. Nearly a third of that
amount is due to drug expenditures,
“‘...these are technical fixes to a
problem that needs a political
decision about what role, if any,
the private sector should play...’“
with another 30% divided between
dental costs and doctor visits,
according to a study by public
health expert Pablo Villalobos of the
University of Santiago. The OECD
has made various recommendations,
including better regulation of the
private insurance market and lower
copayments for medicines.
On Oct 23, Piñera announced a series
of measures that include a pension
increase, a guaranteed minimum wage
of about $460 a month, electricity rate
controls, higher taxes on those earning
more than about $10 700 a month,
and more equitable financing of public
services, including health, to reduce
the gap between wealthier and less
wealthy municipalities.
Specific health-related proposals
included a ceiling on families’ out-
of-pocket expenses for catastrophic
illnesses, creation of an insurance plan
to cover drug costs not covered under
existing plans, and expansion of an
agreement between the public health
service and private pharmacy chains
to reduce the cost of medicines for
users of the public system.
But these are technical fixes to a
problem that needs a political decision
about what role, if any, the private
sector should play, Villalobos said.
There have been various attempts
at health reform over the past
two decades, but much remains to be
done, according to the OECD report
and Chilean experts. Most recently,
a commission formed in 2014 by
then-President Michelle Bachelet
to propose changes to the private
insurance system failed to reach
consensus and never submitted a
proposal to the legislature.
There is growing pressure to
eliminate the private insurance
system, said Paraje, who served on
that commission, but private insurers
have resisted that suggestion. Health-
care reform should be accompanied
by changes in the pension system,
he said, because retirees are hit even
harder by the cost of medicines and by
out-of-pocket expenses if they seek
care in the private system.
The right to “free and egalitarian
access” to health care is enshrined
in Chile’s constitution. The consti­
tution also guarantees that “each
person has the right to choose the
health system they wish to join,
either state or private”. Because
of that language, elimination of
the private system could require
a change to the constitution, said
Cristian Montenegro, a sociologist
at the Pontifical Catholic University
of Chile. Although there have been
some calls for a revamping of the
constitution, that would be a long
process requiring a constituent
assembly, and is not likely in the near
future, he said.
As the protests continue, it is not
clear how the government will address
the multiple, dispersed demands.
A cabinet shake-up on Oct 28 failed
to stem the protests, and calls have
mounted for Piñera’s resignation.
Chile’s upheaval is a cautionary tale
for other Latin American countries
that have wide income gaps and
that still depend largely on revenues
from exports of raw materials,
placing them at the mercy of global
market forces. Income inequality is
greater in Latin America than in any
other region in the world. “In many
rankings, [Chile] has done well in the
region”, Montenegro said. “It seemed
to be economically and institutionally
stable. But the price of this progress
was the inequality it created.”
Barbara Fraser