Explicit Health Guarantees for Chileans : The AUGE Benefits Package

Abstract

This paper focuses on recent and significant health reform implemented in 2005, known as Universal Access with explicit guarantees (Acceso Universal con Garantias Explicitas - AUGE or GES), which mandated SHI insurers to adopt a broad benefits package defined via explicit legal guarantees for all beneficiaries. This innovative reform is a policy reaction to that which previously existed in Chile and which is widespread in many developing countries, whereby the health rights of citizens remain largely undefined or implicit. Limited public resources imply in those countries that access to health care is rationed through queues, patient deflection, legal or under-the-table user fees, and low-quality care. This paper describes the AUGE reform, its implementation, and the functioning of AUGE for the poor and for non-poor citizens. This paper is organized as: section two provides a brief historic overview of health coverage in Chile's SHI system. Section three describes the SHI system in existence today. Section four describes the services offered and mechanisms in place to cover the poor under SHI, while section five spells out the benefits of SHI. Section six introduces the AUGE health reform of 2005, which sought to broaden and make explicit the rights of all SHI beneficiaries. Section seven offers information about the flows and magnitudes of health financing in SHI. Section eight focuses on the system used by Fonasa to target the poor. Section nine explains how Fonasa manages AUGE. Section ten comments on the information environment of AUGE. Section eleven addresses the equity and fiscal implications of expanding the AUGE benefits. Finally, section twelve proposes a pending policy agenda related to the coverage of the poor under SHI and the definition and management of benefits.

Chile, alcanzó una cobertura casi universal por medio del seguro social de salud a mediados del siglo XX ofreció a los pobres cobertura subsidiada con recursos públicos en las primeras etapas de la evolución del seguro social. Chile también fue pionero en la creación de un servicio nacional de salud que constaba de una red pública de hospitales y centros de atención primaria que abarcaba todo el país. Este documento se centra en la reciente y significativa reforma del sistema de salud que se ejecutó en 2005 y se conoce con el nombre de Acceso Universal con Garantías Explícitas, AUGE o GES), la cual dispuso que las aseguradoras del seguro social debían adoptar un plan amplio de beneficios definido por medio de garantías legales explícitas para todos los beneficiarios.