COMPARATIVE HEALTH-CARE SYSTEMShave plagued privatized systems elsewhere: lack of
insurance coverage, increasing costs, maldistribution
of providers, and inequalities in the overall quality
of care (Liu, Liu, and Meng 1994). As in the United
States, the gap between the health-care received by
the rich and that received by the poor is growing
(Shi 1993).
Huge disparities between the rich and poor
are characteristic of Latin America where they
constitute a significant barrier to universal health
coverage. Latin-American health-systems vary con-
siderably, reflecting socioeconomic differences be-
tween countries as well as historical and political
contingencies. The Mexican system illustrates many
of the obstacles faced by developing nations, wheth-
er in Latin America or elsewhere. The Mexican
constitution established federal responsibility for
health-care in 1917, along with a centralized ad-
ministrative tradition that still exists; yet, to date,
the two major government insurance schemes cov-
er only about 47 percent of the population, with
another 7 percent insured privately. Ostensibly,
there are programs for the remaining 46 percent
of the population, most of whom are low income,
but in reality, many low income areas and impov-
erished communities are poorly served. Some have
argued that a basic health-care infrastructure is in
place and that there are sufficient numbers of well-
trained health-care professionals available (Lassey,
Lassey, and Jinks 1997). They contend that, had it
not been for several national crises in the 1980s
and 1990s, coupled with a lack of political will,
more of the Mexican population would now be
covered by the health-care system.
Bertranou (1999) has compared Argentina,
Chile, and Columbia, all of which have employed
various ways to reform health insurance arrange-
ments in recent years. Chile’s reforms date back to
its military dictatorship in the early 1980s. At that
time, private health insurers were allowed to com-
pete for worker payroll contributions. There was
little regulation of the system which encouraged
adverse selection, resulting in significant inequi-
ties within the system. Even so, approximately 70
percent of the Chilean population today is covered
by insurance, compared to 64 percent in Argenti-
na and only 43 percent in Colombia. Argentina
faces numerous obstacles in reforming its com-
plex and confusing system of three types of health-
care arrangements (social insurance organizations,
private health insurers and providers, and the
public health-system). Its goals include universal
coverage and a standard benefits package. In the
case of Columbia, reform goals are more related
to the relative poverty in the country and the fact
that large segments of the population cannot af-
ford health insurance. Per capita expenditures for
health-care in Columbia are 42 percent of what
they are in Chile and 20 percent of the expendi-
ture level in Argentina. Instead of giving free
access to public facilities, Columbia’s reforms in-
volve providing vouchers that allow low-income
families to join the health organization of their
choice. To be successful, all these reform efforts
require social equilibrium where governments are
able to maintain political and economic stability.The political instability and socioeconomic
inequality that have characterized Latin America
are also a hindrance to health-care systems in
Africa. An even more fundamental problem in
Africa, however, is the formidable lack of resourc-
es to address overwhelming health-care needs
(Schieber and Maeda 1999). Even where clinics,
hospitals, and medical personnel exist, there is
likely to be a lack of the required equipment and
medicines. In Africa as a whole, 80 percent of the
physicians live and practice in the cities where less
than 20 percent of the population lives. According
to Sanneh (1999), this continuing situation sup-
ports the prominent role of traditional healers, 85
percent of whom live in rural areas. The difficul-
ties encountered by Ghana in implementing a
system of primary care illustrate the situation af-
fecting many African nations. In 1983, soon after
the primary care system was adopted, the govern-
ment attempted cost containment by introducing
‘‘user fees’’ in all public health facilities, clinics as
well as hospitals. Two years later the fees were
increased and, subsequently, a health insurance
program was instituted. One must question the
practical significance of these developments in a
country where over half of rural residents and
nearly half of those in urban areas live below
poverty (Anyinam 1989). These circumstances are
a reminder that developing countries contain 84
percent of the world’s population, yet account for
only 11 percent of global health-care spending
(Schieber and Maeda 1999), making the task of
designing strategies for effective health-care deliv-
ery in the developing world the true challenge for
comparative health-care system researchers.