Health in Chile’s Constitutional Process: Comparison
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Chile is a high-income country in Latin America that faces great socioeconomic inequality and a segmented–public and private–health system. In response to the serious political crisis which took place in 2019, Chile’s political parties came together to deliberate on an institutional solution, attending to the social demands of fairness around several issues, such as pensions, health, and education. The result was the elaboration of the “Agreement for Social Peace and the New Constitution’’. In the process towards elaborating a draft for a new constitution, different mechanisms of civil participation were enabled, including the Popular Initiatives for Norms, an online website where individuals or collectives could submit proposals to be considered. We aimed to analyze health-related civil proposals uploaded to the official website for Popular Participation for the new constitution in Chile.

  • public health
  • Chile
  • democracy
  • civil participation

1. Chile: An Unequal Country with a Fragmented Health System

Chile is a high-income country, with a GNI per capita of USD 24,020 in 2020 [1]; however, 20.7% of its population, or over 3.5 million people, experiences multidimensional poverty [2], and the proportion of people experiencing income poverty grew between 2017 and 2020 from 8.6% to 10.8% of the population after a sustained drop over the preceding decade [3]. With regard to healthcare, the health system is fragmented between the public system, called the National Health Fund (the Spanish acronym is FONASA), which covers 76.5% of the population, and the private health care system (the Spanish acronym is ISAPRE), covering 15.4%. The armed forces and police system is separate from both of these systems and covers a little over 2% of the population. Additionally, the percentage of the population reporting not being covered increased from 2.8% in 2017 to 4.3% in 2020 [4].
In terms of the provision of care, the institutions covered by FONASA are public healthcare centers managed by the National System of Healthcare Services (the Spanish acronym is SNSS). The institutions covered by the ISAPREs are privately owned healthcare centers or independent healthcare providers, and the armed forces and police system has dedicated centers [5]. Additionally, there is a growing market for complementary private health insurance. In contrast to the public health insurance system, the private health insurance companies can reject applicants if their financial contribution does not match their estimated health risk or simply because they suffered diseases in the past and are at a high risk of new events in the future [6]. In this context, in many cases, effective access to healthcare may depend on the ability to pay for private care, due to inefficiencies in the underfunded and ill-equipped public system, which explains a high proportion of out-of-pocket expenditure in Chile [7,8,9][7][8][9]. From a social determinant of health perspective, experiencing multidimensional poverty and income poverty leads to poorer health outcomes throughout the course of life, especially in a country where the healthcare system is highly unequal and fragmented between two main systems which are vastly different with regard to accessibility and quality of care [10]. The existing inequities in this health system have even led to international ethical discussions in this regard [11].
The Chilean healthcare system went through a major reform in 2005 during President Ricardo Lagos’ term of office (2000–2006). The reform aimed at guaranteeing equal access to healthcare for high priority health problems to people residing in Chile according to their needs and without discrimination [12]. The healthcare reform was implemented in 2003 and defined a set of health interventions that, according to the System of Health Guarantees Law, should be provided to every person that required them in Chile, irrespective of the type of provision entitlement, the ability to pay, or any other non-need factor. The policymakers who designed and implemented this reform expected it to produce a significant impact on the population’s health [13]. However, social inequalities concerning access to healthcare and the population’s health grew significantly over time, especially for those whose health conditions were not prioritized in the AUGE/GES law [14,15][14][15].
Regardless of the changes introduced in the 2005 reform, Chile continued to have a socioeconomically segmented healthcare system, which deepened the inequities derived from risk selection and cream-skimming, which are the typical problems of relatively unregulated insurance markets. Thus, the structure of the system ended up with two different subsystems, one for the relatively more socioeconomically advantaged citizens and another for the relatively more disadvantaged, poorer people. This organization contributed to generating a perception of injustice based on the fact that richer people had timely access to many health services, whereas poorer people had to deal with waiting lists, more restricted access to technologies, and a perception of worse health services [16]. Moreover, differences in effective access to healthcare continued to be reported in the country, based on the type of healthcare insurance, gender, socioeconomic status, borough and region of residence, and other relevant social determinants.

2. Social Unrest and Chile’s Constitutional Process

A sustained period of social, economic, and political unrest took place during October 2019 in Chile, known as the “Social Outburst” or Estallido Social (in Spanish), where, for weeks, mobilization and strikes took place. The outburst was triggered by a rise of CLP 30 for public transport (around USD 0,034, a third of a dollar), and people’s demands revolved mainly around the deep inequalities concerning pensions, health, and education in Chile [17,18,19][17][18][19]. In response to the serious political crisis, which previously led to public disorder and violence, Chile’s political parties came together to deliberate on an institutional solution and attend to the social demands. The result was the elaboration of the “Agreement for Social Peace and the New Constitution’’ (Acuerdo Por la Paz Social y la Nueva Constitución) [20], a document in which the signing parties subscribed to “guarantee their commitment with reestablishing peace and public order in Chile, with total respect to human rights and the current democratic institutions (…) through an unobjectionably democratic procedure”. It was signed on the 15th of November 2019, by most of the political parties. The parties agreed on the initiation of a constitutional process that, if successful, would culminate in a new constitution that would replace the existing one, written in 1980 during Augusto Pinochet’s dictatorship period.
Thereafter, on the 25th of October 2020, an initial national plebiscite was held, where voters decided on: (i) whether they approved or rejected the drafting of a new constitution and (ii) what body should oversee writing it. More than half of eligible voters participated, and the results were: (i) 78% of voters approved the creation of a new constitution and 21% rejected it, and (ii) 79% voted for a democratically elected constitutional convention and 21% voted for a mixed constitutional convention. Previously, on the 11th of April 2020, elections to choose the members of the constitutional convention were held [21].

3. Citizen Participation in the New Constitution

Once the body was elected and formed, a term of 9 to 12 months was established to work on the draft for a new constitution. During this process, to promote citizen participation, the Popular Initiative for Norms (from Iniciativa Popular de Norma in Spanish) platform was created. This initiative acted as a participation mechanism through which an individual or a group of people could present proposals for constitutional norms to the constitutional convention. A total of 6114 proposals were sent through an online platform and underwent an admissibility revision, after which 2496 were approved and published for the public to vote on; each person could support a total of seven proposals. Physical centers were also enabled so that those with no internet access could inscribe their proposals manually. To be eligible to participate, the people were required to be above 16 years of age, of Chilean nationality, foreign nationality with Chilean residence, or Chileans living abroad. They then had to register in a Single Register of Popular Participation (Registro Único de Participación Popular), which could be performed online or at one of the enabled centers [22].
Of these proposals, 10.7% were submitted by social organizations or private institutions and 89.3% were sent by individuals. Following the two-week voting period, 77 proposals (3%) reached the required 15,000 votes or more to pass on to the next stage of discussion. Of these, 60 were supported by organizations or institutions and 17 by individuals [23].

4. Popular Participation in Health Policy and Health-Related Civil Proposals for the New Constitution

Citizen participation in public health initiatives has historically been in the form of social movements. These share a common cause and advocate for change in matters such as urban conditions and health, the health of children, and the behavioral and substance-related determinants of health, amongst others [24]. Health social movements (HSM’s) have been described as those which “challenge state, institutional and cultural authorities in order to enhance public participation in social policy and regulation”, and they can play an important role in influencing health policy [25]. The particularity of the participation mechanism enabled during the constitutional process was that not only could these movements put forth their ideas, but so could individuals who did not form part of a collective and whose perspectives had not been perceived before.
As described before, inequality in health was one of the main social demands brought up by citizens during the period of social unrest in Chile. In this context, a survey carried out by the Center for Conflict and Social Cohesion Studies (COES), in December 2019, asked people to assign a score from 1 to 10 regarding the importance of the different social demands, with 10 being very important. A total of 89.5% of people assigned 10 points to health [26,27,28][26][27][28]. Similarly, a survey carried out by the Center of Public Studies (CEP) during that same period showed that people placed “bad quality public health and education” in the fourth position when asked what they thought to be the main reason for social manifestations in Chile [29].
Additionally, the last National Health Survey (2021) [30] showed that the attributes which were considered to be the most important in building a dignified care system were: having a public and private system of equal quality; having equal access to health for everyone, independently of the socioeconomic situation; that everyone could feel economically safe if they got sick; and having timely access to health, eliminating the waiting time for important situations.
We carried out a qualitative thematic analysis of 126 health-related valid proposals. Also, we analyzed their link to the Health Goals 2030 established by the Ministry of Health of Chile and the Sustainable Development Goals (SDGs). By describing these themes and identifying the priorities put forth by the civil population, this study can be useful to guide future reforms, both constitutional and regarding the health system. The association of these proposals with wider frameworks allows to visualize if institutional priorities are aligned with popular demands and how so. 
A qualitative thematic analysis of 126 health-related valid proposals are carried out. Also, researchers analyzed their link to the Health Goals 2030 established by the Ministry of Health of Chile and the Sustainable Development Goals (SDGs). By describing these themes and identifying the priorities put forth by the civil population, the research can be useful to guide future reforms, both constitutional and regarding the health system. The association of these proposals with wider frameworks allows to visualize if institutional priorities are aligned with popular demands and how so. 

References

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