Introduction
Universal healthcare is considered a means to reduce the inequities and inequalities in health, to which healthcare systems contribute (Navarro and Shi 2001; World Health Organisation [WHO] 2013). The WHO states that âall people [should] obtain the health services they needâprevention, promotion, treatment, rehabilitation and palliationâwithout risk of financial ruin or impoverishment, now and in the futureâ (WHO 2013: 6). Established understandings of universalism in healthcare generally refer to universal insurance or population coverage; however, the issue might be more complex. While access to health services has come to be conceived as a right of citizenship (Frenk 2015), universal healthcare systems vary in terms of organisation, public and private mix, financial arrangements, and entitlements.
Universalism is a term broadly analysed and debated (e.g., StefĂĄnsson 2012; Schmidt et al. 2015; see also Chapter Three of this book). Kildal and Kuhnle (2005: 5) suggest this âmay partly be due to the different dimensions it containsâ. Universalism may be understood in regard to specific policies, benefits and services, to a whole population or some population groups, or to a specific field (e.g., healthcare). Marshall (1950) conceptualised universalism from a social citizenship perspective and saw it ânot ⌠an end in itself, [but] rather as a means to an end of the objective of integrationâ (Powell 2002: 233). Universalism in this sense refers to the equal status of individuals in terms of access to benefits and participation according to the accepted standards of societies. Universalism provides a common and shared experience of cash, kind and service benefits, and entails âa profound effect on the qualitative aspects of social differentiationâ (Marshall 1950: 57) in an equalising way, âconferring on everybody a badge of citizenship, eliminating any public distinction between the social classes, between rich and poor, the eligible and the non-eligibleâ with regard to access, quality and reception of such benefits when in need (Powell 2002: 232). From within this framework, a universal approach must provide a level of public services or benefits available to all: a level that is consistent with accepted standards of societies, available to a majority of the population, and use or reception which does not stigmatise. Such a level and quality of universal services and benefits will result in âgreater equality in manners and texture of social lifeâ (Powell 2002: 232). To realise universalism in healthcare, âsolidarity in provision and financingâ (Mackintosh and Koivusalo 2015: 90) are necessary. Universalism can be considered a âdistributive principle ⌠[that] is associated with some kind of equity and redistributionâ (Kildal and Kuhnle 2005: 5).
Codified social rights are one way to achieve equal status. On the global level, the âright to means for adequate healthâ (e.g., through healthcare services) is codified in the 1948 Universal Declaration of Human Rights (UDHR) (article 25). The 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR) (article 12) specifies that this right refers to âthe highest attainable standard of physical and mental healthâ. On the country level, some states have formulated access to healthcare as a social right while others have not (for information about the constitutions of various countries, see Constituteproject.org. 2019). Constitutionally, codified access to healthcare (âde jure universalismâ) may not be put into practice due to economic or political constraints, and codification need not ensure increased resources to meet the populationâs healthcare needs, nor equally recognise the healthcare needs of all social groups, even if healthcare rights may be legally claimed. Some healthcare systems provide universal access to healthcare in practice (âde facto universalismâ): they do not dispose of an explicit right to health in the constitution (Smith-Nonini 2006) and suggest there are functioning institutions in place, despite lack of codification.
The term social citizenship refers both to social rightsâcodified or notâand to practice, participation and struggle. Social citizenship seems to be a question of degree or properties; âthe right to a modicum of economic welfare and securityâ, when its level is low, is âcompatible with a limited type of social citizenshipâ, whereas the âright to share to the full in the social heritage and to live the life of a civilised being according to the standards prevailing in the societyâ presents the âmaximalist part of the citizenship rangeâ (Powell 2002: 234). Minimal social rights provide the foundation for universal benefits, yet may not result in equal status due to social stigma or assumed inferiority (Powell 2002: 234). Social citizenship, as practices and struggles, points to the importance of institutions, norms and identities, and highlights participation in as well as the institutionalisation and appropriation of collective benefits or services (Isin and Turner 2002: 4).
Given the wide variation in the institutional mix and structure across societies, it is not clear whether all universal healthcare systems are, in fact, providing similar levels of service: the same access, the same packages, range and quality of provision. This chapter scrutinises the notion of âuniversalismâ in three Latin American countries which each claim to have universal healthcare, by focusing on variations in institutional arrangements. The next section offers the rationale for selecting the countries according to the welfare regime typology , followed by a section presenting the constitutive dimensions of healthcare systems. After clarifying the âvariety of universalismâ featured in each of these countriesâ healthcare systems, the final section discusses some of the implications of the analysis for social citizenship.
Welfare Regimes and Country Selection
Welfare regime theory provides a theoretical frame within which to compare institutional arrangements. Welfare regimes refer to country groups with dominant institutional patterns, policy logics and principals, and it is assumed that the organisation of welfare in specific fields varies according to the rationale or principles of the welfare regime (Lundberg et al. 2015). The study of regimes reveals the interplay of responsibilities between state, markets, communities/non-profit organisations and households/individuals, which together enable welfare provision. Each welfare regime is indicative of a specific state-citizen relationship and a way of according social rights and status; it contains a discrete understanding of (social) citizenship (Isin and Turner 2002). The three countries with universal healthcare examined in this chapter were selected according to Esping-Andersonâs typology of welfare regimes (Esping-Andersen 2015), which Filgueira (1999, 2007) applied to the Latin American context: Chile accords to the liberal type, Uruguay to the conservative type and Costa Rica to the social democratic type.
Liberal welfare regimes (Chile ) build on the rationale of individual provision and responsibility and rely on markets to allocate social rights. Benefits, transfers, redistribution and solidarity are minimal, suggesting that the variety of universalism is residual, that is, at a low level and limited. Social citizenship does not refer to rights of equal status, but rather is dependent on market success or income (Isin and Turner 2002) and therefore stratified. This brings with it the risk that beneficiaries of welfare may be considered inferior and are stigmatised (because they are not successful in the market).
Conservative welfare regimes (Uruguay) follow the rationale of corporate or institutional partnerships, or of social groups. Social rights are important, but not universal (Isin and Turner 2002). Welfare provision is differentiated according to status, and benefits are aimed at status maintenance. Social rights are based on employment (and family circumstance). Benefits, transfers, redistribution and solidarity tend to be more generous than in liberal regimes. Universalism refers to institutional arrangements for specific social or population groups. Welfare receipts may stigmatise beneficiaries, and social citizenship may be segmented or stratified.
Social democratic welfare regimes (Costa Rica) are state-oriented and egalitarian. Social rights are important to ensure equity and enhance equality. Policies are oriented towards the whole of the population and welfare benefits are comprehensive and of similar quality for all. This institutional arrangement is universal without stigmatisation; it enables full social citizenship in terms of equality of status.
Social democratic regimes are the best at guaranteeing universalism in healthcare in terms ...