Health systems reforms in Latin America: neoliberal influences and challenges to the Sustainable Development Goals

This study analyzes the characteristics of health system reforms in Latin American and Caribbean (LAC) countries, the trend of public health spending, and the achievement of the Millennium Development Goals (MDGs). It also discusses the neoliberal influences on public health reforms and the possible consequences for the upcoming Sustainable Development Goals (SDGs). The study is a comparative, non-exhaustive literature review of selected countries, with data extracted from CEPALStat, Global Health Observatory, MDG Indicators platforms, and the Health in the Americas reports available in the Institutional Repository for Information Sharing of the Pan American Health Organization. The reforms were divided into three periods, namely: up to 1990, with a prevailing regulated national solidarity logic; 1990-2000, moving towards a market-oriented competitive logic; 2001-2015, evolving towards public logic programs, maintaining competition between service providers. Public spending fluctuated over time, and the MDG targets analyzed were not completely met. Changes in health systems followed the models prescribed by neoliberalism, with market-oriented competitive logic, weakening the care system and the achievement of the SDGs.


Introduction
This paper enquires whether the neoliberal nature of health system reforms in the 1990s in Latin American and Caribbean (LAC) countries can contribute to explain the incomplete achievement of the Millennium Development Goals (MDGs) and points toward challenges to achieve the Sustainable Development Goals (SDGs).
The MDGs were defined in 2000 at the Assembly of the United Nations (UN) as a commitment of the 191 member countries, with targets set for achievement by 2015 [1][2][3] .The post-2015 Agenda came into play from then on, expressed in the Sustainable Development Goals (SDGs), which aspire to transcend the MDGs by 2030, incorporating other dimensions in health policies [2][3][4] .
While representing a commitment to health care outcomes, the MDGs/SDGs tend to homogenize health policies, with a basic care package mainly aimed at some infectious and contagious diseases.The MDGs/SDGs also materialize health strategies promoted by international organizations committed to the neoliberal agenda of creating and expanding markets, especially in health insurance.They are based on the adoption of Universal Health Coverage, a concept compatible with economic neoliberalism and which conceives health as a commodity.This conception is in line with a reduced state intervention, restrictions to the regulation of the system, and a separation between the financing and purchasing functions of health services.In contrast, based on social welfare, the Universal Health Systems are in the hand of the state, which are responsible for financing, managing and providing health services, and ensure that health is a universal right [4][5] .
The territorial and geopolitical space called LAC comprises 20 countries that are very diverse in terms of history, culture, sociodemographic, and economic characteristics.These countries have all experienced radical changes in the processes of colonization, emigration, immigration, and commercial and technological exchange 6 .Their economic and social development has been characterized by cycles, with different politico-social consequences in each of them.
The 1980s feature the LAC debt crisis that led countries across the continent to default on loans, starting with Mexico in 1982 and spreading across the continent [6][7][8][9][10] .As of October 1983, 27 low-and middle-income countries, many in the Americas, were defaulting on their loans or were in the process of debt rescheduling 6 .During this period, the International Monetary Fund (IMF) and the World Bank (WB) were called upon to provide loans to debtor countries.Associated with these loans were recommendations (conditionalities) for implementing economic measures aimed at opening markets and meeting the neoliberal prescriptions of the Washington Consensus.Proposed reforms included drastic cuts in government spending (particularly in health and other social sectors) and policies that dismantled the fragile and incompletely implemented welfare state in LAC [9][10][11] .
For the health sector, the agenda of economic adjustments proposed by international organizations, especially the World Bank 12 , went against what existed in developed countries.LAC countries were encouraged to reduce the state's responsibility in health, to concentrate on services that served everyone, and to restrict themselves to some essential items such as vaccines and the control of vector-borne diseases.International Organizations recommended the imposition of charges on public health system users in curative care services; encouraged the provision of health services by non-governmental and private institutions; promoted the decentralization of health services to local governments, with financial, administrative, planning, budgeting, and implementing autonomy of public health services; and encouraged the establishment of an upfront payment system, such as mandatory health insurance [13][14][15] .
These recommendations implied a reduction in public spending, economic opening to international competition, price liberalization, and measures to improve the economic efficiency of public spending and the proper functioning of the market economy.It was hoped that health conditions would improve in the long run due to more significant economic growth and that the first results would be seen within at least five years -16 .
Reforms should distinguish between the various public health goods and guarantee services with a high positive externality; consider public funding of essential clinical care as a means of poverty alleviation; decentralize and adjust the large public health system by limiting new investments in public tertiary care hospitals, defining a package of essential clinical services and ensuring basic services as recommended by Alma-Ata since 1978 [9][10][11][13][14][15] . The fous was also on the reduction of expenses through transfers to local governments and non-governmental and private initiatives, meeting the rationale of neoliberalism 16 .
The transition from the economic model centered on the welfare state, albeit incompletely implemented in LAC, to a neoliberal model, disseminated in the 1970s and 1980s, reduced state social protection systems and assigned the market to meet the social needs, resulting in a deterioration in the quality of life of populations [9][10] .In the 2000s, with the so-called "pink wave" of LAC, economic regulation and social protection mechanisms were reintroduced by several countries, triggering a "social cycle" that allowed health to play a prominent role, as reflected in the definition of three out of eight MDGs 2, [13][14][15] .
The period that we are interested in evaluating here is that of the growing neoliberalism in the region.This process took place in LAC in the 1980s and mainly in the 1990s.This paper analyzes the main characteristics of the health systems reforms carried out in LAC in the last decades, the trend of public spending on health, and the achievement of the MDGs, to reflect on the neoliberal influences on the reforms of these systems and the current challenges in achieving the SDGs.It is assumed that the domination of neoliberalism characterized the reforms carried out in Latin America, leading to an excessive focus on health services and the dismantling of public health systems and policies as a result of the sector's commodification and financialization.

Methods
We carried out a comparative study of the health systems of selected LAC countries and of the trend in public spending.We then discuss the neoliberal characteristics of the reforms in relation to the difficulties in meeting the MDGs goals.
Countries with the largest populations and for whose analysis of health indicators data were available were selected: Argentina, Brazil, Chile, Colombia, Mexico, and Peru.Venezuela was excluded due to its structural problems in recent years, which could compromise the results.Cuba was included as a counterfactual in the analysis of reforms, allowing to observe results when the logic is not that of the market.
The main features of health systems before 1990 were synthesized from these data and the bibliography on health systems in LAC, comparing them with those resulting from neoliberal reforms in the 1990s and those existing more recently after the 2000s (Chart 1).Also, we examined the trend of public spending on health (Table 1) and the fulfillment of the goals to achieve the MDGs (Tables 2 and 3).

Health systems reform processes in selected countries
Chart 1 shows the evolution of health systems in LAC in the pre-1990 period, when neoliberal reforms had not yet been carried out, traversing the 1990s to the 2000s, when the neoliberal package had been widely installed.
As can be seen in Chart A general trend toward a market-oriented logic was observed in the 1990s.Fiscal concerns have led to the redistribution of service delivery from national to local governments and to the private sector.It is the period of decentralization of responsibilities, creating various forms of financing and the organization of the private provision of health services, the growth of private health plans, a segmented population coverage, and a fragmented provision of services (popular, social insurance, public, and private).The case of Colombia stands out among the most segmented systems, and its segmentation began before 1990.In this period, Brazil followed the opposite path, toward the universal Unified Health System, albeit decentralizing it to municipalities and sharing health services with private plans under a dual system.After the 2000s, we note a gener-  al tendency to return to public health concerns, with the emergence of public and community logic programs and concerns about regulation and coordination, although maintaining competition among health service providers and carrying on a market-oriented logic.This is the case of the expansion of specific public programs in Argentina, the regulation of health plans in Brazil, the increase in taxes for health financing, the regulated freedom of the ISAPRES in Chile, and the expanded public services in some states and the IMSS -Opportunities for beneficiaries of Popular Insurance in Mexico, and the Law Framework for Ensuring Universal Health in Peru.
Cuba was analyzed as a counterfactual.It is usually admitted that it is a successful country in terms of health indicators.Its health reform path goes in a completely different direction than the other study countries.From a system already public and universal since the beginning of the analysis, it has evolved towards deepening and expanding the provision of health services and articulating this provision with internal health training.Externally, the expansion of international cooperation is growing in this country.

Public and private spending on health and against gross domestic product (GDP)
Table 1 shows that, except for Argentina, the countries increased spending on health against GDP in the 1980-2015.However, in all of them, the participation of the public sector in the provision of health care falls between 1980 -when neoliberalism had not yet become widespread in the region -and subsequent years -a period of more significant neoliberalism expansion.In some countries, such as Brazil and Chile, this reduction extends to the 2000s.In the following period that witnessed the so-called pink wave of left-wing governments, the participation of the public sector in health expenditure increases in all countries, albeit in different proportions.However, the effects of the neoliberal resumption could only be analyzed with data after 2015, for which there is still not enough consolidated information.
In this regard, it should be noted that the withdrawal of national states from health spending compromises access to these services.On the one hand, differentiated packages arise in terms of prices, and, on the other hand, plans are segmenting the population's access by income, class, and functional category, as we saw in the health reforms in Chart 1.This mechanism tends to reduce the population's pressure for high-quality and -quantity health services, since it treats differently those who are capable to demand improvement.

Country performance in the MDGs and their transition to the SDGs
Regarding the performance of the MDG indicators, Tables 2 and 3 show that most countries did not reach all the agreed goals.As for the goal of reducing child mortality in children under five years of age by two-thirds, from 1990 to 2015, only five countries in the region, three of which were selected and studied in this paper, reached the goal, which was a reduction of 66%: Brazil (-75.1%),Mexico (-67.0%) and Peru (-80%).Cuba and Chile show the best performance in this indicator during the study period: while they did not reach the reduction target, their mortality rate is by far the lowest in absolute numbers.
Only Peru (-78%) and Brazil (-73.3%)reached the goal of reducing the infant mortality rate (IMR) by 66% among children under one year.Chile and Cuba again had the best overall performance, with the lowest IMR since the 1990s.Brazil, Colombia, Cuba, Mexico, and Peru achieved a final positive change for the proportion of 1-year-old children immunized against measles.The best results are in Brazil and Cuba (99% in 2015).The Maternal Mortality Ratio (MMR) goal was to achieve a 75% reduction.While none of the countries achieved this goal, they all reduced the number of preventable maternal deaths, with the most significant reductions occurring in Peru (-72.9%) and Chile (-61.4%).Chile has the lowest MMR (22/100,000 LB), followed by Mexico (38/100,000 LB).
As for the indicator "proportion of births attended by qualified health personnel" (doctors, nurses, or midwives), according to partially available data, all countries improved, but the overall goal remained unachieved.Not all countries have data available on the percentage of mothers aged 15-19 years (MDG5).Argentina, Colombia, and Cuba show increases in the adolescent birth rate from 2000 to 2015.The other countries have reduced the number of births among adolescents, although the data for Colombia, Peru, and Mexico are incomplete.
Goal 6 of the MDGs (Table 3) aimed to reverse the spread of HIV/AIDS by 2015.According to available data up to 2014, Mexico and Peru have reversed the spread of AIDS in the 15-49 years age group.As for the goal of universal access to treatment, all countries expanded access, emphasizing Brazil (95%) and Cuba (95%), which achieved the best results.
We also sought to analyze the achievement of targets for reversing the incidence of malaria and  3 shows that all countries have curbed the incidence and prevalence of these infectious diseases.

Discussion
The paths of health reforms showed different adherences to two opposite conceptions.The first is Universal Health Coverage, which focuses on funding through a combination of funds (pooling), affiliation by insurance modality, and the definition of a limited basket of services.This form predominated mainly in Mexico in 1990 and in Colombia in 1993 4 .The second conception is that of the Universal Health System, financed by public funds from revenue from general taxes and social contributions, which provides greater solidarity, redistribution, and equity [4][5] .This is the model in Brazil, albeit more in legal than real aspects, as it shares the provision of services with private health plans within a dual system.Between the two extremes, intermediate models Observation: Variation in % represents the difference between the first and last year analyzed.
Source: CEPALStat and Global Health Observatory Data Repository.vary in the level of access and breadth of coverage, the modalities of affiliation to insurance, and the level of integration between the public and private sectors to provide services.In this intermediate pole are the other countries analyzed, namely, Argentina, Peru, and Chile [4][5]9 . Prvate participation in the management and delivery of health services was strengthened in the reforms [11][12][13][14][15][33][34] .Decentralized and segmented health services were produced 26 , regarding access and the type of service provided, and fragmented (dual, tripartite, and even quadripartite) regarding the planning and management of resources among service providers, with copayment schemes, in other words, the payment is partially done by patients, instead of public funding 33 .
The separation of functions between financing and provision implies the pricing of health services, transforming them into commodities produced and demanded competitively.While health expenditure increased in the countries analyzed, public spending dropped in all countries in the second phase, with the diffusion of neoliberalism in the region.As Dardot and Laval 16 point out, the state is not excluded in neoliberal systems but is called to a role that accepts the logic of the market and works trying to imitate it.Previously related to the behavior of companies, in neoliberalism, competition becomes a characteristic of the behavior of individuals, who function as self-run companies, by planning and competing in the labor market to access the health plan that suits them best, and the state, which starts to behave like a company, competing with other service providers.Thus, one observes the transformation of public action, making the state a sphere that is also governed by competition rules and subjected to efficiency requirements similar to those that subject private companies 16:272 (own translation).National, solidary, and regulated health systems predominated until the 1980s, except for Colombia, which showed earlier and broader decentralization and diversification of non-public health sources 33 .In the others, the market logic advances in the 1990s, with some setbacks in this logic in the 2000s onwards, still maintaining, however, an essential role of the private sector and competition in the provision of health services 11,13,29 .
Finally, by fragmenting the provision of services, the devolution of essential services and of healthcare delivery to local governments, to non-governmental entities, and to the private sector expands the segmentation of the population and leads to diseconomies due to inefficient  allocation.This fragmented treatment is reinforced by the differentiation made by the target population of different service packages, financing schemes, and coverage of health services 29 .All these differences characterized the health reforms and underlay the lower public spending on health, making the provision of health services precarious, especially for the most impoverished population.However, this strategy goes against the essence of Goal 3.8 of the SDGs, which aims to achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all 21 , which is why its potential to stimulate structural changes has been questioned 3 .
Based on the Universal Health Coverage model, the strategy of international organizations was insufficient to guarantee the achievement of the MDGs goals.None of them were fully achieved by countries, and some were not met by any country.The high maternal mortality, adolescent pregnancy, and low prenatal coverage in some countries in the region are particularly noteworthy, highlighting the existing challenges to improve womens' sexual and reproductive health 35 .Indicators that refer to women's health, such as the MMR and adolescent pregnancy, point to a perverse effect of health systems in re-lation to the lack of assistance or the low quality of care offered to reproductive health.The longterm effects disrupt families and the economy as a whole, as maternal deaths often leave children and older adults unassisted.The death of women also affects the offer of family care and, even more, household income 35 .
On the other hand, progress has been made in assisted births, in reducing malaria incidence as well as the incidence and prevalence of tuberculosis, but only Brazil and Cuba have come close to the goal of comprehensive care for the population with HIV/AIDS.
One of the limitations of this paper is the descriptive and exploratory nature of its data analysis, which does not allow us to affirm stronger causal relationships between the reforms in each country and the health system outcomes.However, the analysis of the characteristics of the reforms, as shown in Chart 1, and the trend of neoliberalism, show that the role of the state in the provision and regulation of health systems predominates in the first period analyzed (until  1990).The second period (1990-2000) shows a more competitive logic of changes following the logic of the market, while the last period (2001-2015) shows the introduction of public and community programs despite maintaining the stimulus to competition.The analysis of the reforms suggests that the achievement of care results is closely related to the capacity of national states to intervene in a coordinated fashion in social determinants and is related to the increase in public spending on health and the capacity for governance and inter-federative coordination within countries.Inequalities in access to health resources must be addressed through international regulations and national jurisdictions through health systems 34,36 .The trajectory of health systems with strong decentralization, fragmentation of the health coverage, and funding fluctuations in a region with high social inequality shows the need to find new reforms paths to strengthen public health systems.

Conclusions
The significant challenges for health systems continue to be the glaring differences in health outcomes arising from socioeconomic inequalities and differences in the quality of public and private services; the fragmented organization of service provision and the segmented financing that tolerates the existence of access to portfolios of services compatible with the contribution capacity of the population segments; the low regulation of the private sector regarding the offer of services, costs, and profits; and the difficulty of meeting the needs of populations at a time of demographic, epidemiological, and protest movements.
The reforms of the LAC health systems interfered in the countries' health policy trajectories, deepening social and economic inequalities and deteriorating the living conditions of the populations.Such deterioration, aggravated by the economic crises (1980-90, 2008, and post-COVID-19 pandemic), is likely to hinder the achievement of the SDGs and to foster the emergence and resurgence of diseases and public health problems.Moving forward will require a different, broader, and integrated role of the public health system to avoid severe reversal in the population's health situation.

Collaborations
LBD Göttems and LP Camilo worked on the conception, design, collection, analysis, interpretation of data, and paper writing.MLR Mollo worked on the writing of the paper and its critical review.C Mavrot worked on the paper writing and approved the version to be published.

Chart 1 .
Historical context and trajectory of Latin America countries from 1990 to 2015.

Chart 1 .
Historical context and trajectory of Latin America countries from 1990 to 2015.

Country Up to 1990 1990-2000 2001-2015 Prevalence of regulated solidary national logic Advancement of competitive market logic Specific programs of public and community rationael, maintaining the competition of service providers
Captions: EC -Constitutional Amendment; PHC -Primary Health Care; IVA -Value Added Tax; RISS -Integrated Health Services Networks; NHS -National Health Service; SUNASA -National Health Insurance Superintendence; CF: Federal Constitucion.Source: Author´s elaboration.

Table 1 .
Distribution of total public and private expenditures as % of GDP.

Table 2 .
Achievement of Goals 4 and 5 of the MDGs -Maternal and Child Health.

Table 2 .
Achievement of Goals 4 and 5 of the MDGs -Maternal and Child Health.

Table 3 .
Achievement of MDG Goal 6 -Access to Treatment for Infectious Diseases by 2010.

Table 3 .
Achievement of MDG Goal 6 -Access to Treatment for Infectious Diseases by 2010.