A glance over the history of the Chilean health system shows an unusual picture. Chile is one of few countries to successfully implement major reforms in their health sector. This middle income democratic country is now showing good health indicators, and the recent changes in its health sector are thought to be a possible model for other Latin American countries. The picture has not always been so positive, and not only for the health system, because of the Pinochet dictatorial regime.

Before the 1980s, democratic Chile boasted impressive standards of health care, with relatively equal access and equitable funding throughout the country.1 Since the 1950s, the single large public system of healthcare providers dominated, financed by government revenues through planned budgets and rigid salary scales.1 State reform to a military government, with the arrival of Pinochet's dictatorship, saw decreasing funding to the health sector, resulting in deteriorating standards of care.

Decentralisation and privatisation ensued with concurrent reforms of the social insurance system.2 The dictating state, coupled with growing public despair at the deteriorating conditions of standards of the national health system, made this possible. A two tiered, mixed public-private system resulted: the wealthy and the healthy in the private system, the poor and the sick confined to the public system. These characteristic inequalities in healthcare funding and provision persisted, with public opinion showing dislike for both the expensive private system, as well as the deteriorating public system. The fall of the dictator and the return to democracy in 1989 has seen efforts to address these inequities by restoring the size and importance of the public healthcare sector.3 Between 1990 and 1996, public health expediture more than doubled,4 and public opinion on access to adequate health care was seen to be improving.3

The currently mixed public-private health system allows citizens to choose their preferred system by opting out of the public payments and instead placing these into a private health insurance package. About 70% of Chile's population is covered by the public system, the rest opting for private coverage.4 The current emphasis on increasing funding and encouraging modernisation of health care services,3 is aiming towards equitable access for all, regardless of wealth or status. The extension of coverage to previously marginalised groups has also contributed to this. The government has introduced a new initiative to cover the cost of healthcare provision for the poor and for those without any form of insurance.3 Although this is certainly having a positive impact, the full realisation of equitable health access is yet to be known.5

The Chilean example shows how strengthening the public health sector can be beneficial in improving equitable health for all. However, with an ageing population and the need for more sophisticated medical technology, this challenge to improve equity of funding and delivery continues.