Middle-classes and universal health care in Latin American welfare regimes : Chile, Ecuador and Uruguay

Universal health care - understood as sufficient and equitable coverage, generosity (in the extent and quality of services) and financial protection for obtaining health services - has remained elusive in Latin America. Instead, segmentation has endured, despite recent unprecedented fiscal effort and coverage expansion to counter it. Moreover, dissatisfaction with poor quality services has escalated from more disadvantaged groups to the middle-classes, who perceive themselves as abandoned by social protection, thus having progressively turned towards private options. Latin American scholarship has broadly recognised the importance of middle-classes in pushing quality welfare provision and higher degrees of universalism. Furthermore, most recent contributions have benefited from the analytical framework of 'policy architectures' to explain the institutional drivers of universalism. Nevertheless, there is a clear lack of research considering the policy designs and middle-classes perceptions and practices in tandem, especially in the domain of health care. This thesis presents a cross-national study that examines how the policy architecture of health care conditions middle-classes' practices for meeting their health needs and how these practices contribute to the reproduction of segmented health care or advance universalism in three Latin American countries (i.e. Chile, Ecuador and Uruguay). The research involves drawing upon the critical realist ontological approach to understanding social processes, with a comparative case analysis design being adopted. Each case study examines the historical development of the health care policy; the current welfare regime, policy architecture and policy outputs as well as the middle-classes' perceptions of and practices regarding health care. The empirical analysis draws on government reports; memories and public accounts elaborated by governments and international organisations; interviews with policy-makers and scholars; and 54 semi-structured interviews with members of the middle-classes conducted between October 2017 and July 2018. It is concluded that the three countries studied have made progress towards universalism, especially regarding coverage. However, segmentation persists in Chile, generating equity gaps in generosity and financial protection. Segmentation also persists in Ecuador, especially with regard to the sufficiency and equity of generosity and financial protection. Meanwhile, Uruguay shows more significant advances, despite still having pending challenges. I argue that there are three key generative mechanisms that drive the relationship between the policy architectures, the middle-classes´ practices, and the policy outputs of health care in the three studied countries. First, the scope and mode of the market presence in health care provision; second, the presence/absence of a non-commodified alternative capable of providing sufficiently generous health services for the middle-classes; and finally, the effects of policy legacies on both the possibilities of policy reforms and day-to-day practices for health care.