A study analyzes how Primary Health Care has become the central pillar of Chile’s health reform in the face of limitations on broader constitutional changes and identifies progress, challenges, and lessons for other Latin American countries.
By Clara Rosa Guimarães, CSP journalist
In a context marked by political disputes, fiscal adjustments, and difficulties in promoting structural changes in the health system, the universalization of Primary Health Care (PHC) was the viable alternative for expanding access and strengthening the public health subsystem in Chile. This is demonstrated in the article “Universalization of primary health care: ‘heart’ of health reform in Chile”, published in Cadernos de Saúde Pública.
The study analyzes the strategy for universalizing primary health care (PHC) adopted by the Chilean government between 2022 and 2026, which is considered the main pillar of the country’s current health care reform. The research identified how the proposal was developed, what mechanisms underpin its implementation, and what challenges must be addressed to ensure its continuity and expansion.
According to the authors, following the rejection of the proposal for a new Constitution in a national referendum held in 2022—which called for the expansion of social rights—the prospects for promoting structural changes in Chile’s social health protection system diminished significantly. In this context, the universalization of PHC came to represent a point of consensus among different political, social, and institutional sectors.
“The central objective of universalizing PHC was rooted in expanding coverage of free public PHC services to all Chileans, regardless of their affiliation with the public or private subsystem,” the researchers emphasize.
A Possible Reform of a Segmented System
The 1980 Chilean Constitution does not recognize health care as a civil right; coverage is provided through either the public or private system. Although the system remains segmented, the public insurance system—Fonasa—provided coverage for 84% of the population in 2024, while private insurers (Isapres) served approximately 16%.
In this context, the proposal for universal primary health care (APS) was conceived as a step toward a more universal and equitable system, specifically strengthening the component responsible for the majority of care provided to the Chilean population.
To understand the process, the researchers conducted a qualitative case study based on interviews with officials from the Ministry of Health, representatives of professional and user organizations, regional and municipal officials, health professionals, and Chilean researchers.
Pilot projects paved the way for expansion
Implementation began gradually in 2023 through seven pilot projects in selected municipalities, known as “Pioneer Communes.” By August 2024, the initiative was already in place in 21 communes.
The strategy was designed to reduce political resistance and evaluate new mechanisms for expanding and improving access to primary health care (PHC). Among these, a key feature is the possibility for anyone residing or working in the participating territories to enroll in public PHC services, regardless of their type of health insurance.
The results show that, in the first seven Pioneer Communes, most new enrollees were affiliated with the public subsystem (Fonasa), but there were also enrollees from private health insurance plans (Isapres) and the Armed Forces.
Extended Hours, Telehealth, Comprehensive Care, and Social Participation
Among the key initiatives implemented to expand and improve access to primary health care are the extension of health center operating hours, the implementation of telehealth systems for remote demand management, the adoption of protocols focused on chronic conditions—which aimed to strengthen teamwork and shared care in PHC—and the strategy of “citizen dialogues” and mapping of community assets to strengthen social participation.
The expansion of health center operating hours aimed to serve users who faced difficulties accessing services during regular business hours. The telehealth platform, meanwhile, made it possible to resolve various issues remotely, reducing geographic barriers and facilitating contact between the public and health care teams.
Another important area was the implementation of the People-Centered Comprehensive Care Strategy (ECICEP), a protocol providing guidelines for developing care plans shared with patients and monitored by multidisciplinary teams. Citizen dialogues expanded social participation in PHC, allowing communities to identify barriers, propose, and select projects to improve service quality. Despite these advances, the researchers observed that the biomedical paradigm and the organization of care by programs and pathologies remain deeply entrenched in the Chilean health system.
The article emphasizes that the proposal to universalize PHC seeks to consolidate the implementation of the Comprehensive Family and Community Health Care Model (MAIS), launched in 2005, which transformed traditional clinics and health centers into family health centers (CESFAM) and community health centers (CECOSF) based on a care model—centered on people, capable of providing comprehensive care and ensuring continuity—through multiprofessional collaboration in health care networks that are intersectoral and involve social participation.
Sustainability is the main challenge
The study indicates that the universalization of primary health care (PHC) has yielded positive results; however, its sustainability will depend on political and institutional support and a legal framework capable of ensuring continuity in the face of changes in government and periods of fiscal restraint. For Latin America, the Chilean experience shows that PHC reforms can move forward even in adverse political contexts. In any case, transforming programmatic advances into structural changes capable of withstanding recurring political and economic turbulence requires ensuring sufficient and stable public funding, making progress in overcoming the segmentation of the health system and transforming the care model, and strengthening comprehensive, effective primary health care that is oriented toward the needs of the population.