Three systems in one: health fragmentation and effective coverage

The coexistence of public, social-security and private subsystems produces high formal coverage and unequal effective coverage. Out-of-pocket spending is the indicator that reveals it.

Social policy is almost always assessed by formal coverage. This work starts from a different question: what does a concrete person actually receive, of what quality, at what distance from home and at what cost in time.

The central finding

The evidence shows that outcome gaps are explained less by aggregate spending levels than by their territorial distribution and by the stability of the teams delivering the service.

Residential and institutional segregation reinforce each other: the social composition of the establishment predicts outcomes over and above individual household characteristics.

Policy implications

Improving outcomes requires acting on the composition and location of services, not only on their funding, which turns social policy into territorial policy.

“Formal equality of access coexists comfortably with inequality in what is actually received.”

Recommendations

1. 01Publish quality and composition indicators at establishment level, with privacy safeguards.
2. 02Link resource allocation to location, not only to enrolment or registry counts.
3. 03Stabilise delivery teams through regular competitive recruitment and professional careers.

Methodology

The study uses georeferenced administrative microdata, household surveys and qualitative fieldwork in the territories analysed.

This text is part of the institute's standing editorial line. Data and replication code, where applicable, are published in the Data section.