Exit, voice, and segmentation: Recalibration strategies in South American health care systems

Abstract

Welfare systems in which access to social benefits is mediated by formal employment and income level face renewed tensions in the context of increasing labor market heterogeneity and widening income inequality. These pressures give rise to multiple forms of segmentation, which challenge the traditional dualization hypothesis often used to characterize the evolution of welfare architectures in Latin America. In this context, the health care systems of South American countries provide a valuable lens through which to observe these dynamics. This article is guided by the central question: How are the health systems of Argentina, Brazil, Chile, and Uruguay responding to growing pressures for segmentation? We argue that these systems adopt two main strategies in response to user demands: while some countries have opted to increase competition among providers, others have tended to reinforce pre-existing patterns of dualization. Based on this analysis, we identify four distinct institutional responses to segmentation in health care: (1) Market-led dualism, (2) State-led dualism, (3) Frozen corporatism, and (4) Segmented corporatism.