Many Chileans think that their country has lost its way. Massive protests highlight the need for a political reform to prioritise universal health care. The uncritical worship of the most extreme version of the free market by the Pinochet dictatorship led to the dismantling of the social contract and privatisation of the social security system. A system of personal retirement accounts was mandatory for new workers whereas the current workforce could opt out from the existing government-managed schemes. The disability insurance system was also privatised. Insurees could opt out of government-managed health insurance systems (Fondo Nacional de Salud [FONASA]) and join private health insurance plans (Instituciones de Salud Previsional [ISAPRE]). The creation of a two-tier system was the end of the national health-care system created in the early 1950s.

1 Organisation for Economic Co-operation and Development

OECD reviews of public health. Chile: a healthier tomorrow. 2 Roman-Urrestarazu A

Yang JC

Ettelt S

Thalmann I

Seguel Ravest V

Brayne C Private health insurance in Germany and Chile: two stories of co-existence, segmentation and conflict. 3 Castillo-Laborde C

Aguilera-Sanhueza X

Hirmas-Adauy M

et al. Health insurance scheme performance and effects on health and health inequalities in Chile. 4 Gallegos Castillo EA

Muñoz Vergara A Eficiencia de los seguros de salud en Chile un análisis desde la perspectiva de la protección financiera. In Chile, 17–18% of the population opts for private coverage.FONASA has open enrolment policies and is funded by mandatory contributions. ISAPRE charges risk-rated premiums and can reject applicants with pre-existing medical conditions.Premiums are highly restrictive for people who earn a low income. In 2015, the average premium was equivalent to 45% of the minimum wage. The health system institutional design leads to population risk and income segmentation: FONASA covers women and those who are poorer, older, and sicker; whereas ISAPRE covers those who are richer, younger, and healthier. ISAPRE spends 1·35 times more per insuree than FONASA, although they cover people with a favourable risk profile.ISAPRE administrative spending is large, 12·67 times higher per insuree than FONASA,with most of it being spent on marketing to attract insurees at low risk.

5 Ministerio de Salud

Informe sobre brechas de personal de salud por servicio de salud. Santiago. 6 Bossert TJ

Leisewitz T Innovation and change in the Chilean health system. In addition, most Chilean doctors work in the private health-care sector and provide care to the small proportion of the population who are privately insured, for greater financial incentives. Only 44% of physicians have contracts (several on a part-time basis) with public providers.The public sector is underfunded and ill-equipped to provide care for most of the population. As a result, inequality for those who are chronically ill, older, and poor is of alarming concern. Waiting lists for specialist consultations and surgery are common in public hospitalsand emergency rooms are crowded.

The legacy of the dictatorship is pervasive. The result of the broken neoliberal social contract is an unfair distribution of resources and a 40-year period of social disintegration and inequality. Chile must decide if the time has come for a profound structural change, based on a different set of political and ethical principles.

We declare no competing interests.