During the 80s, public health expenditure declined. Since comparative global studies on health expenditure in Latin America have become available only recently, estimations of the scope and effects of this decline must be done indirectly.
Average health care expenditure by governments of the region fell from 0.8 per cent to 0.7 per cent of GDP between 1980 and 1990. In US$ at 1988 prices, this meant a drop from US$18.8 to US$14.6. In the same period, total expenditure of social security systems decreased from 4.8 per cent to 4.1 per cent of GDP. Simultaneously, the proportion of expenditure dedicated to medical care decreased from 27.6 per cent to 25.6 per cent (OPS, 1994d). This was partly related to the outburst of a cholera epidemic in the region in 1991. In 1992, some 160 million people lacked permanent access to health services.
The analysis by components of expenditure in the above study includes 18 countries which make up for more than 95 per cent of the population and the GDP of Latin America and the Caribbean. Their estimates should be considered as conservative, since they do not include certain components of public expenditure (health benefits for the Army and some public companies) or private disbursement (individual or company subscription of private insurance, contributions to prepayment systems, expenditure of national or international NGOs, etc.).
In 1990, the countries of the region spent an average of 5.7 per cent of their GDP on the purchase of health related goods and services. This means an expense of approximately US$122 per capita. The ratio between the average (US$300) of countries who spent most (Antigua and Barbuda, Argentina, Bahamas, Barbados, the Cayman Islands and Monserrat), and the average of the group that spent least (Bolivia, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay and the Dominican Republic) was six to one. The share of GDP spent by three countries (Argentina, Costa Rica and Panama) was greater than the average for the OECD countries that year (7.8 per cent).
Private spending accounted for 57 per cent of health expenditure (3.2 per cent of GDP) while public expenditure was 43 per cent of (2.5 per cent of GDP). The public-private combination ranged from a minority of countries where private expenditure was only one third of the total (Costa Rica and some English-speaking Caribbean countries) to countries where it was more than three quarters (in general, countries with low or medium incomes and more populated: Bolivia, El Salvador, Mexico, Peru, the Dominican Republic and Venezuela). Private spending that year (1990) in developed countries (excluding the USA) did not exceed, on average, 25 per cent of total expenditure.
More than 50 per cent of public expenditure in health corresponds to social security entities (24 per cent of total expenditure and 1.1 per cent of GDP); 28 per cent to central governments (12.2 per cent of total expenditure and less than 1 per cent of the GDP) and 6-7 per cent to regional or local governments. In other words, for each dollar spent by the central government, households spent at least US$4.6 of their own pockets.
Data from the same study indicate that 35 per cent of private spending was dedicated to payment of doctors' visits, 34 per cent to drugs purchase, 11 per cent to hospitalization and diagnoses and the remaining 20 per cent to payment of protheses, laboratory services, and others (with large variations between countries in every case).
Another recent study (GOVINDARAJ, MURRAY and CHELLERAJ, 1994, pp. 13-14) confirmed most of the aforementioned data, estimating total health expenditure in Latin America and the Caribbean in 1990 at 6.3 per cent of GDP. This percentage is significantly higher than that of China (3.5 per cent), the Middle East (3.6 per cent), Africa below the Sahara (4.2 per cent) and Asia (4.5 per cent). Moreover, while overall private spending accounted for 40 per cent of the total, in Latin America this figure was 51 per cent.
The preceding information is very relevant because the argument of inefficiency and inequality of health expenditure coined (and to a great extent still prevailing) over the last decade, through focusing on the public component of expenditure, ignored the problems of inequality and inefficiency of private spending (which is the largest portion in the region), thus contributing to, indirectly, increase them.