Bajo la superficie del universalismo: segmentación y descreme en el sistema de salud uruguayo

This article analyses the results of the segmentation and fragmentation achieved by the National Integrated Health System (SNIS) in Uruguay, based on the incentives generated by the institutional design for the behaviour of private providers. The argument is that this scenario creates conditions that reinforce segmentation, to the detriment of similar quality services for the entire population, regardless of the provider or the individual's ability to pay. Uruguay is an interesting case in point for this discussion, as it appears in all regional rankings among countries with the best health system performance. Among the findings is that the reform implemented in 2008, based on principles of universality, ultimately prioritized the stability of private providers by consolidating a quasi-market tailored to their interests. The new system opened the door for lower-income wage earners to "exit" the public sector, while simultaneously creating the conditions for the upper classes to move to private insurance. At the same time, this double skimming began to generate a new process: segmentation within a single provider based on people's ability to pay, limiting the possibilities of building broad redistributive coalitions.