First published in ITIJ 119, December 2010
Touted as South America’s answer to St Tropez or the Hamptons, resorts on the east coast of Uruguay, the continent’s smallest country, are fast gaining a reputation as exclusive retreats for the super-rich. Tatum Anderson shows how the healthcare facilities match up
Once a fishing village, José Ignacio’s beaches are today more likely to feature the bikini-clad jet set. Summer residencies of the wealthy and up-market seafood restaurants are patronised by the likes of Naomi Campbell and Shakira, and down the road from José Ignacio is Punta Del Este, which has attracted the rich and famous for a century. Nestled between two giants, Brazil and Argentina, on the South Atlantic Ocean, the coast is just a short plane ride from Buenos Aires and so attracts well-to-do Argentine holidaymakers as well as the international jet set from further afield.
Unsurprisingly, there is a great call for health facilities in tourist areas of Uruguay. Dr Jorge Romanelli, medical director of Unidad de Negocios Asistencia – AXA Assistance Argentina, says: “We give assistance to a lot of foreign visitors in tourist areas such as Punta Del Este, Piriápolis and Colonia Del Sacramento, as well as in Montevideo itself.”
Surprisingly, however, there are not many good-quality health facilities used by assistance companies in this part of the country, nicknamed the South American Riviera.
In Punta Del Este, there are just two sanatoria or private clinics: Cantegrill and Mautone, which can provide only limited medical assistance, says Romanelli. “No cardiac surgery or major neurosurgery is available there. Complex cases must be transferred to Montevideo or Buenos Aires for final admission, via ground or air ambulance.”
there are not many good-quality health facilities used by assistance companies in this part of the country
Most of the best healthcare services are in and around the capital city of Montevideo, less than 200km from Punte Del Este. This concentration of resources is perhaps understandable given that Montevideo is the only large city in Uruguay, and has a population of 1.3 million inhabitants (the population of the country is only three million). In fact, 92 per cent of the population is highly concentrated around Montevideo, its suburbs and 20 or so smaller towns. The geography of the country means a transfer from the coast and other areas to the capital is relatively fast and easy, says Uruguay Asistencia, a subsidiary of Mapfre Asistencia, which operates in 40 countries worldwide. For medical specialities including trauma, paediatrics, gynaecology, neurology and cardiology, the three recommended hospitals in Montevideo are Hospital Británico de Montevideo (Montevideo British Hospital), Asociación Española (Spanish Association), and La Asistencial, says Dr Nigel Dowdall, chief medical officer for the AXA Assistance’s Travel Business Unit. He believes there is a very good standard of medical care throughout the country, adding that medical care in Uruguay is considered to be, at the very least, adequate by the US State Department. Asociación Española, for example, is one of the best private hospitals in Montevideo with facilities and services on offer including cardiovascular surgery, neurosurgery, MRI, CT scan and ICU.
Indeed, Uruguay has traditionally suffered from an oversupply of physicians. This middle-income country has a higher number of physicians per 10,000 population than the US, UK and Sweden. According to World Health Statistics 2010, Uruguay had 12,348 physicians (37 per 10,000 population). (In contrast, there were 2,880 licensed nurses, which is about eight per 10,000 head of population, considerably less.)
Like Axa Assistance, Mapfre prefers to use the private clinics of Uruguay for its clients, says Virginia Villanueva de Pedro, medical director at Mapfre Asistencia, who added: “In private clinics you can find quality care and the best technology available. It is possible to manage critical patients.” These services also appeal to expatriates too, and the clinics are able, for the most part, to deal with assistance companies and foreign clients. “People speak fluent English in Montevideo and the main resorts,” she says. “There are no administrative problems for foreign people. In general, Uruguayans are kindly to tourists.”
However, services provided to tourists can be expensive. While a consultation at the clinic costs about US$50, a home visit can be as much as $400 and an outpatient emergency outside Montevideo up to $370. Most institutions will accept credit cards, but some GPs will take cash only, regardless of whether or not the person standing in front of them have travel insurance cover.
Uruguay’s private sector is made up of a complex array of companies and health insurance plans. First, there are a number of private sanatoria (clinics) and hospitals, which offer private medical care to the high-income groups in Uruguay. It is possible to buy membership to one, or a network, of these facilities via a monthly subscription – a number of local and international companies buy such memberships for their employees.
Monthly rates at Hospital Británico, for example, can cost upwards of $1,977 per month for a private room, although this depends on age and whether the patient is a dependant. Applicants for such schemes are interviewed by a medical examiner and issued with an ID card to carry with them at all times.
One of the most well known hospitals in Montevideo, Sanatorio Americano, has a large membership and is associated with medical centres in other parts of the country. The network, called FEMI, provides assistance including house calls, appointments with GPs and specialists in Uruguay as well as other countries in Latin America, offering coverage to half a million members and employing 2,800 physicians. AXA Assistance says that in its experience, neither age nor past medical history are considered to be problems when obtaining this kind of coverage.
Sanatorio Americano itself is just over half an hour from the capital’s airport and boasts five operating rooms, two delivery rooms, 25 ICU beds for adults and children, 10-bed intermediate cardiac treatment and more than 100 conventional beds.
Beyond private hospital schemes, Uruguayans and expatriates can also buy a type of private healthcare that provides partial coverage only. For example, some healthcare companies offer coverage only for emergency care. These so-called mobile emergency systems have their own emergency telephone numbers, clinics, call centres, ground ambulances and can provide diagnostic procedures, non-complex medical and surgical admissions and dentistry services.
The most well known of these mobile emergency groups are Suat, which has been operating since the nineties, Systema de Emergencia Medico Movil (SEMM) and Unidad Coronaria Móvil (UCM), which has operated in Uruguay for over 30 years.
Uruguay’s private sector is made up of a complex array of companies and health insurance plans
Most subscribers to these emergency plans will also have a separate concurrent comprehensive insurance plan too. Some hospitals even arrange emergency coverage with these companies when admitting applicants to their own private insurance plans. For instance, Hospital Británico says that its hospital scheme can be combined with mobile emergency cover, and under that scheme, an ambulance with SEMM costs $325, Suat $310 and UCM $318. These private mobile emergency companies link with the public emergency system too; if Uruguay’s emergency telephone number 911 is called, for example, often emergency call centre operators will send the nearest ambulance to the scene, regardless of whether it is a public or private vehicle.
Private healthcare is not seen just as the preserve of the very wealthy; indeed, Uruguay’s health system is so dominated by private providers that it is seen as unique, because it runs a mandatory private insurance system that covers over 60 per cent of the population. The mandatory private services are managed by so-called Institutions for Collective Medical Attention (IAMCs), which are private, non-profit organisations that provide prepaid comprehensive health insurance and facilities for patrons to use. This mandatory insurance system has been run by IAMC for decades and caters mostly to the formal workforce. In 2007, the IAMC system consisted of 41 medical centres (estimates put them at 48 today) and included 12 based in Montevideo itself. The rest were located in the interior of the country, although many IAMC clinics also lease services from private sanatoria too. AXA Assistance’s Romanelli says visitors are able to use IAMCS for assistance if they have travel health insurance associated with these providers.
State of wellbeing
Uruguayans are generally healthy and benefit from a well-established and professional public healthcare system, according to the UK’s Foreign and Commonwealth Office, and life expectancy at birth is 76.4 years last year. Many people put that down to Uruguay’s well-educated population – the country is well known for its high literacy rates, arguably the highest in South America – a large urban middle class, and relatively even income distribution. Indeed, the average Uruguayan standard of living compares well with that of most other Latin Americans. The country is also famous for having the first welfare system in South America.
However, other groups, such as the Pan-American Health Organisation, say the public health service provided in Uruguay is fragmented and inequitable. The public health service is managed by the State Health Service Administration (ASSE), although there are other parallel health services dedicated to the armed forces, police force and other institutions too. The Armed Forces Health Services has its own hospital infrastructure, with 450 beds in Montevideo and nursing services at military units in the rest of the country. It provides coverage to approximately 165,000 people, including those on active service, retirees, and their dependants.
ASSE operates a network of hospitals, health centres, polyclinics, and family physicians throughout the country and is estimated to cover around 40 per cent of the total population and provide 8,000 beds. (Together ASSE and IAMC cover about 90 percent of the Uruguayan population).
It is not necessary to be member of ASSE to obtain care, and public hospitals run by the administration are largely free and used predominantly by unemployed people and those on low salaries; that includes informal workers, and dependants of formal employees whose parent or guardians are not financing their healthcare through IAMC.
“Waiting lists are improving but some specialties like ophthalmology, urology and anesthesia have less human resources,”
The poorest people in Uruguay receive a Carné Gratuito, a special card that entitles them to free healthcare. They are not required to contribute a co-payment for any services or medications, but those who earn more are allocated a Carné Bonificado and are required to contribute a minimum co-payment.
The public sector, unsurprisingly, has far less to spend per beneficiary than the public sector (the public sector spent approximately $12 per person per month, while the private sector spends $32 per person per month in 2007). As a result, the ASSE suffers from old and inadequate infrastructure, and its users may not always receive prompt service, according to the World Bank. There is also a shortage of staff and long waiting times, especially in emergency departments. “There are often critical delays to major surgeries, as is common in the public hospitals of Argentina,” agrees AXA Assistance’s Romanelli.
Things are getting better, however, says Mapfre’s Villanueva de Pedro. “Waiting lists are improving but some specialties like ophthalmology, urology and anesthesia have less human resources. But it is common for hospital rooms to have 16 to 20 beds together.”
There are good-quality ASSE hospitals, including Hospital Maciel and Hospital Español, both of which are recommended by assistance companies. Hospital Maciel is a tertiary level acute care facility offering vascular surgery, neurosurgery, haematology, diabetology, thoracic surgery, diseases of the respiratory tract, and nephrology.
The hospital is also home to two so-called Highly Specialized Medical Institutes (HSMI), facilities that specialise in high-technology services including chronic dialysis, kidney transplants, prosthesis, hip and knee surgery. The HSMI facilities at Hospital Maciel are dedicated to dialysis and marrow transplantation, although these services are provided privately, and even here, services are limited. Some transplants must still be done in Argentina, says Mapfre.
Within the public health system, first aid assistance, including the ambulance service, is provided free of charge. Any medication required in the first instance is also free to patients, including visitors. If it is necessary to remain hospitalised as a consequence of surgery or for any other reason, fees are charged according to the service provided.
It is not uncommon for patients to be airlifted to Buenos Aires in Argentina or San Pablo in Brazil
(Several private institutions have emergency centres too. Hospital Británico de Montevideo and Sanatorio Americano both offer round-the-clock emergency services and ambulances.)
Patient transfers to other countries, on the other hand, can be very expensive, say experts. Serious medical problems that require hospitalisation and medical evacuation to the US can cost tens of thousands of dollars, explains the US State Department, and it is not uncommon for patients to be airlifted to Buenos Aires in Argentina or San Pablo in Brazil. As a result of this situation, there are a number of private air ambulance companies operating in Uruguay. Aeromás, for instance, is a Montevideo-based firm that transports critical patients, 24 hours a day and says it has a team capable of stabilising and transporting critical patients, while mobile emergency company SEMM provides air ambulance services too.
In conclusion, it is fair to say that the standard of healthcare facilities in Uruguay are good if a little patchy, and for a tourist in need, there are plenty of physicians and specialists on hand to offer their expertise. If the healthcare is deemed not sufficient for your client, then air ambulances are just a phone call away!