World Development 101 (2018) 37–53

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World Development
journal homepage: www.elsevier.com/locate/worlddev

State Capacity and Health Outcomes: Comparing Argentina’s and Chile’s

Reduction of Infant and Maternal Mortality, 1960–2013
Daniel Brieba
School of Government of the Universidad Adolfo Ibáñez, Chile

a r t i c l e i n f o s u m m a r y

Article history: There is substantial quantitative evidence linking higher state capacity to better health outcomes, but
Accepted 25 August 2017 scant attention has been paid to the specific mechanisms through which this causal influence operates.
Available online 23 September 2017 The problem is compounded by the considerable diversity of ways in which the influence of the state on
development outcomes has been conceptualized, making it hard for practitioners to extract policy lessons
Key words: from this literature. In this study, I seek to help to address both of these problems through a historical-
state capacity comparative examination of the ways in which state capacity affected infant and maternal mortality
infant mortality
reduction in Argentina and Chile over the last half century. I show that Chile’s greater investment in
maternal mortality
Chile
health-specific state capacities was behind the remarkable historical ‘‘reversal of fortune” between these
Argentina two countries in terms of infant and maternal mortality levels from 1960 to the present, as well as behind
governance Chile’s notorious reduction in the territorial inequality of these outcomes. I show the key difference
between the two countries was the quality, reach, and homogeneity of their respective public health sys-
tems. From a theoretical standpoint, I argue that the notions of bureaucratic quality and infrastructural
power are both necessary and complementary perspectives through which to conceptualize state capacity
and understand its causal influence over health and other desirable developmental outcomes. In turn, this
suggests that a useful way to specify calls for better ‘‘governance” and to achieve better long-run health
performance may be to invest in the public health system’s technical (bureaucratic) autonomy and in its
system-wide planning and coordination capacities.
Ó 2017 Elsevier Ltd. All rights reserved.

1. Introduction demographic, or cultural factors. States, therefore, seem to auton-

Despite the growing recognition that achieving desirable devel-
opmental outcomes depends in part on having good economic and
political institutions, there remains much discussion as to which
institutions matter most for achieving these outcomes and on
how, concretely, they matter. In recent years, considerable cross-
national quantitative evidence has been produced supporting the
idea that variations in state capacity (broadly defined) are respon-
sible for significant differences in the degrees of achievement of
desirable social and developmental outcomes, such as lower pov-
erty (e.g., Henderson, Hulme, Jalilian, & Phillips, 2007); higher
long-run economic growth (e.g., Dincecco & Katz, 2016); higher
educational achievements (e.g., Rajkumar & Swaroop, 2008), and
better health (e.g., Holmberg & Rothstein, 2011), among others.
Though under varying terminology—such as control of corruption,
quality of government, bureaucratic autonomy, infrastructural
power, and governance, to name a few—this literature has shown
that state capacity impacts outcomes independently of other
influences, such as how democratic the regime is or economic,
omously matter for development.
Detailed historical or comparative evidence of how their influ-
ence unfolds, however, is mostly lacking. This is problematic inas-
much as without attention to mechanisms it is difficult to
persuasively make the case that the observed conditional correla-
tions are, in fact, causal relationships. Moreover, this ‘‘statist” field
still lacks conceptual unity—as the myriad competing explanatory
terms just mentioned show. Both problems are linked, inasmuch as
without the careful examination of processes and mechanisms it is
hard to further the concept- and theory-building process required
to evaluate the different conceptualizations and operationaliza-
tions of state influence that are available. In short, if we want to
theorize and explain how states actually affect development out-
comes, we need to take a closer look at the processes involved.
The aim of this study is to contribute to this task through a com-
parative, historical study of the relationship between state capacity
and two specific health outcomes—infant and maternal mortality—
in Argentina and Chile. This is a particularly fruitful area in which
to trace the ways in which state action affects outcomes, because

https://doi.org/10.1016/j.worlddev.2017.08.011
0305-750X/Ó 2017 Elsevier Ltd. All rights reserved.
38 D. Brieba / World Development 101 (2018) 37–53
most infant and maternal deaths outside the developed world are
avoidable from a medical point of view and are so at a fairly low
cost (McGuire, 2006). As Argentina’s first Health Minister famously
said, ‘‘Health is a political decision” (Iglesias, 2009). Thus, there are
few other development outcomes where deliberate and specific
public action can have such dramatic and visible effects as it can
have on infant and maternal mortality.
In turn, the comparison of Argentina and Chile is particularly
instructive because it starkly illuminates the impact that investing
in state capacities in the health sector can make. In a nutshell, I will
argue that Chile’s greater investment in health-specific state capac-
ities1 was a key element behind the remarkable historical ‘‘reversal
of fortune” (Acemoglu, Johnson, & Robinson, 2002) between these
two countries in terms of infant and maternal mortality levels from
1960 to the present. It was also behind Chile’s notorious reduction in
territorial inequality in mortality rates, an outcome of intrinsic nor-
mative importance but not usually considered in the empirical state
capacity literature. Thus, the evidence provided will allow us to
observe in some detail the mechanisms through which state capacity
in a specific sector actually translated into better outcomes, and
what this implies for discussions about how best to conceptualize
state capacity as an explanatory variable. In particular, I will argu
e—firstly—that a major source of differences in state capacity in
health between countries is the development and quality of their
public health systems; and—secondly—that from a theoretical stand-
point, the notions of bureaucratic quality and infrastructural power (to
be defined in the next section) are both necessary and complemen-
tary perspectives through which to conceptualize state capacity and
understand its causal influence.2
The rest of this paper is organized as follows. In the next section,
the literature on state capacity and health outcomes is reviewed. In
the third section, the methodological logic of the comparison of
these two cases is explained. In the fourth, the historical context
of the comparison is presented and the differences in outcomes
between the two countries are laid out. The fifth and sixth sections
examine the Chilean and Argentinean cases, respectively, while the
last two sections discuss the findings and conclude.
2. State capacity and health outcomes
(a) State capacity, bureaucratic quality, and infrastructural power
Though many terms have been used to denote the degree to
which states are able to effectively implement policy decisions, I
will here use state capacity to cover all of these. Given this focus
on implementation, state capacity is preferable to terms such as
governance—of wide use in the literature concerned with health
outcomes—inasmuch as this latter term is more imprecise and
wider in scope, often bundling together state-related and regime-
related issues (e.g., Kaufmann, Kraay, & Mastruzzi, 2011), or else
referring to civil society or transnational actors (Fukuyama,
2016). Other terms, such as ‘‘quality of government” are similar
to state capacity in intent, but are defined in a way—in this case,
1
Investment in state capacity refers to the allocation of scarce resources (such as
money, time, political capital, and expertise) to the development of the state’s ability
to implement policy in a given policy area. Thus, though it may include financial
investments (such as, in the case of health, construction of hospitals, or the hiring of
doctors), it also includes investments in organizational development, logistics,
protocols, information sharing, and all kinds of regularized procedures that allow a
state to better implement policy. In particular, organizing (and reorganizing) the
functioning of a public health system is an investment in this sense.
2
It should be noted that state capacity is considered a proximate cause of
differential health outcomes, since state capacity itself is partly determined by a
series of political, economic, and historical factors (e.g. Besley & Persson, 2011; Soifer,
2015). In other words, this study aims to study the specific ways in which state
capacity affects outcomes, not to ascertain what causes state capacity in the first
place.
by impartiality in the exercise of political power—that assumes a
sufficient underlying mechanism through which states achieve
good outcomes (Fukuyama, 2013; Rothstein & Teorell, 2008). Yet
others focus on specific capabilities in the exercise of power—such
as military force, law-enforcement, or tax extraction—but without
relating them to a broader notion of a state’s overall policy-
implementation potential and what may affect it, thus making
them less useful for theory-building (see Cingolani, Thomsson, &
Crombrugghe, 2015).
There are, however, two well-established theoretical traditions
that seek to explain which kinds of states will be more effective
than others at policy implementation. The first tradition points to
what we may call the quality of the bureaucracy, with quality refer-
ring to the degree to which it conforms to key aspects of a modern,
rational, rule-based bureaucracy as originally defined by Weber
(1922/2013). One concern coming from this approach is with the
absence of corruption as a necessary feature of a good bureaucracy,
since Weberian bureaucrats do not use their public powers for pri-
vate gain or for the arbitrary benefit of a particular social group
(Evans, 1995; Rothstein & Teorell, 2008). Bureaucracies also need
to be highly competent and professional in the fulfillment of their
tasks, and therefore the meritocratic hiring and promotion of
bureaucrats is seen as crucial for well-performing bureaucracies
(e.g., Geddes, 1996; Rauch & Evans, 2000). High performance also
requires important degrees of technical or bureaucratic autonomy,
so that technical rationality (as opposed to short-term political or
electoral considerations) drives the design and implementation of
policy (Cingolani et al., 2015). In this last sense, autonomy is
important in a way not foreseen by Weber: instead of complete
obedience and subordination, high bureaucratic performance actu-
ally requires granting top bureaucrats a degree of freedom in the
choice of means through which to achieve politically mandated
policy ends (Fukuyama, 2013). Thus, bureaucracies that are clean,
meritocratic, and autonomous are expected to increase the state’s
capacity to provide public goods.
A second tradition of state capacity has focused less on the anal-
ysis of state structures per se, and more on the nature of state–so-
ciety relations. The key concept in this tradition is the notion of
infrastructural power, which can be defined as ‘‘the capacity of the
state to actually penetrate civil society and implement its actions
across its territories” (Mann, 2008, p. 355).3 In turn, this largely
depends on the infrastructures of control at the state’s disposal,
understood as all the ‘‘routinized media through which information
and commands are transmitted” (Mann, 2008, p. 358). Networks of
information, transportation, and communication are therefore cru-
cial for the logistics of policy implementation and enforcement.
More broadly, two related aspects of infrastructural power are
worth emphasizing here. Firstly, it implies a basic centralization
of political power, in the sense that authority radiates outward from
a political center that can coerce populations, extract resources
from it and enforce its laws and policies over it.4 Secondly, the ter-
ritorial penetration of the state, so as to control all populations, is a
key aspect of the concept. Infrastructural power emphasizes the fun-
damentally spatial nature of political relations, and therefore the pos-
sibility of subnational variation in their shape and depth. As Soifer &
vom Hau (2008, p. 222) have pointed out, ‘‘[t]he ability of states to
carry out their projects is territorially organized and crucially shaped
by the organizational networks that they coordinate, control and con-
struct”. Thus, territorial organizational linkages are key: when state
organizations at the local level are coopted by powerful local elites,
the infrastructural power of the state is diminished (e.g., Soifer, 2015).
3
It is to be distinguished from ‘‘despotic” power, which refers to the range of
decisions rulers can take without consulting civil society groups (Mann, 2008, p. 355).
4
This is of course compatible with decentralized governance structures, such as
federal systems (Ziblatt, 2008).
Table 1
Conceptualizations and operationalizations of the influence of state-centric variables on selected health outcomes

Farag Sajedinejad, Majdzadeh, Muldoon Klomp Rajkumar Baldacci, Lazarova Hallerod Holmberg Dietrich Cingolani Siverson Dawson Ziblatt (2008) McGuire
et al. Vedadhir, Tabatabaei, et al. and De and Clements, (2006) et al. and and et al. (2015) and (2010) (2006)
(2012) and Mohammad (2015) (2011) Haan Swaroop Gupta, and Cui (2013) Rothstein Bernahrd Johnson
(2008) (2008) (2008) (2011). (2016) (2014)
Concept Governance Quality of Government State Bureaucratic Corruption Rule of Infrastructural Institutional
Indicators capacity Autonomy Law Power Quality
Government X (X) (X) X X X
effectiveness
Corruption (X) X (X) X (X) (X) X X X X
Meritocratic/ (X) X X X X
bureaucratic quality

D. Brieba / World Development 101 (2018) 37–53

Bureaucratic autonomy XX
Fiscal (tax) X X
Rule of law/Law and (X) (X) (X) X X X XX X
order
State fragility X
Property rights (X) X
protection
Regulation (X) (X) (X)
Legislator effectiveness (X)
Democratic (X) (X)
Accountability
Political Stability/ (X)
Absence of Violence
Strength of Legal Rights (X)
Index
Selected health Infant Maternal Mortality Infant Indiv Child Child Infant Child Life Infant Child DALY Child Hospital Child
outcomes explained mortality mortality health mortality mortality mortality health expectancy mortality mortality mortality spending mortality
by paper deprivation
Child Maternal Health Child Tuberculosis Infant health
mortality mortality care mortality prevalence clinics
sector
Child Maternal
mortality mortality

Note: The second row names the main state-centric explanatory variable the author(s) identify as a source of better health outcomes. The first column lists the different indicators of that main variable that each paper employs. (X)
means indicators are grouped by the author(s) into a single, combined measure. XX means it is the sole intended indicator for the main explanatory variable (in which case the other Xs are controls or complementary state-centric
explanatory variables included in the study).

39
40 D. Brieba / World Development 101 (2018) 37–53
Both the bureaucratic quality and the infrastructural power per-
spectives have significant overlapping implications (e.g., both
agree that a corrupt bureaucracy weakens state capacity), but are
nevertheless distinct. For instance, a society in which bureaucra-
cies have fewer roads, communication, or information networks
at their disposal will have more trouble enforcing policies, inde-
pendently of the bureaucracies’ quality. Likewise, a high-quality
bureaucracy can autonomously influence policy priorities and
improve policy design, and they are therefore not mere imple-
menters of policies, as the infrastructural power perspective
assumes (Soifer & vom Hau, 2008).
(b) State capacity and health outcomes: a review
There is substantial cross-national, quantitative evidence that
suggests that state capacity affects various health outcomes, such
as infant mortality (e.g., Farag et al., 2012; Lazarova, 2006); mater-
nal mortality (e.g., Muldoon et al., 2011); child mortality (e.g.,
Dawson, 2010; Rajkumar & Swaroop, 2008); child health depriva-
tion (Halleröd, Rothstein, Daoud, & Nandy, 2013); and disability-
adjusted life years (Siverson & Johnson, 2014), among others.
Moreover, as some authors have emphasized (e.g., Dietrich &
Bernhard, 2016; Rothstein, 2015), the evidence for this link seems
to be stronger than for the more-studied influence of democracy on
health outcomes.
Despite these largely consistent findings, however, the dominant
picture in the health/state capacity literature is of conceptual and
indicator heterogeneity. As can be seen in Table 1, there is
considerable variation in the way the state’s influence on health out-
comes has been conceptualized, with terms such as ‘‘governance”,
‘‘quality of government”, ‘‘corruption”, or ‘‘rule of law”, among
others, being ascribed the key explanatory role. Surprisingly, how-
ever, these different conceptualizations have sometimes been oper-
ationalized using the same underlying indicators. For instance, as
Table 1 shows, both studies focusing on governance and those
focusing on the quality of government often rely on the same World
Bank’s Worldwide Governance Indicators (such as government
effectiveness) to measure the influence of the state on outcomes.
Conversely, sometimes the same concept is operationalized in quite
different ways: we see that ‘‘governance” can actually mean absence
of corruption, government effectiveness, bureaucratic quality, or
some ad-hoc combination of disparate indicators (e.g., Klomp & De
Haan, 2008). More generally, we can observe substantial divergence
in concepts and indicators, along with scant cross-work consistency
between the concept of choice and its operationalization, even if
some individual works do display considerable theoretical aware-
ness in this regard (e.g., Cingolani et al., 2015; Ziblatt, 2008).
While perhaps useful enough for detecting general associations
between state capacity and health outcomes, such a state of affairs
is unhelpful for thinking about causal mechanisms or assessing their
existence. Indeed, these works either do not mention any possible
mechanisms through which state capacity affects health outcomes,
or else hypothesize surprisingly indirect avenues of influence for
it—such as through citizens’ willingness to pay more taxes when
there is less corruption (Holmberg & Rothstein, 2011), or through
higher health market efficiency and civil society strength when the
rule of law is high (Dawson, 2010). Even those works that most
coherently focus on the quality and/or autonomy of the bureaucracy
(e.g., Cingolani et al., 2015) do not elaborate on the specific causal
processes that translate nationwide bureaucratic quality into better
health outcomes. The public health system as such—the main public
actor responsible for achieving better health outcomes—is largely
invisible in these works. At most, corruption in the health sector
and its mechanisms have been better mapped (Lewis, 2006; Vian,
2008); but as we saw, corruption does not exhaust the hypothesized
influence of the bureaucracy (or infrastructural power) on outcomes.
Talk of ‘‘good governance” or high ‘‘government effectiveness” risks
being largely empty if we cannot pinpoint what it actually means
in concrete settings. This dearth of attention to mechanisms con-
trasts with democracy-centered accounts of infant mortality reduc-
tion, where historical and comparative accounts have provided
much-needed examination of the specific political contexts in which
policy decisions and programs were implemented in different coun-
tries over time, thus illuminating the multiple ways in which that
link may (or not) materialize (McGuire, 2001; Mcguire, 2010).
3. Methods and case selection
To complement the literature just reviewed and improve on our
understanding of the specific ways in which state capacity affects
health outcomes, this study examines the nature of this causal con-
nection. Concretely, it hypothesizes that the quality of the public
health system is a major link between them. To scrutinize this
claim, I use a comparative-historical design which combines
cross-case comparison and within-case process tracing in order
to both confirm a hypothesized relationship, and to trace the speci-
fic mechanisms through which that relationship may have oper-
ated in a particular historical setting.5
Though the study of a single case can illuminate the mecha-
nisms through which a certain cause produces certain effects, there
is considerable payoff from studying two cases simultaneously in
order to increase our confidence that the hypothesized mecha-
nisms are, in fact, responsible for the observed effects
(Rueschemeyer, 2003). In this context, the choice of Argentina
and Chile as the case studies follows a ‘‘most similar systems
design” (Przeworski & Teune, 1970), where the countries are sim-
ilar regarding many causal conditions affecting infant and mater-
nal mortality, but nevertheless differ on the outcome.
Indeed, these countries share important historical conditions
that are expected to influence welfare outcomes such as health.
For instance, the literature on welfare expansion in Latin America
classifies Argentina and Chile as part of the ‘‘pioneer” social security
developers in the region (Mesa-Lago, 1978) and, along with Uru-
guay, Costa Rica, and sometimes Brazil, as within the regional group
of most-developed welfare states (e.g., Pribble, 2011; Segura-
Ubiergo, 2007). In turn, Mahoney (2010) locates both Argentina
and Chile within the group of Latin American countries that
achieved better educational and health outcomes due to their his-
torical combination of higher incomes and low initial levels of
indigenous populations (which led over time to more inclusive
social policy). These countries also share relatively low levels of eth-
nic fragmentation, a condition associated with higher welfare gen-
erosity (Alesina & Glaeser, 2004; Jensen & Skaaning, 2015). Thus,
comparing Argentina and Chile is to compare two cases that share
not only broad similarities as neighboring countries, but specific
and well-recognized past and present similarities as welfare leaders
in the Latin American region and comparable economic and socio-
demographic traits. Just as importantly, as we will see below, in
almost all standard predictors of lower infant mortality not directly
dependent on the actual performance of the public health sector
(such as GDP per capita, income inequality, education, and even
health spending) Argentina and Chile either showed roughly similar
figures, or else Argentina’s were in fact better6.
5
Naturally, this approach trades off breadth for depth, meaning its aim is to
generate a deeper understanding of the mechanisms involved – whose generaliz-
ability to other cases and periods must then be separately assessed.
6
There is also an element of the ‘‘least likely case” design (Gerring, 2007),
inasmuch as, given Argentina’s better numbers on many of these indicators, its
performance should actually have been better than Chile’s if state capacity did not
matter. In other words, the fact that Chile performed better in spite of lower income,
lower health spending, and higher inequality than Argentina, makes Chile a
‘‘confirmatory” case for the importance of state capacity as an explanatory variable.
 D. Brieba / World Development 101 (2018) 37–53 41

(a) (b)

Figure 1. Progress of infant and maternal mortality reduction in Argentina and Chile, 1960–80 (a) and 1980–2013 (b). Note: The right-hand axis reflects maternal mortality
ratios, while the left-hand axis reflects infant mortality rates. The maternal mortality ratio value for Argentina in 1970 is the 1968–1970 average, as reported in Marconi
(1994). Other sources are those reported in Table 2, plus DEIS Argentina (2011), Donoso (2015) and official mortality statistics.

Table 3
Infant Mortality Rate, Maternal Mortality Ratio, and Poverty Rates in Argentina and
Chile, and their provincial/regional coefficient of variation
Table 2
Argentina Chile Difference
Infant and Maternal Mortality in Argentina and Chile: evolution over time, 1960–
2013 Unweighted provincial/regional Infant 11.3 7.6
Mortality Rate 2010–13 (standard (2.3) (0.6)
Period Argentina Chile
deviation)
Infant Mortality Rate in 1960; 2013 1960 62 120
IMR 2010–13 Coefficient of Variation 0.21 0.07
64%*
2013 10.8 7
Unweighted provincial/regional Maternal 50.6 22.5
Yearly rate of decrease 1960–80; 1960–80 3.1% 6.5%
Mortality Ratio 2004–13 (standard (26) (8.3)
1980–2013 1980–2013 3.3% 4.4%
deviation)
IMR Ranking in Latin America in 1960 3 10
MMR 2004–13 Coefficient of Variation 0.51 0.37
29%
1960; 2013 2013 5 2
Maternal Mortality Ratio in 1960 110 275 Unweighted average of provincial/regional 14.4% 22.0%
1960; 2013 2013 32 16 poverty rates (c.2010)
Yearly rate of decrease 1960–80; 1960–80 2.2% 8.0% Poverty Coefficient of Variation 0.38 0.44 15%
1980–2013 1980–2013 2.3% 3.5% *
Note: = significant at 1% (see footnote n.10). N = 15 for Chile and N = 24 for
MMR Ranking in Latin America 2012 5 2
Argentina. Poverty rate for Chile is for 2011; for Argentina it is from the 2010
2012
census. Poverty rates between the two countries are not comparable since they use
Sources: Mazzeo (2014), Jiménez and Romero (2007), Pan American Health different methodologies. Infant mortality is accumulated by region from 2010 to
Organization [PAHO] (2015), Guzmán, Rodríguez, Martínez, Contreras, and 2013 (and the much more infrequent maternal deaths from 2004 to 2013) to obtain
González (2006), Pate, Collado, and Solís (2001), Koch (2013), DEIS Argentina more precise estimates of regional values, since some Chilean regions are thinly
(2014), Chilean National Institute of Statistics (2016), and Burgos (2015). populated. Sources: Argentine Ministry of Economy (2014), DEIS Argentina (2014),
Chilean Ministry of Social Development (2014, p. 25), Chilean National Institute of
Statistics (2016), DEIS Chile (n.d.-a), and DEIS Chile (n.d.-b).

Figure 2. Life expectancy in Argentina, Chile, Latin America & the Caribbean (LAC), and USA, 1960–2013. Data from The World Bank (2016).
42 D. Brieba / World Development 101 (2018) 37–53
Thus controlling by design many factors that could also have
explained differences in outcomes, examining the parallel
evolution of each country’s health system provides a strong com-
parative setting in which to trace the specific mechanisms through
which state capacity variation may have translated into differential
health outcomes.
4. Evolution of outcomes: a historical comparison
(a) Outcomes
(i) Levels
In both infant and maternal mortality, the half-century
(1960–2013) dynamic between Argentina and Chile is one of a
‘‘reversal of fortune”, whereby Chile went from having much
higher mortality rates in 1960 to considerably lower ones in
2013. As can be seen in Figure 1, in 1960 Chile had roughly twice
Argentina’s infant mortality rate (IMR), with 120 deaths per
1,000 live births. Its maternal mortality ratio (MMR) of 275 mater-
nal deaths per 100,000 live births was also very high, and about 2.5
times higher than Argentina’s at the time. By 1980, however, Chile
had caught up with Argentina on both counts, and then leaped
ahead by a considerable relative margin (though of course at
much-reduced absolute levels; see also Table 2). Indeed, Mcguire
(2010, p. 95) reports that Chile had the fifth fastest percent reduc-
tion in the world in infant mortality between 1960 and 2005.
Relative differences between the two countries peaked around
2002–03, but even in 2013 Argentina’s IMR was more than 50%
higher than Chile’s, and its MMR was at least twice as high.7,8 In
fact, Chile’s 2013 infant and maternal mortality figures were close
to those of the much-wealthier United States—a country it had actu-
ally surpassed in terms of overall life expectancy9 (see Figure 2).
(ii) Geographical inequalities and the clustering of disadvantage
Beyond improving overall health levels, reducing health
inequalities is an important policy goal in its own right (Marmot,
2005). Territorial variation in outcomes is a distinct dimension of
inequality, inasmuch as health care is a public (and private) service
that is spatially provided to people (Castro-Landman, 2015). In this
sense, important differences arise between the two countries, with
Argentina having higher territorial health inequality (as reflected
in the distribution of infant and maternal mortality outcomes),
higher persistence in the territorial pattern of that inequality,
7
Data used in this work relies on official statistics from each country, or on works
that in turn are based on those statistics. This official data, based on vital registries, is
generally considered of good quality. For instance, McGuire’s careful analysis (2010, p.
121) concludes that in both countries the data ‘‘are complete and accurate enough to be
used in the depiction of levels and changes of infant mortality during the period from 1960
to 200500 . A recent report by the World Health Organization [WHO] and other
international organizations (2014, p. 47) concurs on their completeness. Even so,
there may be some degree of omission of maternal deaths in Argentina. Recent
international estimates of maternal mortality around the world put Argentina’s MMR
at roughly triple Chile’s ratio, instead of merely twice Chile’s ratio if we follow
national statistics (WHO, 2014, p. 31; Kassebaum et al., 2014, p. 989). On the whole,
however, using both countries’ official data seems reliable enough for depicting the
broad historical changes in levels and trends in mortality that are of interest here, and
is in fact the more conservative strategy given that this paper will argue for the
superior performance of Chile’s health system. It is therefore safe to say that Chile’s
current MMR is no more than half of Argentina’s, if not in fact lower.
8
The unusually high 2009 value in Argentina’s MMR was officially ascribed to the
impact of the H1N1 virus (Argentine Ministry of Health, n.d., p. 10). Aside from that
value, the trend in Argentina’s MMR since the mid-19900 s until about 2010 was
essentially flat.
9 14
The U.S. had an IMR of 6 in 2012 and an MMR of 15.3 in 2013. Data for the U.S. are
from PAHO (2015) for infant mortality and Kassebaum et al. (2014) for maternal
mortality (the MMR figure here reported discounts late maternal deaths, which are
not included in the Chilean or Argentinean figures).
and a higher correlation between poverty and poor health out-
comes at the provincial level.
In Table 3 below, I show the current variance of infant and
maternal mortality rates, plus the variance in poverty rates, by
Argentinean provinces and Chilean regions. As can be seen, vari-
ance in mortality is lower in Chile—significantly so for infant mor-
tality—while the variance in poverty is similar.10 This suggests that
Chile is not territorially more homogeneous than Argentina in terms
of general socioeconomic disadvantage, and yet its infant and
(probably) maternal mortality outcomes nevertheless are.11
Significantly, Chile’s lower inequality in health outcomes was
not always so. In Figure 3, I show the evolution over time of the coef-
ficient of variation of each country’s IMR, by subnational units. I
show two series for Argentina: a shorter series with data since
1980 in which the country’s 24 provinces are considered separately,
and a longer series in which those same 24 provinces are grouped
into six geographically contiguous macro-regions. Both series are
contrasted with data for Chile’s 13 traditional regions.12 We can
see that Chile’s territorial inequality in the late ‘60s and early ‘70s
was similar to Argentina’s, but has consistently gone down since then.
By the 1990s, it was clearly below its neighbor’s, regardless of which
Argentinean series (provincial or macro-regional) is considered.
Moreover, in Argentina the provincial ranking in IMRs has been
quite stable over time, with broadly the same provinces as best and
bottom performers over the decades. Indeed, the 2010–13 Argen-
tinean provincial IMRs still correlated at 0.69 with their own
1980–84 values (statistically significant at 1%; see Figure 4). In
Chile, on the other hand, sustained equalization of regional out-
comes over time meant that by 2010–13 historical regional hierar-
chies had been largely erased.
Finally, while (as we saw) variation in the territorial distribu-
tion of poverty in the two countries is roughly similar, in Argen-
tina—but not in Chile—provincial poverty rates are highly and
significantly correlated with infant mortality rates and with
maternal mortality ratios (see Table 4 and Figures 5 and 6).
As can be seen, in Chile all correlations are close to zero, while
they are consistently high and significant in Argentina. Thus, in
Argentina health-related inequalities are much more driven by
general socioeconomic disadvantage than in Chile13. Since poorer
provinces are also those with higher infant and maternal mortality,
health and socioeconomic disadvantages cluster together territori-
ally in ways that do not occur in Chile, where not even maternal
and infant mortality outcomes are correlated.14
10
The ‘‘unmet basic needs” poverty measure used here for Argentina, based on 2010
census data, is more appropriate than income poverty measures because estimations
of the latter in Argentina are based on urban areas only (and which, in any case, show
lower interprovincial variance).
11
The difference between coefficients of variation was tested using both the Feltz
and Miller (1996) and the Krishnamoorthy and Lee (2014) statistical tests. The latter
is particularly useful in small samples. Both are included in the ‘‘cvequality” package
for R (Marwick & Krishnamoorthy, 2016). Both tests were significant at 1% for the
difference between infant mortality rate coefficients of variation, and not significant
for maternal mortality and poverty coefficients. However, given the very small
number of maternal deaths in many regions, regional/provincial MMRs are measured
imprecisely. If we take the regional MMRs over the entire 2000–13 period (which
allows to register at least 5 total maternal deaths in each region or province), then the
coefficient of variation drops to 0.32 in Chile and climbs to 0.52 in Argentina, and this
difference is marginally significant (p = 0.09) using the Krishnamoorthy and Lee
(2014) test.
12
Two more regions were created in Chile in the late 20000 s. To maintain
comparability, I calculated mortality rates as per the old 13 regions even after this
administrative change.
13
As a further check, I correlated poverty and infant mortality rates at the provincial
level in Chile, thus increasing the number of Chilean subnational units from 15 to 40.
The correlation coefficient decreased from 0.09 to
0.09.
By some accounts, in Chile this lack of association between socioeconomic
disadvantage and the IMR could by 2010 even be observed at the municipal level (the
smallest territorial unit), after a sustained descent in correlation between the two
variables at this level since 1990 (Castro-Landman, 2015).
 D. Brieba / World Development 101 (2018) 37–53 43

Figure 3. Coefficient of Variation of the Infant Mortality Rate in Argentina and Chile, 1950–2013. Note: Values for the Argentinean macro-regional series are single data points
at 10-year intervals from 1950 to 2010. Both other series are composed of yearly data. N = 6 for Argentinean macro-regions (Buenos Aires City, Pampa, Patagonia, Cuyo,
Northeast and Northwest), N = 24 for Argentinean provinces, and N = 13 for Chilean regions. Source: Author’s calculations based on data in: Mazzeo (2014), DEIS Argentina
(2011), DEIS Argentina (2014), De Icaza (1985, p. 17) for Chile 1965–1982, and Chilean National Institute of Statistics (2016) for Chile 1983–2013.

Figure 4. Correlations of Regional/Provincial IMRs over time, Argentina and Chile. Note: the continuous lines represent Argentinean and Chilean regional correlations over
time with a c.1970 baseline of regional IMRs. In Argentina, correlations are at single data points at 10-year intervals with their 1970 values (N = 6). In Chile the baseline is the
1970–74 regional IMRs (N = 13). The dotted lines represent Argentinean and Chilean regional IMR correlations over time with their own respective 1980–84 values (N = 24 in
Argentina and N = 13 in Chile). Sources: see Figure 3.

Table 4
Correlation coefficients between infant mortality rates, maternal mortality ratios, and poverty rates in Argentinean provinces and Chilean regions

Poverty Argentina IMR Argentina Poverty Chile IMR Chile

*
IMR Argentina 0.78 –
MMR Argentina 0.71* 0.80*
IMR Chile 0.09 –
MMR Chile 0.08
0.13

Note: *Significant at 1%. N = 24 for Argentina and N = 15 for Chile. Source: Author’s calculations based on data sources and periods detailed in Table 3.

Taken together, these results strongly suggest a process of
sustained descent in territorial health inequality in Chile, which
substantially equalized infant and maternal mortality outcomes,
and made them largely independent of history and of territorial
socioeconomic disadvantage. In contrast, in Argentina the reduc-
tion in territorial inequality has been slight, current inequalities
are larger and reflect historical patterns, and infant and maternal
mortality are strongly correlated with poverty and with each other,
thus configuring clear clusters of historically rooted territorial
disadvantage.
(b) Toward an explanation
Chile therefore achieved a ‘‘reversal of fortune” with its neigh-
bor in terms of maternal and infant mortality levels, while also
markedly bringing down territorial inequalities. Moreover, as
Table 5 below shows, these results were achieved with many
‘‘usual suspects” of cross-national differences in infant and mater-
nal mortality levels being about equal between both countries, or
else actually benefiting Argentina—sometimes by significant
margins. For instance, Chile caught up in infant mortality with
44 D. Brieba / World Development 101 (2018) 37–53

Figure 5. Infant mortality rate (a) and maternal mortality ratio (b) against poverty rate in Argentina, by province. Source: author’s calculations, based on data sources detailed
in Table 2.

Figure 6. Infant mortality rate (a) and maternal mortality ratio (b) against poverty rate in Chile, by region. Source: author’s calculations, based on data sources detailed in
Table 2.

Table 5
Non health-sector variables affecting infant and maternal mortality, Argentina and Chile 1960–2010

1960 1970 1980 1990 2000 2010

GDP per capita ARG 6043 7617 8496 6928 8908 12340
CHI 3687 4429 4957 5520 9339 12525
Gini index of income inequality ARG 36 43 44 50 42
CHI 46 53 55 55 51 (2009)
Pubic health care spending as% of GDP ARG 3.6 3.6 4.3 5.0 4.2
CHI 2.1 2 3.3 3.3
Total Health care spending as% of GDP ARG 7.7 6.4 7.8 9.2 6.6
CHI 5.5 5.5 6.4 7.0
Total Health care spending per capita ARG 587 544 540 820 814
CHI 273 304 598 877
Female secondary enrollment, gross (%) ARG 47 60 73 (1988) 88 94
CHI 48 67 79 87 96
Safe water access (%) ARG 55 67 (1985) 94 96 98
CHI 59 91 (1985) 90 95 98
Urban sanitation (%) ARG 34 93 (1985) 90 93 95
CHI 31 75 (1985) 91 95 99

Notes: GDP per capita is at purchasing power parity, constant 2005 international dollars (RGDPCH variable), from Heston, Summers, and Aten (2012). Gini index is from
Mcguire (2010) until 2000, and from UNU-WIDER. (2015) for 2010. Public and total health care spending data are from Mcguire (2010) for data until 1990, and from the
World Health Organization (2016) thereafter. Total health care spending per capita is GDP per capita (row 1) times total healthcare spending percentage (row 4). Female
secondary enrollment data are from The World Bank (2016). Safe water access and urban sanitation are from Mcguire (2010) until 1980, and from The World Bank (2016)
thereafter.

Argentina by about 1980, at a time when it had less than 60% of
Argentina’s income per capita. In other words, Chile’s mortality
catch-up preceded its income catch-up by over 15 years, suggesting
no straightforward ‘‘wealthier is healthier” (Pritchett & Summers,
1996) narrative can account for it.15 Chile also suffers from much
higher income inequality and, until very recently, spent far less than
15
In 1960, Argentina had 1.64 times Chile’s GDP per capita and only 51% of its IMR.
By 1980, Argentina had 1.71 times Chile’s GDP per capita but 106% of its IMR.
Argentina on health (and continues to spend less public money on
it). In such a context, some modest and/or temporary differences
in Chile’s favor (as in female secondary schooling and safe water
access) do not seem able to explain such significant differences in
performance. Thus, if on almost all standard predictors of infant
mortality Argentina performed as well as or better than Chile, one
would have expected the former to outperform the latter, and not
the reverse. So how were Chile’s better outcomes achieved? Though
without doubt many factors affected each country’s performance,
 D. Brieba / World Development 101 (2018) 37–53
Table 6
Main forms of intervention to reduce infant and maternal mortality, by phase of
reduction
Type of mortality
Infant Maternal
Phase Early Sanitation; Safe water; Female education;
Vaccinations; Female education; Family planning;
Family planning; Nutrition; Skilled Skilled delivery
delivery (post-neonatal deaths
predominate)
Late High-quality prenatal care; High-quality prenatal
Intensive neonatal care (neonatal care; Emergency
deaths predominate) obstetric care
Source: compiled by author based on Koch et al. (2012), Jiménez and Romero (2007),
and Moore, Castillo, Richardson, and Reid (2003). Neonatal deaths are those that
occur within 28 days of the infant’s birthdate, and tend to be associated with
endogenous causes (such as congenital malformations). Post-neonatal deaths are
those that occur after 28 days but before a year since the infant’s birthdate, and
tend to be associated with exogenous causes (such as infections due to poor
nutritional or sanitary conditions).
the explanation, I will argue, lies to a significant degree in the perfor-
mance of the respective public health sector systems.
To see how this may be so, it is useful to break down the anal-
ysis of long-term reductions in infant and maternal mortality into
two phases: an early phase in which major reductions can be
achieved through an emphasis on primary health care and broad
preventive public health interventions, and a slower, advanced
phase in which timely access to (often advanced) curative care
becomes more relevant (Jiménez & Romero, 2007, p. 459). Table 6
sums up some of the interventions that are more relevant in each
phase.
I will argue, then, that a key reason why Chile performed better
than Argentina is that the Chilean state invested much more heav-
ily in its health capacities from the mid-20th century onward,
through the creation and improvement of a public health system
that had greater reach, homogeneity, and quality. The Chilean
state’s greater build-up of its delivery capacities in the health sec-
tor made a difference in both the early and late phases of infant and
maternal mortality reduction. In the early phase, because it
allowed better implementation, coordination and coverage of
those broad public health interventions relevant for reducing
mortality. I thus stress the organizational underpinnings of those
interventions. In the later phase, I will argue that state capacity
mattered because the superior organization of its public health
system allowed for better delivery of curative care within a system
that was more coordinated and efficient.
5. Chile
The creation in 1952 of the Servicio Nacional de Salud (SNS) or
National Health Service marked a watershed in Chile’s health sec-
tor history, since the Service provided the backbone to Chile’s pub-
lic health system as it would develop to this day—major public and
private health sector reforms in the 1980s notwithstanding. The
name was hardly a coincidence: Chilean doctors had been inspired
by (and visited) the then recently created UK National Health
Service (Labra, 2002; Molina, 2010). Chile had created a Health
Ministry in 1924 and the state already played a significant role in
the provision and coordination of health services before 1952
(Mardones-Restat & Azevedo, 2006). However, the SNS brought
all other public and semi-public health providers under its aegis,
including previously autonomous 16 health services, plus workers’
insurance schemes and medical facilities, thus avoiding duplica-
tion and instituting from the start a unified and strongly central-
ized public health system (Jiménez de la Jara, 2001; Labra, 2002).
45
By the 1970s, the SNS covered around 70% of the population, par-
ticularly the middle class and the poor.16
The initial organizational efforts of the SNS extended into sev-
eral distinct tasks. Firstly, the SNS secured for itself bureaucratic
autonomy through an inclusive governing board (Mardones-
Restat & Azevedo, 2006) and, more importantly, through the
mutual support—across party lines—of the high-level public health
professionals that were at the core of the project (Jiménez, 2001).
The SNS leadership was thus a technocratic elite of Rockefeller
Foundation-trained doctors unified around a state organization.
This autonomy allowed for technical rather than political
decision-making: while the SNS doctors wanted a service with a
strong focus on prevention and the primary level, politicians and
the public at large wanted to privilege hospitals and curative med-
ical care. According to Jiménez (2001), the founding fathers of the
Service were able to defend this ‘‘uncomprehended” vision against
adverse political winds; indeed, they accumulated considerable
power and were often at odds with government authorities who
resented the Service’s autonomy (Labra, 2002).
In second place, the SNS worked toward ensuring an adequate
supply of health professionals for the public health system. Firstly,
it implemented in 1957 the Rural Practitioners Program, which
provided financial, scholarship, and civil service career path incen-
tives for recently graduated physicians to work in rural and under-
served areas for three or more years. This program is to this day the
main mechanism through which scarce medical resources are
deployed to the remotest areas of the country (Mardones-Restat
& Azevedo, 2006). The SNS also developed a cooperation program
with universities to increase the supply of doctors and particularly
other health professionals. During 1965–70 seven Nurse Schools,
five Midwives’ Schools, and four Nutrition Schools were created
in various universities throughout the country, with an emphasis
on joint education of different health professionals (Mardones-
Restat & Azevedo, 2006; Szot, 2002).
In third place, the SNS established regulations to achieve stan-
dardization and uniformity across the territory. It created a techni-
cal council that drew up the ‘‘technical norms for application at every
level of the service’s structure”, thus introducing ‘‘a number of
important changes (. . .) in health practices as a consequence of the
unification of public health services” (Mardones-Restat & Azevedo,
2006, p. 507). The formulation of standardized medical protocols
with national applicability is a regular feature of Chile’s public
health system to this day.
This was closely linked with (fourthly) the progressive develop-
ment of a national network for health care delivery, which fol-
lowed a strict geographical organization of services defined by
Regional Health Zones, each under the charge of a medical Direc-
tor. Within these zones, rural posts, local health centers, and hos-
pitals worked in coordination (Goic, 2015). Finally, a strong
emphasis was placed on primary health centers as a key location
for delivering many of the SNS’ services in an integrated and mutu-
ally reinforcing way (Jiménez, 2001; Goic, 2015).
At the beginning, territorial differences in coverage of basic
medical services were acute: for instance, in 1957–59 the highest
infant mortality health zones had a median of barely 31% of profes-
sionally attended deliveries, while the lowest mortality zones
(such as Santiago) had a median of 92% (Behm et al., 1970). Thus,
the expansion of the health network into the countryside and the
provision of services to the urban poor were key efforts of the
SNS in the 1960s and 1970s (McGuire, 2001, p. 1684). This physical
expansion, coupled with systematic and active outreach efforts so
16
Technically, and unlike the British NHS, the Chilean SNS was only for those poor
and middle-class people formally employed and contributing through their wages; in
practice and informally, however, the uninsured also had access to it (Labra, 2002, p.
1044).
46 D. Brieba / World Development 101 (2018) 37–53
as to reach pregnant women in even the remotest areas of the
country, allowed Chile to increase the rate of deliveries attended
by trained health staff from 38% in 1954 to 91% in 1980
(Mardones-Restat, 1962; Mcguire, 2010; World Food Program
[WFP], 2008, p. 59).
The network of primary health clinics contributed crucially to
the health of mothers and infants through the delivery of a diverse
but coordinated and integrated range of services. Indeed, by the
1970s the services delivered at the primary level for mothers and
infants included ‘‘periodic check-ups for women before, during and
after delivery; children’s check-ups; diagnosis and prevention of sick-
ness in mothers and infants; vaccinations; health and nutritional edu-
cation for mothers; programs encouraging breast-feeding, responsible
parenting and birth-control; and nutritional interventions” (Idiart,
2013, p. 66; see also Goic, 2015). These services were delivered
by interdisciplinary health teams that included doctors, nurses,
midwives, nutritionists, social workers, and eventually (since the
1990s) physiotherapists.
The high impact of Chile’s primary health centers was most
clearly seen in the nutritional and health care programs of the
SNS. Since 1954, a free powdered milk program in Chilean public
ambulatory clinics (the Programa Nacional de Alimentación Comple-
mentaria, or PNAC) had been available for pregnant mothers and
children under six. The milk was only part of a more comprehen-
sive package of services related to mother and infant care, and
was delivered to mothers in return for attending pregnancy or
infant check-ups. The program also included nutritional education
for mothers, delivered by nutritionists and social workers both at
clinics and in people’s homes, as part of the general outreach effort
of local health centers (WFP, 2008; Idiart, 2013). By the mid-1970s,
a national nutrition surveillance system had also been imple-
mented, registering personal and nutritional data of all infants at
primary health center check-ups. This system allowed real-time
monitoring and thus timely action. For instance, in 1983 the mili-
tary dictatorship reversed its initial decision to cut by 30% the
amount of milk given to children when the system detected an
immediate hike in malnutrition (WFP, 2008, p. 53; Goldsmith-
Weil, 2017, p. 5617). Because through this system nearly all poor
children were registered and were thus findable by the SNS, it was
also possible to give targeted additional aid to those with more
advanced malnutrition, including—as a last resource—their intern-
ment in specialized centers until fully recovered (Foxley &
Raczynski, 1984). The results of these complementary strategies
were remarkable: malnutrition in under-6s dropped from 37% to less
than 3% during 1960–2000, with most of the reduction occurring
before 1980 (Jiménez & Romero, 2007).
Active steps were also taken to combat maternal mortality. The
first major initiative in this regard was the introduction in 1965 of
a family planning program. Its main purpose was to reduce the
amount of illegal and unsafe abortions, which were responsible
at the time for half of all maternal deaths and which consumed
(because of emergency treatments to save mothers) half of Chilean
hospitals’ total blood supply (Casas, 2004, p. 430). The family plan-
ning program was so effective that already by 1968 about 10% of
fertile-age women in Chile were using some form of contraception,
and about 20% were doing so by 1972 (Adriazola, 1980). These
numbers were by far the highest in Latin America, along with Costa
Rica’s (Rosselot, 1971). Remarkably, during 1965–80 Chile’s total
17
As Goldsmith-Weil (2017) notes, the military tried again in 1985 to cut back
heavily on milk spending, but the resistance of program beneficiaries and of
influential doctors close to the regime (who had championed the fight against
malnutrition) made the dictatorship backtrack and allow the program to continue.
Though by then the largest advances against malnutrition had already been made, the
measure would have probably had deleterious consequences – even if a serious
rebound in malnutrition might have prompted either the military or the 1990
democratic government to reinstate the decades-old program.
fertility rate plunged from a very high 4.8 children per woman to
2.7, while much-wealthier Argentina’s rate (which did not imple-
ment a family planning program) was largely stable during the
same period, going from 3.1 to 3.3 (Mcguire, 2010, p. 321). The
introduction of this fertility program also coincided with a halving
of both abortion-related and overall maternal mortality rates dur-
ing 1965–71, and continued and sustained decreases thereafter
(Koch et al., 2012).
In this effort, midwives were from the start in charge of provid-
ing contraceptive and family planning advice to mothers in hospi-
tals and local health clinics. Additionally, through their provision of
prenatal control services, they were crucial for linking poorer Chi-
lean women with the health system in a trust-building relationship
(Zárate & González, 2015, pp. 217–219; Zárate & Godoy, 2011, p.
146). More broadly, the presence of midwives at local clinics has
been historically key for providing high-quality prenatal care to
Chilean women. In fact, a decades-old policy of hiring and relocat-
ing midwives across the country meant that by 1992 midwives
were ‘‘. . .one of the professional health cadres most closely correlated
with the geographic distribution of the population”, delivering 80% of
all births in that year and carrying out ‘‘. . .over 90% of prenatal,
puerperium care, and family planning and gynecological services”
(Ruiz-Rodrigues, Wirtz & Nigenda, 2009, pp. 151–153). This study
argued, moreover, that the combination of the geographical orga-
nization of Chile’s health system, the integrated package of services
delivered at the primary level and the territorial distribution of
midwives were three key factors in explaining Chile’s success in
maternal mortality reduction.
During the 1990s, besides additional (and highly successful)
programs for combating infant mortality at the primary level
(see Jiménez & Romero, 2007), progress was also made in the treat-
ment of highly complex neonatal and obstetric conditions, which
are dealt with at the hospital level. Neonatal treatment initiatives
included universal access to surgical correction of congenital heart
defects; a national surfactant program (to treat respiratory distress
syndrome); and a major upgrading of neonatal intensive care units
[NICUs] (Jiménez & Romero, 2007). At least one NICU was estab-
lished in each regional health service, all similar in standards of
care and equipment, and all following the centrally determined
staffing and training requirements. NICUs were themselves reorga-
nized into three levels of (increasing) complexity, with the reorga-
nization occurring simultaneously throughout the country, in line
with the ‘‘strong focus on uniform nationwide implementation of
health policies that characterizes the Chilean health system”
(González et al., 2006, p. e953). Standardized protocols were devel-
oped for referrals from other hospitals to ones with NICUs, as well
as for treatment of respiratory distress syndrome and of very-low
birthweight newborns. The strict regionalization of perinatal ser-
vices also meant that high-risk pregnancies, women with a prena-
tal diagnosis of intrauterine growth restriction, and those with
preterm labor were all delivered (by protocol) at the highest com-
plexity regional hospitals, which, being in major urban centers,
actually delivered 68% of all births (González et al., 2006). As a
result, the neonatal mortality rate fell from an already low 8.3 in
1990 to 5.7 in 2000, while maternal mortality plunged from an
MMR of 42.5 to 19.3 in the same period. By this century, the distri-
bution of maternal deaths had a completely changed profile, with
abortion-related cases practically disappearing and a much greater
weight of indirect causes of death (Aedo et al., 2010; Donoso,
2015).
Though the rate of descent of infant mortality slowed down
after the early 2000s, its territorial inequality kept falling. This
may have been helped by a major health reform in the mid-
2000s that sought to deepen citizens’ access to health care—the
‘‘Plan AUGE”—and which innovated by legally guaranteeing timely
and universal access to a specific, high-priority set of medical
 D. Brieba / World Development 101 (2018) 37–53
interventions, including some related to pregnant mothers and
newborns (Donoso, 2005). For instance, after AUGE there was a
significant improvement in the early (antenatal) detection of
congenital heart defects in infants, as well as in these infants’
survival rates (Concha, Pastén, Espinosa, & López, 2008). On the
other hand, further maternal mortality reduction was being
challenged by the higher pregnancy risks of increasingly delayed
motherhood; indeed, Chile’s percentage of mothers aged 35 or
more was the highest in South America (Donoso & Carvajal,
2012; Ramírez, Nazer, Cifuentes, Águila, & Gutiérrez, 2012).
To deal with this stagnation in the MMR leading specialists in
the field were recommending, among many specific measures,
the reinforcement of care in the 5% of deliveries that took place
in remote areas of the country, as well as revision of some medical
practices such as overuse of cesarean sections (González et al.,
2013).
6. Argentina
In Argentina the crucial reform period was the first democratic
Perón presidency, when Dr. Ramón Carrillo became the country’s
first Minister of Public Health in 1949. Under his leadership plans
were drawn up to create a universal insurance system, centralize
the administration of the health system and increase its articula-
tion, increase installed capacity, develop planning capacities for
the system as a whole, and develop ambulatory preventive and
curative medical attention through local health centers serving
specific populations (Mcguire, 2010, p. 131; Perrone & Teixidó,
2007). This conception was remarkably similar to the (contempo-
raneous) Chilean one. However, these plans could not be realized
because the Ministry’s initial success in expanding public hospital
coverage ‘‘. . .led to rivalry with the labor unions and the Ministry of
Labor and Welfare, with each side aspiring to establish the dominant
national health-care system” (Lloyd-Sherlock, 2006, p. 357). It soon
became clear that the labor unions (a key Perón constituency) had
won. Their victory meant that the principle of a work-related or
Bismarckian social health insurance system for the middle classes,
operating in parallel to the public sector, was established. In this
context the latter’s funding was scaled back and by the 1990s
the quality of its provision had suffered significant deterioration
(Lloyd-Sherlock, 2006). By the end of the 1990s, almost half of
Argentineans, but particularly the poor, relied on the public health
system for medical coverage (Mcguire, 2010, p. 132).
To this split between public and social insurance schemes a ter-
ritorial fragmentation would be added, as in the 1950s and 1960s
the federal government reversed Dr. Carrillo’s centralization poli-
cies and started a ‘‘devolution” program of public hospitals to the
respective provinces, which in any case have the constitutional
mandate in this policy area (Perrone & Teixidó, 2007). As health
provision became a provincial responsibility, federal resources
injected into the system eventually became marginal and the 24
provincial health systems largely autonomous. The Argentinean
health system was thus territorially and organizationally frag-
mented, both in terms of provision and insurance, with a veritable
mosaic of institutions on all sides curtailing ‘‘. . .the establishment of
a unified, efficient, universal health system” (Pan American Health
Organization [PAHO] 2010, p. 41).
Partly because of these processes, ‘‘the federal Ministry of Health
(MOH) [became] a relatively marginal figure in national health policy”
(Lloyd-Sherlock, 2005, p. 1895), with scant capacity to define
sanitary priorities, coordinate efforts, or strengthen provincial
capacities (Tobar, 2002). Moreover, and unlike in Chile, there was
a split between doctors—trained to cure illness—and the actual
organization of the health system, which was left to politicians,
local authorities, and medical administrators (De Mucio, Fescina,
Schwarcz, Garibaldi, & Méndez, 2011, p. 26). Consequently, a
47
historical characteristic of health services in Argentina would be
the confrontation between technical and political rationality
(Belmartino, 2005, p. 162).
In terms of the primary health level, Argentina’s health system
has traditionally suffered from an ‘‘extreme curative bias” (Lloyd-
Sherlock, 2005, p. 1894) that has prioritized hospitals and complex
technology over preventive health initiatives (see also Mcguire,
2010).
This weakness in preventive and primary care could be clearly
seen in the defective implementation of purportedly core pro-
grams, such as the National Mother and Infant Program (PNMI),
which was broadly similar to the Chilean PNAC in seeking to pro-
vide integrated care to mothers and infants along with a strong
nutritional component. This program had been credited with a
sharp reduction in infant mortality in Argentina in the 1940s, but
by the late 1990s it was devoting more than 90% of its budget
solely to milk, as opposed to just 49% in 1965 (Mcguire, 2010,
pp. 129–130). The program had also suffered over the decades
from cutbacks and instability in its budget and in technical
resources (Idiart, 2013, pp. 65–66).
To reverse these deficits, in the 1990s a more targeted but
broadly similar program (PROMIN) was introduced. However,
PNMI was not discontinued, so that tensions arose between the
staff of the two programs, which ‘‘were poorly coordinated and com-
peted for employees and beneficiaries” (Mcguire, 2010, p. 140).
McGuire also reports high levels of financial instability in both pro-
grams, unhelpful splits in authority over design, hiring, and actual
implementation between the national and provincial health min-
istries, and lack of outreach efforts and tools with which to target
the poorest. As a result, there was both overlap between programs
and substantial under-coverage, with some people receiving dupli-
cated benefits and some none at all (Idiart, 2013, p. 78). Thus, while
PNMI was reaching only 30–35% of its theoretical target, Chile’s
programs were reaching between 70% and 95% (Mcguire, 2010).
Moreover, and unlike the Chilean PNAC, the PNMI lacked an accu-
rate registry of beneficiaries. Monitoring capacity at the national
central level was weak, meaning that both inter-institutional and
inter-provincial coordination deficits were recurrent, and that
implementation at the local level was highly heterogeneous and
dependent on local conditions (Idiart, 2013, pp. 74–75). Finally,
neither PNMI nor PROMIN were linked to education programs,
and therefore their approach was less integrated. While Chile’s
PNAC ‘‘effectively subordinat[ed] milk distribution to primary health
care aims”, beneficiaries of the PNMI referred to it as the ‘‘milk
program” and did not ‘‘even recognize the curative and preventive
health care component, which is purportedly the fundamental pillar
and goal” of the program (Idiart, 2013, p. 70). Therefore, as
Mcguire (2010, p. 141) concludes, it is likely that Chile’s greater
success in reducing infant mortality was partly due to the better
implementation and higher coverage of its nutritional and
mother-and-infant public health programs. Thus, despite the
similar policy content and timing between the Chilean and
Argentinean programs, their impact differed substantially.
More broadly, however, Argentinean primary health care has
suffered from several institutional weaknesses. Firstly, since public
health care is not a federal responsibility, there is significant vari-
ability in quantity and quality of provision across the system.
Therefore, while in some provinces health infrastructures, systems,
and programs have been developed, in others almost the entire
health budget goes to personnel expenses (Lloyd-Sherlock, 2005,
p. 1896).
Secondly, fragmentation and overlap of services between pro-
vinces and municipalities are frequent, with no clear intergovern-
mental division of responsibilities. For instance, in the year 2005,
of the 6433 primary health centers in the country, 54% were oper-
ated by provincial authorities and 45% by municipalities (Stolkiner,
48 D. Brieba / World Development 101 (2018) 37–53
Comes, & Garbus, 2011). Moreover, the opening of new primary
health centers has not always followed a planning-based logic in
either geographical or health-need terms (Tobar, Montiel, Falbo,
& Drake, 2006, p. 8). This has led to an overlap of services in some
areas and under-coverage in others in a dynamic often related to
short-term political reasons, such as territorial competition
between provincial and city authorities to provide services, or
the need to strengthen clientelistic loyalties in certain areas, as
Enria and Staffolani (2004) show for the city of Rosario.
Thirdly, the system suffers from lack of coordination between
the primary health centers and the hospitals, with modalities of
articulation being heterogeneous and depending more on local ini-
tiative than on an established norm (Stolkiner et al., 2011, p. 2812–
2814). Finally, there is a lack of health planning capacities in the
local health centers. These often lack epidemiological and georefer-
enced information systems and, crucially, they function (at least in
practice) on the basis not of catchment areas but of spontaneous
demand, which means that people are often not registered in a par-
ticular center and information on their health status is not
recorded (Paganini et al., 2010; Tobar et al., 2006). The centers
themselves vary widely in their staffing levels and composition,
in their capacity for conducting basic diagnoses, and in their avail-
ability of equipment and materials (PROAPS-Remediar, 2007).
Argentinean practitioners and researchers are well aware of the
health care system’s organizational deficits. For instance, a group
of physicians pointed out that the main cause of relatively high
infant mortality because of acute respiratory infection (ARI) was
‘‘the poor quality” of health care services for infancy (Speranza,
Orazi, Manfredi, & Sarasqueta, 2005, p. 282). They noted, among
other failures, a lack of appropriate risk assessment of patients;
treatment focused only on dealing with the stated reason for the
appointment; lack of medical files for patients (that included treat-
ment, evolution, later check-ups, and past referrals to hospitals);
and deficient conditions for the referral of seriously ill cases
because of poor coordination between primary health centers
and hospitals. Another study found wide variability among pro-
vinces in the way they diagnosed and treated ARI cases in primary
health centers, with chances of being diagnosed bronchiolitis vary-
ing by up to a factor of four, and with a (mistaken) antibiotics pre-
scription being handed out anywhere between 12% and 71% of
times in dealing with this condition (Bernztein, Drake, & Elordi,
2008). Thus, calls were being made to imitate the successful
Chilean experience based on a uniform protocol for treatment of
ARI (Speranza et al., 2005).
The hospital-based level of care was also burdened with several
problems. Firstly, public hospitals suffer from substantial manage-
ment inefficiencies18 (Belmartino, 2005; Cavagnero, 2008), even as
hospital staffing is a ‘‘key source of patronage” in many provinces
(Lloyd-Sherlock, 2005, p. 1898). Moreover, planning deficits are rife.
For instance, the descent of neonatal infant mortality in Argentina
has been due to the same investments in high-technology equip-
ment and curative services than in Chile, such as mechanical respi-
ration equipment, lung surfactant, and a growth in availability of
neonatology specialists and NICUs (De Sarasqueta, 2001a; Speranza
& Kurlat, 2011). However, lack of territorial planning led to an anar-
chic (and territorially biased) growth in NICUs: while in Chile’s pub-
lic health system there are 28—one per regional health service—for
16 million people, in Argentina’s public health system there are
223 for 38 million people, plus a further 250 in private facilities
(Bernztein & González, 2011, p. 33). Moreover, as a well-known
Argentinean neonatologist noted, ‘‘fascination” with new equipment
18
For instance, a study estimated that Argentina could have maintained its level of
hospital inpatient services with 27% less beds than it actually had, and that with the
same level of physicians it should have been able to undertake between 20% and 40%
more appointments, depending on the province (Belmartino, 2005, p. 159).
coexisted with a lack of guidelines and training for their use, high
infection rates in the services that housed them, irrational organiza-
tion of neonatologists’ working conditions, and a pervasive lack of
qualified nurses (De Sarasqueta, 2001b). Nursing shortages are
indeed a problem: while countries such as the UK, Canada, and the
USA have roughly between three and five nurses per doctor, and
Chile roughly one nurse per doctor, Argentina has five doctors per
nurse (Bernztein & González, 2011). Thus, deficits in human
resources and in the basic quality of health services undermined
the advantages of having a high density of neonatology specialists
and equipment.
The analysis of maternal mortality also suggests problems with
uneven access to essential medical services amidst wider deficits in
health system organization. The main problem is the existence of
too many small and mid-sized maternities that do not comply with
basic standards of maternal care. In fact, a study found that in
2010–11 only 44% of all maternities fully complied with the mini-
mal Ministry of Health conditions for providing adequate maternal
care during deliveries, but there was 11% of compliance in the
smallest maternities and 97% compliance in the largest. There
was also wide variation in the territorial organization of materni-
ties by province, with an average of 4200 deliveries per maternity
in the province of Tucumán and of only 89 in La Pampa (Speranza,
Lomuto, Santa María, Nigri, & Williams, 2011). An excessive num-
ber of maternities translated into a national average of only 600
deliveries per maternity, as opposed to 1000 in Chile. The problem
with smaller maternities is that they usually lack on-duty obstetric
specialists or essential supplies, such as blood for transfusions or
ambulances. Indeed, a study covering six Argentinean provinces
found that maternal death was nine times likelier in a small hospi-
tal than in larger ones. The study also detected ‘‘lack (. . .) of staff
proficiency in the management of obstetric emergencies”, as well as
‘‘delays in referrals and lack of coordination within the health-care
network response”, and therefore recommended a reorganization
of the system so as to promote timely referrals (Ramos,
Karolinski, Romero, & Mercer, 2007, pp. 618–619).
Nonetheless, in the last decade some promising signs of change
began to occur at both the primary and hospital-based levels. In
2005, a new infant and maternal health program—Plan Nacer—
was introduced in the poorer Northeastern and Northwestern
regions of the country, and due to its success was then rolled out
nationally at the end of 2007. The key innovation of the program
is that the federal government delivers funds to provinces accord-
ing to the degree of actual coverage of the target population, while
provinces pay health centers according to medical services actually
performed and sanitary goals (such as high rates of early detection
of pregnancies or of regular checkups of infants) actually reached.
This has led to outreach efforts and to the creation of a national
database with patient information and services delivered. An
impact evaluation conducted by the World Bank for seven of the
original provinces to implement the program found that Plan
Nacer had been effective in reducing neonatal mortality (Gertler,
Giovagnoli & Martínez, 2014).
New investments in capacity were also begun in obstetric and
neonatal interventions. In 2010, a national network of hospitals
was organized to operate congenital heart malformation in infants,
after coverage of this condition was included in Plan Nacer. Cover-
age was later also given to other congenital malformations, to
high-risk pregnancies, and to the follow-up of premature new-
borns. In 2013, a major perinatal information system was imple-
mented, providing real-time information not just on obstetric
and neonatal outcomes but also on a host of specific medical inter-
ventions at the hospital level in over 100 of the largest public
maternities (Karolinski et al., 2013). Most significantly, in 2009
the Ministry of Health begun to promote, after an agreement taken
with the provinces in the Federal Health Council—which groups
 D. Brieba / World Development 101 (2018) 37–53
the heads of provincial health authorities and the Federal Ministry
–, the regionalization of perinatal health services at the provincial
level. This would establish, as in Chile, a coordinated network of
risk-differentiated maternities in each province. Although the
process has been slow and faced political difficulties—not least
the need to close down many maternities –some important
provinces (such as Buenos Aires) had made important headway.
Complementary efforts were also being made to move deliveries
to maternities that satisfied minimal obstetric conditions, thus
increasing deliveries in ‘‘safe” maternities from 83% in 2010 to
91% in 2014 (Speranza, 2015).
7. Discussion
The preceding analysis has shown that differences in the quality
of public health services between Argentina and Chile were signif-
icant and enduring, at both the primary and hospital-based levels
of care. This happened even though the policy orientation of both
countries regarding mother and infant health was broadly similar
over both phases of mortality reduction: health-and-nutrition pro-
grams for mothers and infants since the mid-20th century and
investment in advanced neonatal care since the 1980s–1990s.19
We must therefore look at the underlying organizational character-
istics of these countries’ public health systems to understand why
the quality of implementation of substantially the same policies
was so different.
In this vein, three interrelated organizational factors help
explain these differences in performance and their endurance over
time. The first was the considerably greater strength of the primary
health center in Chile as a key node between the public health sys-
tem and the community, and particularly the poor. The primary
health center was the main organizational locus of the family plan-
ning, nutritional, pregnancy check-up, and infancy check-up ser-
vices. The second factor was the greater planning and
coordination capacities of the Chilean public health system as a
whole, as seen in its geographically defined system of referrals
between establishments of differing levels of complexity and in
its ability to better match the supply of health-sector human
resources with the public health system’s demand. The third was
the better territorial coverage (avoiding gaps and duplication)
and relatively greater standardization of health services across
geographical spaces seen in the Chilean case.
All three are related to (without being the inevitable conse-
quence of) the regionalization of health services applied in Chile
since 1952. In turn, regionalization was in Chile a strategic choice
implemented by the SNS, the actor without which the entire Chi-
lean story in this field cannot be understood. Thus, the creation
of the SNS was a critical juncture in Chilean public health history
that constituted a key investment in state capacity. By unifying
organizations, standardizing protocols, centralizing policies and
decision-making, monitoring compliance, and sustaining policies
over time, it allowed for a decided, coherent and persistent drive
for infant and maternal mortality reduction in a way not seen in
Argentina. This latter country’s experience, on the other hand,
bears out De Sarasqueta’s claim (cited in De Mucio et al., 2011, p.
26) that ‘‘. . .in the origin of mortality and morbidity poor organization
is as important as the lack of clinical competence”.
It is important to note that these differences in investment in
state capacity were not merely the by-product of differing
19
The main exception to this similarity in programs was Chile’s family planning
program, which had no counterpart in Argentina. Other interventions, such as
investment in safe water and sanitation, or the expansion of secondary female
schooling, were implemented in both countries in a broadly parallel fashion.
Furthermore, both Plan AUGE in Chile and Plan NACER/SUMAR in Argentina share a
focus on early detection and treatment of newborns’ neonatal complications.
49
democratic pressures. Despite Mcguire’s (2010) contention that it
is democracy and its pro-poor incentives that lead to greater
investments in infant mortality reduction, in these cases state
capacity played an independent (and partly self-reinforcing) role.
Significantly, the key bill which created the Chilean SNS in 1952
by unifying health services was hardly the product of popular
pressures: indeed, it was legislatively ‘‘almost contraband” since
only doctors cared for it, and it thus ‘‘did not have much support,
but neither did it finally meet opposition” (Jiménez, 2001, p. 489).
These same doctors were then able to defend a health-system
design based on primary health centers, rather than on hospital
investment, against popular and politicians’ pressures to the con-
trary. Equivalently, in Argentina it was not during authoritarian
regimes but during the democratic Perón government, and amidst
strong pressure to secure popular support, that Dr. Carrillo’s plans
for a universalist, regionalized and pro-poor health system
(remarkably similar to the Chilean one) were undone by bureau-
cratic division within the government and the power of organized
labor. So all in all, the greater influence and involvement of techno-
cratic elite groups—notably doctors—in the politics of health in
Chile, able to operate along technical rather than political lines,
seems to be a strong complementary explanation to democracy
and the dynamics of electoral competition as a source of health
state capacity.
A related point can be made regarding the recent literature that
has studied the political causes behind the recent push in Latin
America toward more universalistic and equitable health care. In
addition to the intensity of electoral competition, these studies
have identified factors such as the role of programmatic parties
(Pribble, 2013), leftist governments (Huber & Stephens, 2012),
social mobilization from below (Garay, 2016), and techno-
political alliances (Ewig, 2016), among others, as shaping the scope
and nature of these coverage-expanding, pro-equity health
reforms. Important as these factors may be in increasing the cover-
age and reducing the segmentation of health insurance (the main
focus of this literature20), over the long run health outcomes do
not depend only on such factors. A system could be egalitarian, gen-
erous, and universal in its insurance coverage, and yet have acute
territorial inequities in the quality of doctors, be poorly organized
and coordinated, and spend its money on hospitals (wanted by vot-
ers) rather than on a more effective and cheaper network of primary
health centers. Thus, explaining outcomes also requires looking at
how medical services themselves are organized, distributed, coordi-
nated, and delivered. In the specific case of Argentina and Chile, I
argue that it was precisely these organizational differences in their
respective public health systems—rather than (unclear) differences
in insurance generosity or coverage– that were crucial over the long
run, and help explain why lower spending Chile has nevertheless
achieved better outcomes. More generally, Chile’s better infant and
maternal mortality performance over many decades cannot easily
be pinned down to any single period, party coalition, government,
or reform beyond the creation of the SNS itself. Thus, state capacity
is a distinct and complementary perspective from which to analyze
and explain differences in health outcomes.21
20
A partial exception is Ewig (2016), who develops a multidimensional measure of
equity that includes aspects related to geographical access and actual outcomes, as
well as of coverage and stratification in benefits.
21
This is not to deny that state capacity itself may be influenced by political factors
such as those mentioned above. Indeed, politicians motivated (for whatever reason)
to deliver better health care to their voters may well choose to invest in improving the
public health system as a way to do so – though such reforms may be less visible or
popular with voters than those that increase coverage or funding. For the purposes of
the present argument, the point is simply that, just as with democracy, the influence
of state capacity is not reducible to these other factors, even if it may well be partly
shaped by them (since the construction of state capacity is itself a long-run political
process).
50 D. Brieba / World Development 101 (2018) 37–53
This leads back to the question of how best to understand and
conceptualize state capacity as an explanatory variable for devel-
opmental outcomes. The historical-comparative exercise here
undertaken suggests that both bureaucratic quality and infrastruc-
tural power are relevant and complementary perspectives for
understanding state influence on such outcomes. As we saw,
bureaucracy-centered approaches include concerns with corrup-
tion, with meritocratic recruitment and with the relative auton-
omy of the bureaucracy from high-level politicization. The
evidence here reviewed suggests that probably in all three aspects
the Chilean health bureaucracies performed better; indeed, from
early on the SNS’ technical competence and its planning approach
to public health issues had made it a ‘‘paradigmatic” model in Latin
America (Labra, 2002, p. 1043). Nonetheless, the key long-term his-
torical difference was surely the top-level bureaucratic autonomy
of the Chilean SNS, which allowed it to create and sustain over time
a health system based on technical rather than short-term political
criteria, as evidenced by regionalization of the Service and its focus
on preventive primary health. This autonomy was, we saw, a speci-
fic goal of the doctors that founded and directed the Service in its
first years, and—despite significant changes in the organization of
the SNS and the health system at large during the military dictator-
ship (1973–90)22—the primacy of technical criteria has been largely
maintained over time.23 By contrast, we saw that political and
technical rationality have been at odds in Argentina, with such key
elements as the location of health centers and the staffing of hospi-
tals being decided on electoral and clientelistic considerations.
Bureaucratic autonomy was thus—in line with Cingolani et al.’s
(2015) findings—a crucial source of state capacity.
In turn, the infrastructural power perspective highlights that,
beyond the quality of the bureaucracy as such, implementation
depends on effective state penetration throughout territories and
on the logistics of information-gathering, coordination, enforce-
ment, and control. In these respects, the difference between Chile
and Argentina was considerable. Because Chile—a highly central-
ized country—managed to unify and integrate all previously exist-
ing public or semi-public health providers under the SNS’ sole
command-and-control structure, public resources could then be
deployed with greater efficiency and as needed to all parts of the
territory. The mandatory standardization of medical norms and
protocols, the assignment of doctors, midwives, and nurses to
remote geographical areas and the organized expansion of services
into the countryside and urban shantytowns were a product of this
hierarchical, centralized, and authoritative organizational struc-
ture. This allowed considerable homogenization of services across
regions and facilitated regionalization, a policy that requires signif-
icant investment in protocols and coordination of services.
In Argentina, on the other hand, the combination of federalism
and the lack of a strong central health authority translated into dis-
parate and idiosyncratic provincial health systems, without any
kind of unity or countrywide coordination in terms of protocols,
organization of human resources, or joint planning. Unsurprisingly,
variations in provincial poverty rates translated rather closely into
corresponding variations in infant and maternal mortality risk, as
22
The military dictatorship de-concentrated the National Health Service (SNS) into
27 regional health services, thus becoming the National System of Health Services
(SNSS), without a central governing board. The military also transferred primary
health centers unilaterally to the 341 municipalities, maintaining their geographical
logic but placing them outside the direct control of the national government.
Nonetheless, the Ministry of Health retained its financial, normative, supervisory,
evaluative, coordination, and directive roles over the whole system (see Annick,
2002).
23
This was clearly seen in the last major health reform (AUGE), where the selection
of the conditions to be covered by the program followed strict medical criteria related
to their contribution to the burden of disease and the effectiveness of available
treatments, as well as participatory inputs.
the federal government was powerless to sever the link between
the underlying provincial socioeconomic realities and their health
outcomes. In this sense, the reactivation of the Federal Health
Council at the end of the 2000s, and its agreement to regionalize
all provincial health services, bodes well for Argentina’s health
future. It also shows that even under Argentina’s dysfunctional
form of federalism (Ardanaz, Leiras, & Tommasi, 2014) investments
in national health state capacity are possible when the federal gov-
ernment assumes a sustained leadership role in the coordination
and technical guidance of provincial health services.
In sum, while an infrastructural power perspective would
emphasize differences in central authority, enforcement, informa-
tion, reach, and coordination, a bureaucratic quality perspective
would emphasize that these features themselves were, in part,
achieved through the creation, on the Chilean side, of a specific
bureaucratic body that was politically autonomous and technically
oriented.
8. Conclusion
Although there is wide agreement that ‘‘good governance”,
‘‘government effectiveness”, or simply state capacity matter for
achieving desirable health outcomes, the processes and mecha-
nisms through which this occurs have been mostly unexplored
empirically. In this work, I have tried to show that the characteris-
tics and organization of the public health system may be a major
path through which this influence unfolds. Thus, in spite of having
much worse initial outcomes, its greater poverty, and historically
much lower public and overall health spending, Chile achieved bet-
ter infant and maternal mortality results than Argentina—in both
absolute levels and in terms of territorial equality—because of the
better overall functioning of its public health system. The main les-
son of this study is thus simple enough: having a high-coverage,
well-organized, territorially homogeneous public health system is
a major root of ‘‘government effectiveness” in this area, and the pos-
session of such a system is (health-specific) state capacity—or at
least a major component thereof. In turn, the construction of such
a system requires investing in autonomous high-quality bureaucra-
cies, on the one hand, and in infrastructural power (to logistically
coordinate and enforce policy), on the other. Thus, while public
health systems are clearly a health-specific manifestation of state
capacity, the broader point this research suggests is that bureau-
cratic quality and infrastructural power may be useful ways to the-
orize and explain the influence of state capacity on many different
social and development outcomes. Certainly, further research
should evaluate the generalizability of this explanatory approach
to other geographical areas, periods, and policy areas.
Finally, this study suggests three policy lessons, from a state
capacity perspective, for the improvement of health outcomes in
developing countries. Firstly, Chile’s experience shows that even
countries with high and persistent income inequality can nonethe-
less reduce other key inequalities for human development, such as
health-related ones, if they invest in the appropriate state capaci-
ties to that effect. Secondly, this study emphasizes the importance
of investing in public health systems, in as much as such a system
will be able to better implement and deliver a wider range of speci-
fic health policies, thus improving overall effectiveness and effi-
ciency (WHO, 2000). This is true both for countries still going
through the first (accelerated) phase of infant and maternal mor-
tality reduction, where investments in a system of primary health
centers may be crucial, and also for countries entering the
advanced (slower) phase, where the organization and adequate
coordination of curative and high-technology medical services
become more important. And thirdly, it suggests that challenges
of state capacity in health should not be reduced only to issues
of controlling corruption in the health sector. Important as that
 D. Brieba / World Development 101 (2018) 37–53 51

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