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Annual Report of the Director 1996
The Health Situation HEALTHY SPACES IN THE AMERICAS In 1996, most of the countries in the Region of the Americas advanced, in varying degrees, with their efforts to modernize the State, including their efforts to reform the health sector. This progress is mirrored in the dynamics of the countries' macroeconomic situations--lower levels of inflation, more capital investments, fiscal adjustment programs, privatization initiatives, greater financial regulation--as well as in the social sphere, especially in the dynamics of health. Although trends in health status are determined by long-term historical and social contexts, when the State changes the way it pursues its social agenda--and specifically its health agenda--this has an immediate effect on how social groups adapt to changing circumstances and alters the population's health situation, for better or worse. In the Region of the Americas, the structural shifts that are under way in the health sector--decentralization, cost containment, the search for new ways of financing health services, adoption of basic health care packages--bring with them the need to accurately identify, measure, and reduce inequities in access opportunities, use, and gains in terms of health. These inequities deeply affect living conditions, the development of citizen participation, the democratization of society, and the building of human capital; in other words, they have an impact on human development itself. The Pan American Health Organization has redoubled its efforts to place the issue of equity at the center of its technical cooperation activities. In the pursuit of equal opportunities for individual and collective development, attaining equity implies that unjust, unnecessary, and avoidable differences in living conditions and health status will be reduced and, ultimately, eliminated. However, if these equity gaps in health are to be identified, information must be available and comparisons must be able to be made. It is precisely in this aspect that the Secretariat has assumed an active role in conducting epidemiological analyses of the health situation and trends. The Organization also continues to assign priority to setting up mechanisms that document inequities in health and any progress made toward reducing them at the national, subnational, and, especially, local levels. It is essential that a series of basic data be available in order to know who is affected, where equity gaps occur, and what is the outcome of health interventions directed at reducing them, so that the Organization can cooperate with the countries in an ongoing effort to improve the human condition. This chapter analyzes the Region's health situation from a healthy spaces point of view. Although a working definition of healthy spaces is still under discussion, it can be stated that the concept refers to space/population units displaying equity in health. In other words, these are local settings where living conditions and health status are comparatively better in terms of the opportunities for individual and collective development available to the various groups that make up society. The countries' capability to identify and replicate healthy spaces--with healthy people--is a key aspect of the Secretariat's efforts to monitor equity. However, there is not enough data or information that is sufficiently disaggregated in geopolitical terms to conduct a thorough analysis of the multiple dimensions of the health situation that are brought forth when equity is considered as an idée-force. METHODOLOGY With a view to describing healthy spaces, the analysis of the Region's health situation stressed the distribution and spatial dynamics of inequalities in health status and living conditions, as measured by selected basic indicators. In order to identify where healthy environments exist, a geostatistical analysis was conducted at the national, provincial, and municipal levels. This analysis coupled cartographic information with available data on health and living conditions. The national-level analyses drew on basic data from Basic Indicators, 1996. Information at the subnational and local levels was obtained from data provided by the countries to the Organization's Technical Information System and from calculations based on census and sampling data from official publications of Member Countries. The geostatistical cartographic data were obtained from various sources and are part of the Geographic Information System (Epi-GIS) operated by the Organization's Health Situation Analysis Program. The description of the Region's health profile--based on 53 national and 33 subregional indicators--is presented in Basic Indicators, 1996. Figure 1. Distribution of per capita gross national product (GNP) in countries in the Americas, 1994.
Source: Basic Indicators 1996. Health Situation in the Americas. Health Situation Analysis Program, Division of Health and Human Development (HDP/HDA). Pan American Health Organization. Washington, DC, 1996. PAHO/HDP/HDA/96.02.
As a first analytical step, the countries were organized into five groups according to per capita gross national product (GNP)(Figure 1). This indicator serves as a proxy to gauge the resources available for satisfying the population's basic needs. The countries were grouped according to the most recent data available and by using a cluster analysis procedure that made the groups as homogeneous as possible (Figure 2). Figure 2. Gross national product of the countries of the Americas, frquency distribution summary calculated according to a hierarchical clustering analysis, 1994.
Source: Basic Indicators 1996. Health Situation in the Americas. Health Situation Analysis Program, Division of Health and Human Development (HDP/HDA). Pan American Health Organization. Washington, DC, 1996. PAHO/HDP/HDA/96.02. Once the countries had been grouped by income, quintile intervals were calculated for each of the indicators covered in the analysis (Table 1). This served to identify optimal cutoff points for the indicators, in order to rank the geographical units (country, state, department, province, canton, or municipio, as applicable) according to their level of "healthy conditions": the first quintile comprises the best values for each indicator (quintile with the least inequity), while the fifth quintile represents the least favorable values (quintile with the greatest inequity). This distribution of indicators by quintiles, arrived at by using national figures, served as the benchmark for comparing more disaggregated space/population units in the course of the analysis. Table 1. Levels of inequality according to quintile intervals for selected basic indicators, Region of the Americas, 1996.
SOURCE: Basic Indicators 1996. Health Situation in the Americas. Health Situation Analysis Program, Division of Health and Human Development (HDP/HDA). Pan American Health Organization. Washington, DC, 1996. PAHO?HDP/HDA/96.02.
To identify the space/population units that presented one or more basic "healthy" indicators, in terms of either health status or living conditions, a composite indicator--called the index of healthy conditions (IHC)--was devised. Based on the availability and quality of information for each level of disaggregation, six indicators were selected to calculate the IHC: (1) number of physicians per 10,000 population; (2) number of hospital beds per 1,000 population; (3) oral polio vaccine coverage among children under 1 year old; (4) coverage of drinking water supply services; (5) coverage of sewerage and excreta disposal services; and (6) percentage of urban population. The IHC reflects the number of favorable indicators, i.e., the number of healthy conditions present in a given geographical area and represents a "favorable and attainable horizon" for each geographic level. A "favorable, attainable horizon" is defined as a value that falls in one of the top three quintiles for each indicator. Using the five GNP-based country groupings and the indicator quintiles as calculated, an analysis was conducted that combined the numerical values with the cartographic figures for each spatial disaggregation level. The country-level analysis considered the Region's 48 countries and territories; the countries examined in the subnational-level analysis were selected according to their placement in one of the groups of countries classified according to GNP and according to how representative of that group their conditions were. A further selection criterion was the availability of data disaggregated by internal geopolitical division. The next step was to establish a standard format for graphic representation: the geographical areas located in the top quintiles for each indicator (or set of indicators, in the case of the index of healthy conditions) would be shown by using darker colors, except in Map 14. Healthy environments for each indicator can be distinguished on the map, then, as the areas that are darker in color. Lastly, for each of the five GNP-ranked country groups, average values were calculated for the IHC, weighted by population size, along with three indicators of health outcomes: infant mortality rate, life expectancy at birth, and total fertility rate. This would make it possible to present a comparative analysis of trends and illustrate the relationship between the presence of healthy environments and positive health outcomes in the Region. |
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