Annual Report of the Director 1996

The Health Situation

HEALTHY PEOPLE IN HEALTHY SPACES:
AN INTEGRATED APPROACH TO EQUITY IN HEALTH

The preceding sections examined the Region's health situation with emphasis on inequities in the spatial distribution of the basic indicators that were analyzed individually. Such an analysis goes a long way toward explaining the selective location of equity gaps in health. The analysis can be taken even further by studying these indicators simultaneously. The presence of healthy people in healthy environments can be determined by identifying the number and type of healthy conditions observed among the populations studied. The following analysis uses a simple indicator combining six healthy conditions, which we termed IHC. The methodology was described earlier herein. The IHC reflects the number of favorable indicators of health status and living conditions that are present in a given space/population.

Map 15 and Table 14 present IHC values for the 48 countries and territories studied in the Region of the Americas. According to this indicator, only 6 of the 48 countries present all the healthy conditions studied. More than 70 million individuals in 31 countries live in environments that have three or fewer healthy conditions. Two of these countries have none of the six healthy conditions included in the IHC.

The differences become even more accentuated when the IHC is analyzed at a deeper level of geographical and political disaggregation, as occurs within the countries. Accordingly, in Mexico, 26 million people (28.5% of the total population) in eight states live in environments having five healthy conditions; however, two states (Chiapas and Oaxaca), with a combined population of 7 million, have none of the conditions mentioned.

Similarly, in Argentina, 3 million people (8.6% of the country's population) live in environments with six favorable indicators; in contrast, 900,000 persons in the province of Chaco live in an environment with only three healthy conditions. In Peru, 7 million people (28.5% of the national population) live in environments with five healthy indicators, but 5 million (20.8% of the population) live in seven departments (Amazonas, Apurímac, Ayacucho, Cajamarca, Huancavelica, Huánuco, and Puno) which do not have even one healthy indicator. In Bolivia, the situation is even more critical, where 81.6% of the population (6 million) lives in six departments with only one IHC; the rest of the population (1.4 million) lives in the three remaining departments (Chuquisaca, Pando, and Potosí), with an IHC equal to zero (Table 14).

Figure 3 illustrates the performance of the IHC as a function of the five groups of countries classified by GNP; the index is weighted to reflect population size. Map 15 shows where the Region's healthy spaces are located. Similarly, the IHC makes it possible to identify attainable horizons for healthy spaces that can be included as objectives in health promotion and development plans and programs.

Finally, Figures 4a, 4b, and 4c present an analysis of trends in infant mortality, life expectancy at birth, and total fertility by country group. Here, one can plainly see the vast inequities that continue to persist in the Americas with regard to the distribution of these indicators.

With a view to promoting health, PAHO has supported the healthy municipalities initiative, a regional health action movement based on the Healthy Cities Project. One specific application of the concept and practice of healthy spaces has been the "Municipalities for Health" project that is under way in Cuba. Map 16 shows the situation of infant mortality in provinces that are representative of four regions of Cuba, comparing municipalities that are part of the Cuban network of "Municipalities for Health" and those that are not. Map 17 shows the distribution of low birthweight in the same network. In both cases, it can be seen, on the one hand, that within the provinces there are significant inequalities from one municipality to the next and, on the other, that the best environments are not always located within the network of healthy municipalities.

The geostatistical analysis of the Region's health situation based on the countries' political and administrative divisions, as presented in this chapter, has allowed the relativity of average national and regional values to be viewed and has documented the scope and diversity of inequities in health in greater detail. In turn, this approach has helped to identify and characterize the presence of healthy environments, i.e., local space/population units where determining factors of health and health outcomes are more favorable for human development.

Looking toward the next millennium, promoting the analysis of healthy spaces in the Americas is of paramount importance. As health sector reforms deepen and decentralization processes accelerate, it will be necessary to document and monitor inequalities and inequities in health at the local level, and promote processes aimed at developing healthy environments. To do this will require more reliable data that are sufficiently disaggregated in geopolitical terms, in order to better describe the complex dynamics affecting peoples' health and their environment. It also is important to note that, once inequities in the distribution of basic indicators have been defined, it is then possible to adjust health and human development policies accordingly.

Number of healthy conditions

Source: PAHO. Technical Information System, Health Situation Analysis Program, Division of Health and Human Development.

Figure 4a. Infant mortality rate per 1,000 live births, weighted by population size, according to gross national product, Region of the Americas, most recent data for 1991-1996.

rate per 1,000 live births

Source: PAHO. Technical Information System, Health Situation Analysis Program, Division of Health and Human Development.

Figure 4b. Life expectancy at birth (in years), weighted by population size, according to gross national product, Region of the Americas, most recent data for 1991-1996.

Source: PAHO. Technical Information System, Health Situation Analysis Program, Division of Health and Human Development.

Figure 4c. Total fertility rate, weighted by population size, according to gross national product, Region of the Americas, most recent data for 1991-1996.

Number of children per woman.

Source: PAHO. Technical Information System, Health Situation Analysis Program, Division of Health and Human Development.

Analysis of the health situation and trends based on local conditions can be enhanced by using geographic information systems (Epi-GIS) and specific healthy conditions indicators for the local level to describe population groups and their environments. Geographic information systems not only show the distribution and magnitude of the indicators studied, but they also allow for the identification of maximum and minimum values and show which health conditions require closer attention from health programs and services. Beyond providing an individual description of health-related variables, the analysis of a basic set of factors that interact to affect people and their environments is of singular importance in channeling health interventions toward priority space/population units. This analytic process supports the activity of identifying selective interventions and making informed decisions. It also supports the development of health policies that are equitable, effective, and of a quality that can help to improve the population's well-being.

For the Organization, analysis of the health situation and trends holds special importance, in that this activity is part of its mandate and it provides input for setting priorities for technical cooperation. In particular, this sort of analysis is one of the mechanisms that the Secretariat uses to monitor equity. Coupled with the basic regional data initiative, the findings of the Third Evaluation of Health for All, and implementation of the tenth revision of the International Classification of Diseases (ICD-10), this analysis helps to enhance basic public health functions as part of the joint effort to attain sustainable human development in the Americas.

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