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Epidemiological Bulletin
      Vol. 17, No. 3
 September 1996  


INEQUITIES IN HEALTH AND THE REGION OF THE AMERICAS

Introduction

In addition to the many health problems that Latin American and Caribbean countries have traditionally faced, they now must cope with new challenges brought about by such health risks as the AIDS epidemic, increasing violence, environmental hazards, and new and re-emerging diseases. These changes are occurring in the context of political and economic reforms, the increasing decentralization of health services that is inherent to the health sector reform process and escalating costs.

In any society, health status is related to individual biological and social characteristics, economic and political organization, social structure, and cultural background, as well as demographic and macroecological processes, all of which must be considered in order to discern long-term trends of the health/disease process. Developing the capability to establish reliable information systems and to analyze health status measures will facilitate a more precise definition of sectoral priorities, improved programming, monitoring, and evaluation of health programs.

During 1995, the health situation of the Region's countries in large part resulted from complex economic and social adjustments that pushed segments of the population into deeper poverty. This situation, in turn, translated into great disparities in the health conditions of different countries and population groups: Latin American and Caribbean countries show some of the greatest social inequities in the world. These socioeconomic changes have sharply curtailed the ability of health institutions to adequately distribute equitable services to vulnerable segments of the population, bringing the problem of inequity and the search for a solution to it to the forefront.

For the Pan American Health Organization, the search for a way to ensure equity in the provision of and access to health care services represents one of the greatest challenges to its technical cooperation. Only by identifying gaps in equity and access can effective actions that target the populations at greatest risk be programmed and implemented. Acknowledging this critical need, the Director of the Pan American Sanitary Bureau assigned high priority to a work plan designed to improve the Organization's capability to describe, analyze, and interpret the health situation and trends of the Region's countries and to strengthen the capability of the countries themselves to analyze their health situation and target their interventions accordingly. Data gathered and studies and analyses conducted will supply invaluable information to political and strategic planning and management processes and to efforts to evaluate and redirect technical cooperation activities in the countries. This information also will inform technical cooperation activities directed at defining and formulating investment projects or special programs and effective disease prevention and control strategies. Further, the information will help mobilize financial resources, define research priorities, and provide data for periodic publications on monitoring the health situation and trends in the Region.

To this end, the Organization has been working to define a set of core data that can be used for health and trend assessment analyses. The data will be complemented with important bibliographic and background information that can contribute to better understand the health situation. A special effort is being made to select basic indicators disaggregated by major inequity characteristics such as gender, ethnicity, social class, race, and geographic distribution.

This article will review the health situation of countries in the Region of the Americas and provide documentation of the importance of addressing equity gaps in health as part of health sector reform processes. This review will utilize basic health and health policy indicators that the countries provided to PAHO's Technical Information System.

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Methodology

Various indicators of health conditions, resources, coverage, mortality, and morbidity were analyzed in order to highlight inequities among the countries. All the data analyzed were obtained from Health Conditions in the Americas (1) and Health Situation in the Americas: Basic Indicators 1995 (2).

Using discriminant analysis, 42 countries and other political units were classified in 5 groups, according to their per capita gross national product (GNP) (Table 1). This indicator represents a reasonable approximation of the resources available to each country for satisfying the basic needs of their people. The minimum and maximum values within each per capita GNP range, correspond to the lowest and highest values reported within each group.

The other indicators were analyzed by comparing the value of each country in a group with a calculated average for the group distribution. There were instances when the data was not available for all the countries within a group, as was the case with the income ratio of the highest 20% vs. the lowest 20% of the population, for which only 23 of the 42 countries had data. The percent of the gross domestic product (GDP) spent on health should not be analyzed independently from the GDP for each country. Any analysis of mortality data should consider the limitations inherent in this type of indicator; most importantly, data availability and quality.


TABLE 1.
Selected Countries and Other Political Units of the Region of the Americas,
Grouped by per Capita GNP in US$, Around 1993.


Group Country Per Capita GNP(US$)
I Cayman Islands
United States of America
Canada
Bermuda
Aruba
Bahamas
British Virgin Islands		 24,740
20,555
20,000
12,900
11,420
10,600
26,200
II Netherlands Antilles
Argentina
Puerto Rico
Antigua and Barbuda
Barbados
Anguilla
Turks and Caicos Islands		 7,220
7,000
6,540
6,230
5,930
5,700
7,800
III Saint Kitts and Nevis
Trinidad and Tobago
Uruguay
Mexico
Saint Lucia
Chile
Brazil
Venezuela
Dominica
Panama
Belize
Grenada
Costa Rica
Saint Vincent and the Grenadines		 4,410
3,830
3,830
3,610
3,380
3,170
2,930
2,840
2,720
2,600
2,450
2,380
2,150
2,120
IV Paraguay
Peru
Jamaica
Colombia
El Salvador
Dominican Republic
Ecuador
Suriname
Guatemala		 1,510
1,490
1,440
1,400
1,320
1,230
1,200
1,180
1,100
V Bolivia
Honduras
Guyana
Nicaragua
Haiti		 760
600
350
340
280

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Inequities in the Population's Living Conditions

The grouping of countries by GNP was the first step in evaluating equity gaps in health; it is the initial approach in estimating the resources that are available for meeting the population's needs.

Table 2 shows that 38.6% of the population of the Region of the Americas lives in the countries assigned to Group I, where the average per capita GNP is 3.4 times greater than for the countries in Group II and 48.3 times greater than that of the countries in Group V.


TABLE 2.
Total Population (1995) and per Capita GNP Range and per Capita GNP Weighted Average
in US$ (around 1993) in the Region of the Americas, by Groups of Countries.1


  Per capita GNP (US$)
Group Population
(in thousands)		 Range Weighted Average
I 293,155 26,200 to 10,600 24,304
II 38,810 7,800 to 5,700 7,193
III 300,261 4,410 to 2,120 3,142
IV 102,383 1,510 to 1,100 1,355
V 25,516 760 to 280 503

1. Groups of countries from Table 1.


In examining the income ratios of those in the wealthiest 20% and those in the poorest 20% of the population within each country, a skewed trend is observed--the poorest countries have the highest ratios and the richest countries, the lowest (Figure 1).

According to data from Health Situation in the Americas: Basic Indicators 1995, in Canada, for example, the wealthiest 20% of the population has an income that is seven times greater than that of the poorest 20%. In the United States, the ratio is nine. Yet, in groups III and IV there are countries such as Brazil with a ratio of 32, Guatemala with 31, Panama with 30, Honduras with 24, and Ecuador with a ratio of 20. When the average values of the incomes in the poorest quintile in the poorest countries are compared with those in the wealthiest, the incomes in countries such as Guatemala and Honduras are 60 times lower than those in countries such as the United States and Canada.

If the change in per capita GDP between 1991 and 1993 is considered (Figure 2), the greatest growth is observed in group II and III countries: Argentina, 21.0%; Chile, 17.9%; and Panama, 17.4%. On the other hand, Group IV shows the smallest increase and Group V, the greatest decrease; these are the groups with countries that have lower GNPs (Haiti, -24.4%; Nicaragua, -11.0%; Suriname, -10.8%). By the same token, when group averages are compared, the poorer the country, the lower the growth (Group II, 6.15%; Group III, 7.57%; Group IV, 0.86%; and Group V, -2.94%).

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Inequities in the Distribution of Resources for Health

Vast differences exist among the five groups of countries in terms of expenditures in health. For example, countries in Group I spend 6.2 times more than those in group II and 80 times more than those in group V (Figure 3).

A disturbing trend is observed when the percentage of the GNP invested in health by the countries in each group is analyzed. Poorer countries tend to invest a lower percentage of their GNP (Figure 4), and this trend tends to widen inequities in availability and accessibility of health care.

For purposes of this analysis, the availability of physicians per inhabitants is being used as a proxy indicator of the availability of medical care and the proportion of population living in rural areas as an indicator of accessibility. (Figure 5) shows the number of physicians per 10,000 inhabitants and the percentage of the population living in rural areas for each of the five groups of countries.

The data show that the availability of medical care decreases in the groups of countries where the per capita GNP decreases. On the contrary, the proportion of the population inhabiting rural areas increases in the groups of countries with lower GNPs. Therefore, based on these two proxy indicators, both accessibility and availability decrease with lower GNPs.

In poorer countries, less money is available for health care. Concomitantly, one could say that the number of physicians per capita is lower and the problems associated with geographical access to health centers are greater.

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Inequities in the Health Status of the Population

Inequities in the risk of becoming ill and dying prematurely correlate with inequities in the distribution of resources. This phenomenon is demonstrated in the infant mortality rates for countries in the Region, which range from 7 to 98 per 1,000 live births. Significant increases in this indicator are observed as important socioeconomic indicators decline. (Figure 6).

Infant mortality rates vary from country to country and within a given country. In Peru, for example, the city of Lima has an infant mortality rate of 50 per 1,000 live births, but some of the country's rural areas have rates as high as 140 infant deaths per 1,000 live births. In Panama, an indigenous infant is 3.5 times more likely to die than a non-indigenous infant. In Mexico City, the infant mortality rate ranges from 13.4 to 109.8 per 1,000 live births; the proportion of children with low birth weights tend to increase as poverty levels increase (Table 3).


TABLE 3.
Percentage of Newborns with Low Birthweight (<2,500 g) of Total Births
in the Region of the Americas, by Groups of Countries, 1 1990.


Group Newborns with low birthweight
(<2,500 g), 1990 2
I 8.7
II 8.0
III 10.9
IV 12.0
V 13.2

1. Groups of countries from Table 1.
2. Average of percentages of countries in each group.


A similar situation occurs with the proportion of deaths due to acute diarrheal diseases among children under 5 years of age. Acute diarrheal diseases, long known to be preventable, kill more children in the countries with the lowest GNPs (Figure 7).

The emergence of new infectious diseases or the resurgence of others thought to have been controlled by public health measures also have significantly affected the health conditions of the countries of the Region. Two dramatic examples of the latter are malaria and dengue. In the case of malaria, morbidity rates (as measured by annual parasite incidence rates) began to steadily rise in the mid-1970s, and have stabilized at rates that more than double the rates recorded two decades ago (Figure 8). A similar trend can be observed in the resurgence of dengue and dengue hemorrhagic fever (Figure 9).

Over the past four years, a cholera epidemic has swept through most of the Region's countries, leaving a toll of more than a million cases and nearly 10,000 deaths. This constitutes yet another example of a disease that had been virtually eliminated and then returned with a vengeance, ravaging the population's poorer and more disadvantaged segments. As shown previously, these infectious diseases tend to present with higher incidence, mortality, and case fatality rates in the countries with the lower GNPs.

Regarding tuberculosis, nine countries (representing 20% of the Region's population) present with incidence rates that reflect a serious situation for pulmonary tuberculosis, while eight countries (representing 67% of the population) present a less serious situation. An increase in the number of cases also is observed in these countries (Figure 10).

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Inequities in Accessibility to the Health Services

Even though every country in the Region is undergoing reform and adjustment processes, there are country-to-country differences in the stage of development of the health systems, especially in terms of accessibility and availability of health care resources.

The following indicators were used to assess the population's accessibility to the health services: percent of pregnant women receiving prenatal care and percentage of births attended by trained personnel. As shown in Table 4, coverage is lower for both indicators in countries with lower GNPs. The differences in both indicators among the countries in groups IV and V are worth noting. When the percentages for prenatal care in the countries in Group V are compared, they show variations that range from 95% in Guyana to 38% in Bolivia. The percentage of births attended by trained personnel within group IV ranges from 23% in Guatemala to 90% in Suriname.

TABLE 4.
Percentage of Pregnant Women Receiving Prenatal Care and Percentage
of Live Births Attended by Trained Personnel, Around 1990 1.


Group Percentage prenatal care
(average)		 Percentage of births attended by trained personnel
(average)
I 98.2 99.1
II 96.0 95.0
III 75.4 86.4
IV 56.8 45.5
V 58.4 40.5

1. Groups of countries from Table 1.


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Bridging the Gaps

Many countries are downsizing their health systems are rapidly changing as a consequence of health sector reforms, and resources available to finance social sector programs, including important health activities, are being reduced. Given this, the health sector faces an enormous challenge if it is to implement social and health policies directed at reducing inequities without unacceptably sacrificing other policy goals. In every country, the health reform process aims at searching for equity, defined as accessibility of services to those who need them, regardless of geographic location, social status, or the type of ailment affecting them. While equity does not imply absolute equality, it does carry a sense of justice--and all health sector reform processes ultimately strive to attain justice in the delivery of services.

As a first step in the search for equity, indicators that will make it possible to evaluate and assess the population's health conditions must be identified. The need to show the impact of the international technical cooperation process grows. The principal criterion for evaluating technical cooperation programs in health should be their impact on the health of the population, and the most important indicators of impact should be linked to changes in the equity of the delivery of the health services.

The technical cooperation provided by an international agency specializing in health, such as PAHO, includes a wide spectrum of areas and projects that are determined by the countries' national priorities. Some health initiatives have easily quantifiable results, and the impact of PAHO's technical cooperation can be unequivocally demonstrated: for example, the projects associated with the goal of eradicating polio from the Region of the Americas. Without question, important improvements in the health of the population can be accomplished when targeted public health interventions such as these receive political and technical support and are undertaken with a common goal. Figure 11 shows that, notwithstanding the vast differences in health status previously analyzed in the five groups of countries, Oral Polio Vaccination (OPV3) and measles vaccination coverages are relatively stable and do not vary significantly. The low case fatality rates that have been maintained during the cholera epidemic also represent an example of how control measures can be successfully derived as a result of concerted efforts directed at proper environmental management and prompt and adequate treatment. The recent outbreak of plague in Peru also showed the efficacy of control through sound environmental management.

Other health initiatives, however, involve technical cooperation projects designed to have an effect on national processes such as health sector reform, decentralization, and poverty alleviation. These areas of technical cooperation are characterized by their intersectoral nature (meaning that, at times, even the role of the health sector needs to be advocated), by being of interest to and influenced by a wide variety of actors, and by being sensitive to political processes. These projects, which fall within the more qualitative side of the spectrum, are the most difficult to evaluate. On the one hand, it is not easy to unequivocally establish causality and its direction; on the other, it is difficult to isolate the determinants of change and assign attribution to individual players.

Some memorable examples of efficient and effective interventions along this line are those that fall under the aegis of humanitarian assistance, whether in response to natural or man-made complex disasters, and those directed at health promotion, including healthy lifestyles and the promotion of a healthy environment. The Ministers of Health of Central America devised the concept of health as a "bridge for peace" during the days in which that area was wracked by conflict. It has been well-documented that the ability to come together to discuss and plan health initiatives galvanized the peace process by raising the moral and ethical aspects of health and the preservation of life. There was a clear perception of the mutual self-interest that could be served by adopting common approaches to health problems. In addition, the willingness of the health sector to establish joint activities caught the imagination of the international community and led to a channeling of substantial resources to that area. We now need to mobilize the same energy and build a "bridge for equity."

In using the indicators shown in this article to describe and analyze the Region's health situation, the effect of multiple socioeconomic processes on the health status of populations becomes apparent. This kind of data-driven analysis facilitates the identification of important differences and gaps in health that exist in the Region. An understanding of the differential impact of various public and private sector interventions on the health and living conditions of the population also is paramount. However, the existing health conditions provide more than ample justification for the need to develop policies and programs that will help to bridge gaps in equity in health while searching for mechanisms to help to build a more equitable and sustainable health care delivery system.

The Organization is committed to work toward the consolidation of information systems in the Member Countries that will help document the impact of health nterventions and also support the development of health policies that will lead the path to sustainable human development. When the countries work in collaboration with international technical agencies to address health problems, significant achievements can be accomplished for population groups at risk.

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References

  1. Pan American Health Organization. Health Condition in the Americas. 1994 Edition. Scientifici Publication No. 549

  2. Basic Indicators 1995. Health Situation in the Americas PAHO/HDP/sha/95.03

Source: Prepared by Health Situation Analysis Program, Division of Health and Human Development, for The Search for Equity, Annual Report of the Director, 1995, Official Document No. 277, PAHO/WHO.

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