Introduction: Universal health
In October 2014, the Member States of the Pan American Health Organization (PAHO) marked a milestone with their approval of the Strategy for Universal Access to Health and Universal Health Coverage () through Directing Council Resolution CD53.R14 (). This commitment was the culmination of a long history of efforts to improve the health of the peoples of the Region of the Americas—a history that included the adoption of the World Health Organization’s Constitution in 1946 (); progress in the affirmation of human, economic, social, and cultural rights through the Universal Declaration of Human Rights () issued by the United Nations General Assembly in 1948; and the 1978 Declaration of Alma-Ata (). Throughout these years, recognition that health is a right was gaining ground, and these documents became the backbone of important international strategies in pursuit of universal health and well-being for all in the Region of the Americas.
After several sustained periods of political instability in the 1960s and 1970s, especially in Latin America and the Caribbean, democracy rapidly spread throughout the Region, leading to 25 years of relative stability that fostered institutional and social reform, especially civil society engagement in policy development and implementation. As democratic processes took root, the right to the highest attainable standard of health became enshrined in many national constitutions and health laws, reflecting a commitment by governments to the health of their citizens that, in turn, provided the legal framework necessary for the protection of that right ().
This period coincided with sustained economic growth in the Americas; in fact, the Region’s economic performance in recent decades often surpassed that of higher-income countries, despite the regional and global economic crisis. The work force and middle class grew as a result, lifting many individuals and households out of poverty. Higher compensation for labor was the principal driving force behind the reduction of extreme and moderate poverty, coupled with the creation of social protection mechanisms to support income transfer and pension management. During this period of sustained growth, the countries expanded their fiscal space and increased social sector investment, targeting the poorest populations to reduce inequalities (). The result has been longer life expectancy and improvements in the principal aggregate health indicators, such as nutrition, infant mortality, maternal mortality, HIV infection, malaria, and tuberculosis. Following the Declaration of Alma – Ata, rapid expansion in primary health care was observed in the countries of the Region, with particular emphasis on outreach to the poor. This included several initiatives to reach even neglected rural populations by expanding the health care network and focusing on the delivery of maternal and child health services, which included the use of new health technologies and the provision of vaccines, oral rehydration salts, and family planning methods. Sustained economic growth during the period, coupled with the primary health care approach, substantially improved health outcomes; however, the emphasis on special programs for particular poor populations was selective and perpetuated exclusion in health. Despite the progress made, not all population groups benefited from the improvements in income and health outcomes, as the disaggregated health data for the period show ().
In this context, there is a need to seek equity in health among the different population groups, with the specific goal of reaching people unable to exercise their right to health. The evidence shows that the use of aggregate national indicators to monitor progress in health tends to conceal these differences and limits the information needed for developing policies, strategies, and programs. As a result, disaggregated indicators are needed that describe the actual situation and evolution of the health status of these populations. In principle, the inequities are associated with income level, place of residence (rural, urban, peripheral), educational level, ethnicity, sex, and age. Moreover,social solidarity is critical to the exercise of the right to health and the reduction of inequities, since it promotes a culture with an appreciation of and commitment to social justice.
Democratization and economic growth have been accompanied by social policy reforms aimed at mitigating widespread inequities throughout the Region. In the area of health, these reforms have focused on expanding and transforming health systems to improve health coverage and meet the needs of the population, especially those of populations in situations of vulnerability. For the purposes of this publication, a health system consists of all the organizations, people, and actions whose intent is to promote, restore, or maintain health. This includes initiatives aimed at influencing health determinants, as well as more direct activities to improve health. A health system is therefore more than just the network of public facilities that delivers individual and group health services. It includes private service providers, behavior modification programs, vector control campaigns, and social security and health organizations—for example, schools for promoting children’s health, universities that provide human resources education for health, etc. (). Unfortunately, in an effort to meet the different needs of population groups in situations of vulnerability, health systems have exacerbated the problem of segmentation, since populations receiving basic packages of services through specific programs to promote well-being have been excluded from the broader packages of guaranteed services available to other segments of the population. This has become an obstacle to achieving real equity in the context of explicit government efforts to fight poverty and reduce inequality ().
In recent decades, the countries of the Region have pursued different adjustments and recovery paths in each economic cycle, influencing access and health outcomes in different ways. For example, the health sector reforms of the 1990s were a corollary to the structural government reforms adopted in response to the economic downturn of the 1980s—a period known as “the lost decade,” due to the deterioration in economic capacity and social progress (). Structural adjustment required cutbacks in public spending, reducing public health expenditure and leading to the introduction of direct payment for services (user fees). The evidence shows that direct payment at the point of service is a major barrier to health service access, especially for poorer communities, that jeopardizes long-term treatment adherence and can led to impoverishment ().
During the 1980s and 1990s, several countries (including Brazil, Chile, Colombia, and Costa Rica) launched major reforms to minimize the segmentation and fragmentation of the health services created by two-tier systems, one for people in the formal employment sector and another for the poor and the uninsured. Since then, several more countries, including Argentina, the Dominican Republic, Ecuador, Guatemala, Jamaica, Mexico, Peru, the United States, and Uruguay, have adopted a much broader series of policies to improve the coverage of the population and access to comprehensive, quality services, particularly with the adoption of an approach designed to reduce inequities in access.
These and other health system reforms have been adopted in keeping with major global and regional commitments. For example, in 2000, the United Nations General Assembly approved the Millennium Development Goals (MDGs), setting specific targets for each of the eight goals. Although three of these goals were specific to maternal health, child health, and HIV/AIDS, their achievement was not independent of the progress made in meeting the other MDGs aimed at reducing poverty and hunger and promoting gender equality, women’s empowerment, and environmental sustainability, whose specific targets included access to safe drinking water and basic sanitation and improvement of the living conditions of slum dwellers. In 2003, marking the 25th anniversary of the Alma-Ata conference, the countries of the Region of the Americas began renewing the commitment in the Declaration of Alma-Ata to formulating their future strategic and programmatic orientations for primary health care, stressing the principles of universality and social inclusion (in a regional movement against selective primary health care) (). In 2007, the ministers and secretaries of health of the Americas presented the Health Agenda for the Americas 2008–2017 () to “guide the collective action of national and international stakeholders who seek to improve the health of the peoples of this Region” during that period. This Agenda, which still influences the formulation of strategic plans and technical cooperation, was based on the values of the right to health and equity in health. It charted a course by stating that “…in order to make this right a reality, the countries should work toward achieving universality, access, integrity, quality, and inclusion in health systems that are available for individuals, families, and communities,” and calling on health systems to be accountable to citizens for the degree to which these conditions are met. At the same time, the Agenda encourages a results-based search for equity, noting that the “…search for equity in health is manifested in the effort to eliminate all health inequalities that are avoidable, unjust, and remediable among populations or groups.”
In 2010, the World Health Organization marked a milestone with its publication Health Systems Financing: The Path to Universal Health Coverage (), which urged the countries to improve health financing so as to increase population coverage and the availability of services. At the same time, the 2011 Political Declaration of Río () issued a global call to action to address the social determinants of health. This resulted in the United Nations Conference on Sustainable Development (Río + 20), held in 2012 (); Resolution WHA67.14 (2014) of the World Health Assembly on Health in the post-2015 Development Agenda (); and, finally, the new 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs) (). The need to tackle the social, economic, and environmental determinants of health to influence health outcomes is centered on each of these commitments, but with greater emphasis on intersectoral action and the differential distribution of access to comprehensive health services across social gradients in order to close and eliminate the existing gaps in health equity.
The Region of the Americas continues to be marked by significant social and economic inequalities among and within countries. Some 29% of the population is still living below the poverty line, and 40% of the population receives less than 15% of the total income, with greater inequalities and conspicuous differences among countries (). The wealthiest 10% of the population has 14 times the average income of the poorest 40% in the Latin American and Caribbean countries (). Furthermore, an estimated 30% of the population has no access to health care due to financial barriers, while 21% is discouraged from seeking care by geographical barriers (). Population aging and lower fertility rates have drastically altered the population profile: the Region’s population is now almost double what it was in the 1970s. Thus, the epidemiological profile continues its transition from high levels of morbidity and mortality from infectious diseases to a high prevalence of mortality and morbidity from noncommunicable diseases and external causes (i.e., traffic accidents, violence, etc.). Noncommunicable diseases (NCDs), mainly cardiovascular disease, cancer, diabetes, and chronic respiratory diseases, together with their four shared risk factors—tobacco use, poor diet, physical inactivity and the harmful use of alcohol— are responsible for more than 80% of all deaths in the Region (). Equity concerns persist, with the evidence suggesting that mortality from these diseases is higher among the poorest population ().
In the context of continuing social exclusion, health system segmentation and fragmentation, the expiration of the MDGs and the negotiation of the new SDGs, and a growing global consensus around the concept of universal health coverage, the member countries of the Pan American Health Organization have examined the links between universal health coverage, health, and development. In October, the 53rd Directing Council of PAHO approved the Strategy for Universal Access to Health and Universal Health Coverage (Resolution CD53.R14), rooted firmly in the values that have been central to health and development in the Region of the Americas–that is, the right to health, equity, and solidarity. The strategy’s approval was preceded by an intense and extensive dialogue that began in September 2013, when the Member States confirmed their commitment to universal health coverage with the approval of the PAHO Strategic Plan 2014–2019, which recognizes universal health coverage, together with the social determinants of health, as one of the pillars of progress toward health for individuals, families, and communities.
The deliberations involved 31 consultations that brought together over 1,200 people representing the different stakeholders in the health system and related sectors involved in public policy-making. These meetings revisited the experience and studied the relevant regional health policy documents, as well as the values and principles that inspired them.
While the global discussions focused on universal coverage—that is, on financing mechanisms and the organization of service delivery to cover all people in the Region of the Americas—they emphasized access to health and its linkage with the social determinants of health. The national and regional deliberations considered the experiences with health sector reform that followed the government reforms of the 1990s, which focused on changes to financing strategies and mechanisms, while giving lower priority to eliminating health service access barriers. The participants reached the conclusion that while universal coverage lays the necessary foundations, it is not enough to guarantee health, well-being, and health equity. They therefore agreed to make an explicit commitment to universal access, defined as the absence of geographical, economic, sociocultural, organizational, and gender barriers that prevent all people from using comprehensive health services and living a healthy life that fosters their development and well-being. Recognition that policy-making and action to eliminate or lower these barriers are beyond the mandate of the health system led to the explicit inclusion of intersectoral efforts to address the social determinants of health in the universal health strategy.
The Strategy for Universal Access to Health and Universal Health Coverage, adopted in October 2014 (Resolution CD53.R14), recognizes that “universal access to health and universal health coverage imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate, and timely, quality health services determined at the national level…as well as access to safe, affordable, effective, quality medicines, while ensuring that the use of these services does not expose users to financial hardship, especially groups in conditions of vulnerability…Universal access to health and universal health coverage require determining and implementing policies and actions with a multisector approach to address the social determinants of health and promote a society-wide commitment to further health and well-being”( p. 2).
Access is the capacity to use comprehensive, appropriate, timely, quality, health services when they are needed. Universal access is defined as the absence of geographical, economic, sociocultural, organizational, or gender barriers that prevent all people from having equitable use of comprehensive health services and living a healthy life that promotes their development and well-being.
Health coverage is defined as the capacity of the health system to serve the needs of the population, including the availability of infrastructure, human resources, health technologies (including medicines) and financing. Universal health coverage implies that the organizational mechanisms and financing are sufficient to cover the entire population ().
Universal health is grounded in the core values of the right to health, equity, and solidarity. The strategy reaffirms the values of the 1978 Declaration of Alma-Ata, which constitute the moral and ethical basis for the design and implementation of public policies that affect the health of individuals and communities. The strategy approved by the Governing Bodies of PAHO contains four strategic lines of action that call on the Member States to:
- expand equitable access to comprehensive, quality, people- and community-centered health services;
- strengthen stewardship and governance;
- increase and improve financing, with equity and efficiency, and advance toward the elimination of direct payment that constitutes a barrier to access at the point of service; and
- strengthen intersectoral coordination to address social determinants of health.
The Strategy for Universal Access to Health and Universal Health Coverage provides the Region of the Americas with a single framework for improving the health and well-being of all people through the development of inclusive policies and robust and receptive health systems, as well as intersectoral action to address the social, economic, and environmental determinants of health. It offers a way forward so that the countries, regardless of where they are on the path toward universal health, can set equitable and sustainable national priorities and take action to prospectively address current health problems. The strategy is aligned with the basic principles of the 2030 Agenda for Sustainable Development, designed to ensure that no one is left behind, and provides the countries of the Region with a roadmap for developing their health systems to meet the 2030 goals. That is why this publication, and this chapter in particular, examines progress in health in the Region from a universal health standpoint. This requires a deeper analysis of the values and basic underpinnings of universal health and their influence on health system transformation processes; of how countries are mobilizing to gradually increase access to quality health services that are comprehensive, integrated, and equitable; of the current picture and trends in financing; and of how a renewed approach to governance and leadership in health can accelerate the achievement of health and development. Our frame of reference for this analysis is the period 2010–2015, and the emphasis is on how the values of the rights-, equity-, and solidarity-based approach continue to influence health, development, and public policies in the Region of the Americas, constituting gradual steps toward achievement of the Sustainable Development Goals.
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1. The “right to health” is defined CD53.R14 in the context of “the perspective of the right to health where nationally recognized and promoting the right to the enjoyment of the highest attainable standard of health.”
2. The Commission on Social Determinants called for closing the health gap in a generation and stated that “Social justice is a matter of life and death…These inequalities in health, avoidable inequalities, arise because of the circumstances in which people grow, live, work, and age and the systems put in place to deal with illness. The conditions in which people live and die, in turn, are shaped by political, social, and economic forces” (WHO, Commission on Social Determinants of Health. Final report. Health equity through action on the social determinants of health. Final report. Health equity through action on the social determinants of health. Geneva: WHO; 2009).