Pan American Health Organization

Health financing in the Americas

  • Introduction
  • Financing and its characteristics in the Americas
  • Financing challenges for the countries
  • Summary
  • References
  • Full Article
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Introduction

Despite the economic growth and progress in health of the past decade, poverty and inequity within and among countries remain a challenge for the Region of the Americas. Some 29% of the Region’s population is still below the poverty line, and 40% receives less than 15% of total income, with marked differences among the countries (). The wealthiest 10% of the population receives 14 times the average income of the poorest 40% in Latin America and the Caribbean (LAC) (). Furthermore, an estimated 30% of the population has no access to health care for financial reasons, and 21% is kept from seeking by geographic barriers ().

At the same time, exclusion and lack of access to quality services persist for large sectors of the population. The prevailing models of care, based more on hospital care for episodes of acute illness than on disease prevention and health promotion, often with excessive use of technologies and poor distribution of medical specialists, do not necessarily meet the health needs of individuals and communities. Investments to reform and improve health systems have not always been designed to deal with new challenges related largely to the demographic and epidemiological transition or the expectations of the population.

The result is a lack of universality and equity in access to quality services and appropriate coverage, which entails a substantial social cost and impoverishes the more vulnerable population groups. The evidence shows that when there are access barriers to services (whether economic, geographic, cultural, demographic, or other), a deterioration in health implies not only greater expenditure but a loss of income as well. The absence of mechanisms to protect against the financial risk of ill health creates and perpetuates a vicious cycle of disease and poverty.

Inadequate financing and inefficient allocation and use of the available health care resources are major obstacles to progress toward equity and financial protection. Indeed, average public health expenditure in the Region of the Americas is around 4% of gross domestic product (GDP)–a very low level compared to the 8% allocated to this budget line by the countries of the Organisation for Economic Co- operation and Development (OECD) (). Direct payment (or out-of-pocket expenditure) at the point of service, the most inefficient and regressive form of financing, yields an unstable flow of financial resources and constitutes an access barrier that impedes or delays care and makes it more expensive for both patients and the system. Furthermore, it has a relatively greater impact on the poor, as even the smallest payment can represent a substantial portion of their budget. Only six countries in the Region of the Americas have direct expenditure levels of under 20% of total health expenditure, the figure that, according to the World Health Organization (WHO) (), protects their populations against the risk of impoverishing or catastrophic health expenditures.

Efficient allocation of public expenditure is a prerequisite for reducing inequities. Implementing the people- and community-centered model of care requires greater efficiency through the priority allocation of new resources to the first level of care and networks to increase the availability of quality services and speedily address unmet health needs. A series of mechanisms must be implemented simultaneously to transform the model of care and the health services structure. Particularly important are payment systems that foster integrated care and the continuity of care ().

The segmentation and fragmentation that characterize the majority of the Region’s health systems give rise to inequities and inefficiencies that compromise universal access, quality, and financing. Weak health system regulatory capacity, excessive verticality in some public health programs, lack of integrated service delivery, and, occasionally, union pressure to protect privileges and lack of political will to make the necessary changes exacerbate and perpetuate this problem.

The strategy for universal access to health and universal health coverage of the Pan American Health Organization (PAHO) redefined the concept of coverage and access to health and stressed the values of solidarity, equity, and the right to health; it also recognized financing as a necessary, though insufficient, factor in reducing inequities and increasing financial protection for the population. The core value in the strategy’s definition of “access,” embraced as a priority for society as a whole, is “the right to health,” which requires adequate, allocated, and efficiently managed financing. This vision stands in sharp contrast to the traditional view, in which access depended on an individual’s and household’s ability to pay and went hand in hand with the proposals to adopt direct payments and the promotion of policies that had led to the fragmentation of health systems in previous decades. At the same time, the strategy acknowledges the need to foster the necessary changes through political and social action that puts health squarely at the center of the policy agenda.

Strategic Line 3 of the PAHO strategy proposes “Increasing and improving financing, with equity and efficiency, and advancing toward the elimination of direct payment that constitutes barrier to access at the point of service.” Three interrelated lines of action flow from this:

  • Increase financial protection by eliminating direct payment, which constitutes an access barrier, thus preventing exposure to catastrophic expenditures or those that lead to or exacerbate poverty. The replacement of direct payment as a financial mechanism should be planned and progressively achieved through prepaid pooling mechanisms, using sources of funding that guarantee their stability and sustainability.
  • Increase public health expenditure to the benchmark of 6% of GDP, which implies a commitment by society as a whole to increase the fiscal space reserved for health in terms of new public sources of financing, with the search for equity as the main objective.
  • Boost efficiency in the health system by adopting a series of measures that specifically impact its financing and organization, such as aligning payment mechanisms with health system objectives and rationalizing the introduction of new medicines and other technologies that contribute significantly to rising health expenditures.

This chapter is a response to the need for an extensive overview of the health system financing situation in the countries of the Region and the challenges they face. Following this introduction, which outlines the theoretical framework in relation to PAHO’s current regional strategy and its financial scope, health financing in the Region will be examined in a conceptual and descriptive section, with special attention to financial protection. The third and final section completes the analysis and describes the immediate challenges facing the countries in terms of the need to equitably and efficiently increase financing.

Financing and its characteristics in the Americas

Any characterization of health financing in the Region would do well to start with the definition of the structures in which health financing functions are performed, the type of health system constructed, and its processes of development and change.

Health financing structure in the Americas

Institutional arrangements in financing decisions are critical. In securing resources and identifying and structuring funding sources, they involve decisions in the realm of tax policy that have developed over time, and in the absence of a major change or reform, are neither directly nor exclusively related to the health sector, but rather, the State and government. In the majority of the countries, operational financing decisions are made year-to-year by the ministries of finance and health as part of a planning process in which the democratic political system is involved, since in most cases, the main source of funding (or a significant part of it) – the budget – is approved by the parliament or congress. Other sources of financing are determined by the market through private expenditure.

Pooled resource arrangements, in turn, are usually long-term and have also taken shape during the historical development of the systems. The Region is largely characterized by segmented systems in which different entities exercise this function hermetically and hence with little or no solidarity (with the notable exceptions of Brazil, Canada, Costa Rica, Cuba, and Uruguay). On the other hand, the purchase of services as a resource allocation mechanism takes many forms, with payments from the historical budget in the public sector and the fee-for-service mechanism in the private sector predominating. However, some countries have made significant progress in planning or implementing payment systems designed to efficiently reaffirm health objectives by operating in networks, as seen in Brazil, Chile, Costa Rica, Ecuador, Peru, and Suriname.

In the same way that financing can be characterized by its functions, the development factor and transformation of systems can be added. In fact, the universal health strategy characterizes health system segmentation and fragmentation as a serious problem. Countries continually launch processes of transformation, reform, or change, and these efforts also determine financing strategies.

For example, when Chile began reforming its explicit health guarantees in 2005, this appeared to be a remedy for the health system’s access and fragmentation problems; however, it failed to address the segmentation of the existing funds for mitigating risk (). In Mexico, the design of the People’s Insurance created a new health care system in the attempt to cover a population group that had been excluded from access to health care; this implied greater equity () but not less segmentation. Something similar happened in Peru with the creation and gradual roll out of its Comprehensive Health Insurance, although in this case, it appears that broader coverage has led to greater equity (). The Uruguayan reform, with a single revenue collector and payer (FONASA), vigorously addresses segmentation, pools resources, and promotes solidarity in financing. However, there is still the challenge of reducing fragmentation, which could perhaps be addressed by using ways of financing the purchase of services that facilitate movement toward a comprehensive integrated system based on primary care.

Between 2010 and 2016, the United States implemented the Affordable Care Act (ACA), a substantive reform for that country’s context that has brought insurance and coverage to major population groups through a three-pronged approach: 1) compulsory universal insurance, so that all citizens are covered; 2) the regulation of group premiums and open enrollment to prevent discrimination against seniors and the rejection of beneficiaries by insurance companies; and 3) subsidies for people who meet the criteria (low income) so that they can receive coverage, along with a significant expansion of the national Medicare and Medicaid programs. Thus, whether or not segmentation predominates is reflected in the composition of health financing in the countries, as seen in Figure 1.

Figure 1. Segmentation reflected in financing

Source: WHO, Global Health Expenditure Database (accessed June 2016).

Countries with national public health systems and broad-based coverage, such as Brazil, Costa Rica, Cuba, and Ecuador, must still confront the need to boost efficiency through payment mechanisms and the creation of fiscal space (sustainable resources to finance increases in public expenditure), which will help them achieve health objectives and the sustainability of the system. In contrast, several Caribbean countries, such as Belize, the Bahamas, and Jamaica, promote the policy of establishing single-payer systems, creating a new source of funding in the form of compulsory social security contributions. In addition to the considerable effort that shifting to this new institutional arrangement implies, they will have to deal with its potential consequences in terms of equity levels.

By instituting reforms, changes, or transformations grounded in the principles of equity, solidarity, and health as a right, PAHO’s Member States have committed to moving toward the elimination of direct or out-of-pocket expenditure, the creation of the largest possible pooled funds, and more efficient public financing as the way of promoting greater individual and community access to comprehensive quality services in integrated health systems, with strengthening of the first level of care. This effort is determining the types of health systems that are being developed in the Region.

Health financing and expenditure in the Americas

This section contains a descriptive comparative analysis of health accounts in the Americas, emphasizing public health expenditure and out-of-pocket, or direct, payment. It also provides other relevant data, such as private and per capita expenditure, together with the weight of the tax burden and the fiscal priority of health in the countries. The first two variables are emphasized, since public health expenditure is the variable that is positively correlated with health outcomes and out of-pocket expenditure is one of the main obstacles to access to health.

a) Public health expenditure and its weight in total expenditure

Considering the universal health strategy’s public health expenditure benchmark of at least 6% of GDP, Figure 2 shows that only 5 of the 34 countries that provided information are above that threshold: Canada, Costa Rica, Cuba, the United States, and Uruguay. The countries below the threshold include three with public health expenditure above 5% of GDP: Colombia (5.4%), Nicaragua (5.1%), and Panama (5.9%).

Observing what happens with total health expenditure and its public-private mix, we discover that in countries that exceed the 6% benchmark, public health expenditure accounts for more than 70% of total health expenditure, except in the United States. Furthermore, in the case of Bolivia, Canada, Colombia, Costa Rica, Panama, and Uruguay, this balance is similar to the average for the OECD member countries (73%). At 17%, total health expenditure in relation to GDP in the United States is known to be the highest in the world, without proportionally better health outcomes (). This indicates the need not only for more resources but greater efficiency in their use.

At the opposite extreme, countries with lower public health expenditure are also those in which the composition of total health expenditure is more skewed toward the private component: Guatemala (private expenditure of 62%), Haiti (79%), Saint Kitts and Nevis (58%), and Venezuela (71%). However, Peru and the Dominican Republic are examples of the opposite, with low public health expenditure (3.3% and 2.9% of GDP, respectively) and a high share of public health expenditure in total health expenditure (61% and 67%, respectively). Added to this is the case of the United States, with high public health expenditure (8.3%), but health expenditure that is predominantly private (52%).

Figure 2. Health expenditure (as a percentage of GDP) and composition (public-private, as a percentage of total expenditure), 2014

Source: WHO, Global Health Expenditure Database and OECD Data (accessed June 2016).

b) Per capita expenditure and equity in expenditure

Total per capita health expenditure in the Region averages 1,320 international dollars (Intl$) per year (adjusted by purchasing power parity) and ranges from Intl$ 160 in Haiti to Intl$ 9,145 in the United States (Figure 3). This absolute level of expenditure can be compared with the average for the OECD countries, which is triple that of the Region and far less scattered. Furthermore, in each country the different segments have different amounts of per capita expenditure, which is one of the most unmistakable signs of inequity. Some countries move toward the convergence of these figures, but slowly, as seen in Colombia, Chile, and El Salvador. With the reform of 2008, Uruguay’s transition was faster in closing this gap, leading to a drop in the difference between the per capita expenditure of social security providers and the public provider from 2.3 times greater in 2007 to just 25% greater in 2012.

Figure 3. Per capita health expenditure in the Americas

Source: WHO, Global Health Expenditure Database and OECD Data (accessed June 2016).

c) Out-of-pocket health expenditure

When examining the impact of health expenditure on household well-being and access and use of the health services, out-of-pocket health expenditure (or direct payment) merits special attention. These terms refer to the payment required at the time of service and at the point of access to the health services and health products, after discounting any subsequent reimbursement. In practice, this can take different forms, such as direct payments for medicines, copayments, coinsurance rates, and deductibles. It can also involve formal or official payments, informal or “under-the-table” payments, or both at the same time ().

The fact that this type of payment may be required to receive care or access the necessary health services makes them a health care access barrier. Even among people who can cover these expenses, incurring them may adversely affect their household’s well being and the consumption of other goods and services or may even be harmful to health if the alternative is self-treatment. It also has implications for the efficiency of the health system, since by discouraging the use of the health services, it causes many users to seek care from the system at more advanced stages of an illness, requiring more complex and expensive services. Thus, out-of-pocket expenditure can result in higher costs in the medium and long term, with worse health outcomes, poorer health system response capacity, and less efficiency and effectiveness.

The indicator most commonly used to measure the burden of out-of-pocket health expenditure in a country is the proportion of total health expenditure that it represents: the higher the proportion, the greater the number of households likely to face financial difficulties as a result of using health services. Figure 4 shows the value of the indicator for the countries of the Region and, as a reference, the average value for the countries of the European Union (EU). First, it shows that while out-of-pocket health expenditure in the EU countries averages 21% of total health expenditure, 29 countries in the Region (83%) exceed that value. Furthermore, the countries with a lower proportion of out-of-pocket health expenditure are also those with higher public health expenditure (as a percentage of GDP) (Figure 1): Canada, Colombia, Cuba, the United States, and Uruguay. Some exceptions are conspicuous: Suriname has low public health expenditure (2.9% of GDP) and also a low proportion of out-of-pocket expenditure (11% of total health expenditure); and Costa Rica, with very high public health expenditure for the Region (6.8% of GDP), has a moderate proportion of out-of-pocket expenditure (25% of total health expenditure).

Low out-of-pocket expenditure is not always an indication of equitable access, since it may also be due to lack of access to the services. Also, it can sometimes increase with the desired increase in access, although the ratio with coinsurance rates or unit values of copayment remains constant.

Figure 4. Proportion of out-of-pocket health expenditure in the Region of the Americas, 2014

Source: WHO, Global Health Expenditure Database (accessed June 2016).

The weight of direct payment (out-of-pocket expenditure) by households in total health expenditure is trending downward in certain countries in the Region, among them Chile, Colombia, El Salvador, and Mexico.

Here, the case of El Salvador is worth examining. In 1995, more than 60% of its health expenditure was financed through direct payments; today, the figure is less than 30% and though still high, represents a significant decline. In Colombia, the indicator fell from 38% to 15% in that same period, and the country currently has one of the lowest percentages of out-of-pocket expenditure in the Region. Other countries show a certain stability in the indicator and remain at very high levels, as in Guatemala (above 52% throughout the period), or low levels, as in Costa Rica, although with a certain upward trend (from 21% to 25% during the period). In Ecuador, a marked increase in the indicator was observed between 1995 and 2000 (moving from 32% to 62%), subsequently shifting downward, but nevertheless remaining at very high levels (48% in 2014).

Figure 5. Trends in out-of-pocket health expenditure in the Americas, 1995–2014 (selected countries)

Source: WHO, Global Health Expenditure Database (accessed June 2016).

While out-of-pocket expenditure is generally more of a direct barrier to care for households with less purchasing power, it also is for the middle class (). Thus, having access to health services does not prevent out-of-pocket payments from undermining health equity, since “overcoming” the barrier can significantly jeopardize a household’s well-being, driving it into poverty (impoverishing expenditure) or representing a painfully high proportion of its total expenditure or ability to pay (catastrophic expenditure). Expenditure is considered impoverishing for a household when it represents the difference between being above or below the poverty line (). Expenditure is considered catastrophic when out-of-pocket health expenditure represents a substantial percentage of household expenditure–usually 30% or 40% of its ability to pay (), or 25% of total expenditure (), with “ability to pay” understood as total household income minus the expenditure necessary for meeting basic subsistence needs (). The values of catastrophic and impoverishing expenditure indicators vary with the methodology used. However, a recent PAHO study of 11 countries in the Region shows that in 7 of them, 2.5% of households have catastrophic expenditures according to any of the known methodologies. These methodologies generally vary in whether the catastrophe threshold is 30% or 40% of a household’s ability to pay or use the more recent threshold established by WHO and the World Bank for the Millennium Development Goals, which is 25% of total household expenditure.

d) Trends in public health and out-of-pocket expenditure

Observing the averages of these two key indicators in the Region in a 20-year series, we see a slight increase in public expenditure, together with a slight decrease in out-of-pocket expenditure. The point of intersection in Figure 6, which was 3.6% of GDP and 34% of total health expenditure in 2007, did not augur well. In 2012, the figures were 4.1% of GDP for public health expenditure and 32.6% for out of-pocket expenditure. In fact, since 2008, this trend has continued its moderate path without reaching sufficiency, especially in the LAC countries. However, in the non-Latin Caribbean countries, the general trend exhibited in the Region did not materialize; instead, the two indicators have remained stable. North America, which had already reached 6% of GDP at the beginning of the series (1995), was almost at 7% and 13.8% of out-of-pocket health expenditure in 2007, and in 2012 had increased the share of public expenditure in GDP to 8% and decreased out-of-pocket expenditure to 12% of total health expenditure.

Figure 6. Trends in public health expenditure and out-of-pocket health expenditure

Source: WHO, Global Health Expenditure Database (accessed June 2016).

e) Decomposing public health expenditure

The following is an intuitive way of decomposing the indicator for public health expenditure as a proportion of GDP to facilitate analysis of its determinants ():

Public health expenditure

=

Total public expenditure

×

Public health expenditure

GDP GDP Total public expenditure

Thus stated, the indicator in the formula is expressed as the product of two factors. The first of them, total public expenditure as a proportion of GDP, refers to a country’s fiscal capacity. The second, public health expenditure as a proportion of total public expenditure, represents the fiscal priority of health.

Figure 7 presents data on fiscal capacity in the Americas, as well as the simple average for EU countries. The median for the Region, around 30% of GDP (with considerable variability between countries), stands in marked contrast to the average of 48% of GDP for total public expenditure in the EU countries. Fiscal capacity (understood as total public-sector resource mobilization) should be a potential source of fiscal space for health in the Region. Furthermore, the combination of a low tax burden and weaknesses in tax collection—manifested, for example, in tax evasion and tax fraud—create a scenario not uncommon in the Region that must be considered in the specific analyses.

Figure 7. Fiscal capacity in the Region of the Americas, 2014

Source:International Monetary Fund, World Economic Outlook Database (accessed June 2016).

When analyzing the fiscal priority of health in the Region (Figure 8), the variability of the indicator is even greater. While public health expenditure in the EU member countries averages 14% of total public expenditure, almost half the countries in the Region of the Americas give higher priority to the health sector. In the case of Costa Rica and Nicaragua, for example, public health expenditure accounts for almost one quarter of total public expenditure (23% and 24%, respectively). At the opposite extreme, however, nine countries allocate less than 10% of their total budget to the health sector: Haiti (5%), Venezuela (5.8%), Brazil (6.8%), Saint Kitts and Nevis (6.9%), Argentina (6.9%), Trinidad and Tobago (7.6%), Jamaica (8.1%), Grenada (9.2%), and Guyana (9.4%). Painting a more complete picture of the countries’ health financing efforts requires at least this dual perspective in order to see how countries that prioritize health in their budget may be spending little due to their excessively low level of total public expenditure, while countries with a high level of total public expenditure may not be prioritizing the health sector, even though health expenditure figures are relatively high in absolute terms.

Figure 8. Fiscal priority of health in the Region of the Americas, 2014

Source:International Monetary Fund, World Economic Outlook Database (accessed June 2016).

Combining the data on fiscal capacity and fiscal priority reveals very unequal country performance. For example, despite its relatively low fiscal capacity (25% of GDP), public health expenditure in Nicaragua is relatively high for the Region (5.1% of GDP), thanks to the high priority of health in the national budget (24% of total public expenditure). However, in Guatemala, where the fiscal priority of health is relatively high for the Region (17.8% of total public expenditure), public health expenditure is low (2.3% of GDP), due to the country’s excessively low fiscal capacity (13.4% of GDP, the lowest in the Region). In Brazil, public health expenditure stands at 3.8% of GDP, despite a high fiscal capacity (almost 40% of GDP), since health has a low fiscal priority (6.8%). In general, the data show that in the eight countries where public health expenditure exceeds 5% of GDP (Canada, Colombia, Costa Rica, Cuba, Nicaragua, Panama, the United States, and Uruguay) the fiscal priority of health is more than 14% of public expenditure.

f) Health outcomes and expenditure

It should be pointed out that these indicators provide no information about the quality of the expenditure, which can be obtained only by comparing them with health outcomes in the population. One way to do so would be to compare health expenditure with life expectancy and mortality from diabetes, as shown in Figure 9 and Table 1.

Here, we can see a correlation between higher public health expenditure and better health outcomes. The figure shows the association between life expectancy at birth and public health expenditure as a percentage of GDP in the countries of the Americas. In Table 1, moreover, the results of a preliminary study of 34 countries, using data from 2000, 2010, and 2014, show that increased public health expenditure is highly correlated with longer life expectancy and lower mortality from diabetes mellitus, as well as lower out-of-pocket health expenditure. Thus, public health expenditure is essential for improving health outcomes and financial protection in the Americas, and increased investment in public health is expected to result in a further reduction in mortality and longer life expectancy, bringing significant economic benefits to the Region. This association has been confirmed in other regions and countries in the world (), serving as additional support for the argument to convince governments to increase resources for the health sector.

Figure 9. Relationship between public health expenditure and life expectancy

Source: WHO, Global Health Expenditure Database (accessed June 2016).

Table 1. Summary of regression analysis

Outcome variable Year Coefficient SE 95 % CI Lower 95 % CI Upper
Mortality from diabetes mellitus 2000 -32.26188 5.19368 -42.86878 -21.65498*
2010 -34.82691 7.34039 -49.81798 -19.83584*
2014 -20.66315 5.89383 -32.66849 -8.6578*
Life expectancy at birth 2000 4.58267 1.02212 2.49522 6.67013*
2010 6.88649 1.56629 3.69607 10.07691*
2014 3.10145 0.73388 1.60659 4.59631*
Out-of-pocket health expenditure 2014 -20.83396403 4.29818 -4.84715 -29.62474*

Note: * p<0.001; SE = standard error of the coefficient; CI = confidence interval. Source: PAHO/WHO from WHO Database (accessed June 2016).

g) Pharmaceutical expenditure

Total pharmaceutical expenditure accounts for a growing proportion of total health expenditure in LAC, increasing from 17% in 2010 to a projected 33% in 2017. Per capita pharmaceutical expenditure in 2015 was calculated at nominal US$176 (US$ 264, adjusted by purchasing power parity), where 25% of the expenditure is covered by the public sector and the remaining 75% by private insurance and households (the latter, through direct payments). In 2010, total expenditure on pharmaceutical products came to US$ 9.4 billion, or 1.2% of GDP, and in 2015, US$ 16.7 billion, or 1.8% of GDP. This upward trend is expected to continue and reach 2.2% in 2017. The LAC countries are net importers of pharmaceutical products. Between 2010 and 2015, the share of pharmaceutical products in the global value of trade rose by 15%, from 1.2% to 1.38% of GDP.

Financing challenges for the countries

Increasing public investment: a priority need

Health financing in the Region is far from meeting the objectives set by the countries in 2014 when they adopted the strategy for universal health. In fact, as stated earlier, only a small group of countries has achieved public health expenditure of 6% of GDP (Figure 10), and direct expenditure in the Region accounts for 33% of total health expenditure.

Figure 10. Public health expenditure and out-of-pocket health expenditure in the Americas

Source: WHO, Global Health Expenditure Database and OECD Data (accessed June 2016).

Recent calculations show that the targets are unlikely to be met unless specific planned action is taken to increase fiscal space for health. In fact, if the rate of increase in public health expenditure of the past 20 years continues, it will take an average of 80 years to meet them (Table 2).

Table 2. Estimated year for reaching the benchmark of 6% of GDP, considering only economic growth

Country Initial public health expenditure Elasticity Gap Year
Cuba 8 · 19
United States 7 · 58
Canada 7 · 40
Costa Rica 8 · 05
Uruguay 6 · 14
Ecuador 3 · 94 2 · 90 2 · 06 2024
Nicaragua 4 · 49 1 · 56 1 · 51 2026
Brazil 4 · 66 1 · 68 1 · 34 2030
Colombia 5 · 18 1 · 22 0 · 82 2032
Barbados 4 · 14 2 · 68 1 · 86 2034
El Salvador 4 · 63 1 · 49 1 · 37 2039
Honduras 4 · 28 1 · 35 1 · 72 2040
Bolivia 4 · 75 1 · 22 1 · 25 2042
Saint Kitts and Nevis 2 · 30 1 · 94 3 · 70 2050
Suriname 3 · 24 1 · 42 2 · 76 2053
Chile 3 · 66 1 · 26 2 · 34 2068
Grenada 3 · 00 1 · 41 3 · 00 2083
Paraguay 3 · 46 1 · 16 2 · 54 After 2099
Guyana 4 · 30 1 · 08 1 · 70 After 2099
Antigua and Barbuda 3 · 14 1 · 14 2 · 86 After 2099
Belize 3 · 39 1 · 01 2 · 61 After 2099
Jamaica 3 · 38 <1 2 · 62 Never
Dominican Republic 2 · 82 <1 3 · 18 Never
Panama 4 · 93 <1 1 · 07 Never
Haiti 0 · 70 <1 5 · 30 Never
Argentina 4 · 92 <1 1 · 08 Never
Trinidad and Tobago 2 · 62 <1 3 · 38 Never
Peru 3 · 12 <1 2 · 88 Never
Venezuela 0 · 98 <1 5 · 02 Never
Guatemala 2 · 42 <1 3 · 58 Never
Bahamas 3 · 20 <1 2 · 80 Never
Saint Lucia 4 · 70 <1 1 · 30 Never
Dominica 4 · 20 <1 1 · 80 Never
Mexico 3 · 23 <1 2 · 77 Never
Saint Vincent and the Grenadines 4 · 30 <1 1 · 70 Never

Source: IMF/WHO and World Bank data.

This is because the increase in per capita public expenditure has historically been moderate, with relatively low elasticities in health expenditure with respect to economic growth (below 1 in many countries). Even the peak public health expenditure of 2009 was due to the impact of the economic crisis on the GDP of the countries of the Region and not to an absolute increase in that expenditure. However, although the average GDP growth rate would recover by 2010 and continue until 2014 (), the particular situations in the Region in response to the global crisis caused the decline in public health expenditure as a percentage of GDP to continue in several countries, as seen in Figure 11.

Figure 11. Trends in public health expenditure in the Americas, 1995-2014 (selected countries)

Source: The World Bank Data (accessed June 2016).

The calculations also show that reasonable modifications in some sources of fiscal space (such as taxes and efficiency levels) would accelerate progress (). In fact, a simulation in which the fiscal priority of health was at least 15%, like the figure established in the Abuja Declaration for the African countries, and some tax rates were equalized to the LAC average finds that 8 more countries would reach the target and raise expectations about another important group of nations.

Table 3. Changes in health investment simulating changes in the tax burden (exercise with 13 Latin American and Caribbean countries)

Countries Public expenditure in
health as a percentage
of GDP (2013)
Increase scenario (1) Increase scenario (2)
Bolivia 4.8 5.6 7.6
Honduras 4.3 4.30* 5.9
Nicaragua 4.5 6.2 5.8
Paraguay 3.5 S/D 5.1
Colombia 5.2 6.4 6.7
Ecuador 3.9 4.4 5.2
Peru 3.1 3.8 4.5
Argentina 4.9 5.3 5.3
Brazil 4.5 6.0 6.0
Chile 3.7 4.1 4.0
Barbados 4.1 S/D 4.7
Guyana 4.3 S/D 4.6
Jamaica 3.4 3.7 4.3
Countries reach 6%
or nearly (5,8%)
0 3 5
Percentage 0% 23.1% 38.5%

Source: PAHO from Collecting Taxes Database 2010/2011, BID-CIAT and CEPAL.
Scenario (1): current priority fiscal levels.
Scenario (2): fiscal priority of 15% of total public expenditure.

The economic context today is complex and makes the challenge more difficult. The majority of the LAC countries are experiencing zero growth (-0.5%, on average, in 2015, with projections of -0.8% in 2016) and fiscal contraction. Especially in South America, some countries, such as Argentina, Brazil, Ecuador, and Venezuela, will experience a significant drop in GDP (2.1% on average), and in the Caribbean, GDP in Suriname and Trinidad and Tobago will fall. Despite this somber picture, however, Central America and Mexico will grow at an average of nearly 2.6% ().

Notwithstanding, according to economic theory, fiscal policy should be countercyclical. Countercyclical policies generally cool the economy down when it is growing (covering the fiscal deficit) and stimulate it when there is a downturn (increasing government expenditure to attenuate economic and financial fluctuations). One component of these programs is countercyclical social policy, which includes health and education, as well as unemployment benefits and other social transfers. Several studies hold that countercyclical government spending has been essential for meeting long term economic and human development targets () and will surely be today to meet the United Nations Sustainable Development Goals adopted in 2015 with a 2030 horizon.

In spite of this consensus, there is evidence that in the low and lower-middle income countries, protecting public health investment and maintaining expenditure during crises has not been the norm. Indeed, the contraction of public expenditure, beginning with the social sectors, has unfortunately been routine. While this procyclical practice can attenuate economic fluctuations, it adversely affects State revenues, poverty levels, long-term growth, and human capital formation. As the facts show, the more advanced countries have historically favored countercyclical policy. In fact, Europe and Central Asia exhibited countercyclical behavior during the Asian crisis of 1997-1998 and up to 2007. After that, however, their behavior was procyclical. In LAC, procyclical behavior was generally seen in both periods ().

Due to cyclical nature of the economy, the health sector must be sustainable and resilient to the economic cycle, as it must in disasters and emergencies. Countercyclical policy is key to protecting the health of the population and mitigating the risks posed to households by illness and the impoverishment that may accompany it. Thus, reacting to the global crisis of 2008, WHO proposed several lines of work to the countries to mitigate the effects of these changes in the economic cycle (): (a) raise awareness about the ways in which the drop in GDP can affect health expenditure, health services, healthy behaviors, and medium- and long-term health outcomes; (b) protect investments in health; and (c) identify action, including the monitoring of troubling signs, to mitigate the adverse impact of the economic cycle.

Fiscal space for universal health

Since the 1950s, health has gone from being a residual explanatory factor in economic growth theories to having a place of its own among the main factors that spur productivity, growth, and poverty reduction. The WHO report of 2001 () was definitive. Its recommendations leave no room for doubt about the link between health and growth and promote the economic development of the world’s poorest countries through investment in health (). The arguments of the international agencies that backed the formulation of the Millennium Development Goals in 2000 and the Sustainable Development Goals today have also been supported in these recommendations. In 2013, the Lancet Commission report, Global Health 2035, once again emphasized this link (). Finally, the 2016 UN report on investing in the health workforce, co-sponsored by the Director of WHO together with the Presidents of France and South Africa, bases its findings on the association between health and economic growth ().

There are several historical examples of countries whose development was rapidly stimulated largely by the good health of their populations. Some authors maintain that this is what happened in the United Kingdom, the United States, and Japan (). Certainly, the countries with longer life expectancy in the 1960s grew faster in the next four decades (). Furthermore, in a study of 138 countries, Barro () showed that a 5-year increase in life expectancy was responsible for annual growth of 0.3 to 0.5 points from 1965 to 1990. The Sachs Commission’s estimates also showed that each 10-percentage-point increase in life expectancy is associated with an annual growth increase of no less than 0.3-0.4 percentage points. Several studies also demonstrate the inverse: that countries with high disease rates do not develop or they grow less.

PAHO has identified the following sources of fiscal space ():

  1. Creating conducive macroeconomic conditions.
  2. Greater prioritization for health.
  3. Creating new tax revenues through a greater tax burden.
  4. Increasing the efficiency of tax collection.
  5. External aid with loans and specific donations for the health sector.
  6. Increased efficiency in existing health expenditures.

Economic growth, the most direct and generic source of all, which is based on the assumption of economic stability, consists of creating fiscal space through GDP growth and a consequent increase in State revenues. Greater prioritization of health, in turn, implies an increase in public health expenditure at the expense of other sectors, such as defense or foreign affairs. On this point, PAHO’s analytical framework presents two ways of accomplishing this: first, by increasing the proportion of health expenditure in public social expenditure or total public expenditure; and the second, by increasing public social expenditure as a whole to prevent competition between health expenditure and other complementary budget lines for an “intersectoral approach” to universal health ().

In addition to providing resources, creating new revenues through a higher tax burden and taxation is positively correlated with better health indicators, as seen in the scientific literature (). In addition to the level of taxation, the tax structure is key to meeting the objective of increasing equity: systems based on indirect taxes (as in the majority of countries in the Region) tend to be more regressive (that is, they impose a greater burden on poorer households) than those in which direct taxes (on income or inheritance) have greater weight. Related to this, “increasing the efficiency of tax collection” means preventing tax evasion and avoidance and promoting formal economies. Here, it is worth calling attention to matters such as the granting of tax reductions or special exemptions from the general tax regulations (), which occurs when the regulations are waived for an agent, sector, or type of income, resulting in lower taxes than are levied on similar activities or income. Many such exemptions were created at specific times for specific purposes, but the need for them has not been reexamined. Finally, “external aid with loans and specific donations for the health sector” refers to two mechanisms: debt and donations. Based on the scientific literature, it is important to point out the macroeconomic implications of the former and the volatility and fragmentation of the latter.

Promoting greater fiscal space requires a broader social dialogue among all stakeholders. These decisions, which involve States, tend to be political and are based primarily on technical arguments. There are several ways of fostering this type of dialogue, for which technical studies are also essential. The PAHO studies of fiscal space — a regional study covering 14 countries () and three individual studies for Peru (), Honduras (), and Bolivia () — show the following:

  • The countries generally have fiscal space for health, and economic growth is not enough to fill that space and meet financing needs.
  • Additional fiscal revenue must be collected, using better methods.
  • Tax expenditures should be reviewed to identify exemptions that are unfair or not beneficial to the countries.
  • There are arguments and space for increasing specific health taxes (primarily on alcohol and tobacco). Although revenues are low in these cases, the projected savings to the system can be substantial.
  • From a policy standpoint, loans and donations are not a viable source of revenue for governments in the medium and long term.
  • Measures to boost efficiency should accompany these efforts, promoting the principles established in the strategy for universal access to health and universal health coverage.

Boosting efficiency: necessary, but not enough

From the financing standpoint, efficiency should be an objective in itself. However, it is also important to consider that it can be an additional source of fiscal space (since making better use of existing resources or combatting waste has the same effect as injecting new resources). Efficiency in the organization of services implies, among other things, the adoption of people- and community-centered models of care and the delivery of quality services by strengthening the first level of care and building integrated networks.

a) What is “efficiency in the health sector”?

Resource allocation in a health system is efficient when it achieves an optimal combination of morbidity and mortality reduction and greater financial protection for households that permits equitable access to the health services with given resources. In this case, the efforts are designed to yield what society needs and expects in terms of health and well-being—a task that involves both the State and society. The degree of productive and technical efficiency achieved will depend on how the health services are managed—or to put it another way, on obtaining the best response capacity through better coordination and linkage between levels of care and care networks. It is necessary for resource allocation to achieve a balance among the inputs used in the health sector (technical efficiency); and for technical efficiency to be transformed into productive efficiency, it is also necessary to meet the aforementioned objectives as fully as possible, given the existing resources. Dynamic efficiency, in turn, implies guaranteeing conditions and efficiency levels over time through innovation in the health systems in the broadest sense of the word ().

b) Payment systems to boost efficiency

Payment mechanisms must be aligned with system objectives. Thus, it is important to note that territorial and population-based payment systems—keeping in mind morbidity levels and combined with mixed-level payment mechanisms—are potentially effective regulatory mechanisms for meeting these objectives (). Aligning incentives with health system objectives to promote integrated care and comprehensive services, and putting emphasis on the first level of care are initiatives that can boost the efficiency of the system as a whole. Studies coincide in recommending the adoption of payment mechanisms with circumstantial margins of flexibility and empirically contrasted macro- and micro-allocation instruments. Territorial capitation and episode-based payment (also called bundled payment or case rates, as in diagnosis-related groups) are two examples of tools that can boost the efficiency of expenditure. Thus, capitation adjusted by territorial and population risk is a powerful regulatory tool already in use in several initiatives that makes it possible to align incentives with health-system and health objectives ().

There are known mechanisms for boosting efficiency in resource utilization, among them protocols for reducing clinical variability, centralized drug procurement systems, economic evaluation, and the evaluation of other aspects, such as safety and quality in the introduction of new technologies, programs to boost workforce efficiency and productivity, and the strengthening of disease prevention and health promotion. In this context, the measures with the greatest short-term impact are related to resource allocation mechanisms, including those involving drug procurement. For example, as a result of the financial crisis of 2008, the United Kingdom recently took steps to improve productivity and cost control, with various results. For example, from 2011 to 2013 the greatest savings in resources were obtained with measures involving changes in payment mechanisms and organized drug procurement ().

From 2010 to 2015, several countries in the Region, among them Brazil, El Salvador, and Ecuador, made progress in this regard, channeling most of the growth in expenditure to the first level of care to broaden access to these services and improve their quality. For cases like those of Chile, Mexico, Peru, and Uruguay, results based payment systems were also established (). The 2008 reform in 2008 in the latter country involved the expansion of coverage and pooling of social security and State funds to finance services to the beneficiaries of FONASA, the national health insurance program that currently covers more than 70% of the population. The risk-adjusted capitation payment system used in this fund also considers four targeted areas associated with preventive measures for pregnant women and older persons and the allocation of human resources. During this period, Peru launched a results-based payment system through a project implemented at the more general level of results—based budgets. Chile, in turn, introduced targets in the per capita transfer system in primary health care and is developing a hospital payment system based on diagnosis-related groups, aspiring to be the first country in LAC to employ this tool. Suriname currently uses a capitation system for first-level providers and payment per day and bed in the hospital setting.

c) Prioritization to equitably boost efficiency

Finally, it should be noted that the countries of the Region are increasingly adopting prioritization as a way of meeting health objectives through efficient and equitable resource allocation. This process takes different forms and involves different approaches; thus, we find processes related to the definition of the services offered and the use of positive lists of standardized services, lists of generic medicines, and the preparation of clinical treatment guidelines and protocols, in addition to health promotion, disease prevention, and the prioritization of first-level services to build strong systems based on primary care. The use of economic analysis in the health sector to evaluate cost-effectiveness and cost-utility in prioritization processes is also growing in the countries. In this context, efficiently increasing expenditure implies identifying specific action to prevent losses in health (as measured by indicators such as quality-adjusted life years [QALY]) to ensure that services reach the neediest beneficiaries based on their health deficits.

Improving financial protection through pooled funding

Increasing financial protection requires greater public expenditure, adopting efficient interventions primarily at the first level of care to boost response capacity and increase linkage among service networks. Increasing financial protection will reduce inequity in access. However, the replacement of direct payments should be done gradually through collective prepayment mechanisms involving different sources of financing, such as contributions to social security, taxes, and fiscal revenues. Thus, the main components of a financing system designed to offer financial protection to the population are the elimination or minimization of direct payments by households and the pooling of funds.

Pooled funds, in which the risk of disease and the need for health services are shared by a group of people through collectively financed prepayment mechanisms, is therefore key to financial protection. Sharing risk under any institutional arrangement implies the transfer of resources or a subsidy from healthy people to patients, as well as from young people to older people — basically, from people who are not using the health services at a particular moment to those who are. Moreover, for this financing to be solidarity-based, there should also be a subsidy, grounded in redistributive policies, from households with greater contributory capacity (the wealthiest) to those with fewer resources (the poorest), whose contributions are limited but whose health care needs tend to be greater.

There is no ideal number of people who should share risks, but the larger the fund, the greater the probability that all of these population groups will be covered. The existence of numerous small and fragmented funds hinders the cross-subsidies mentioned above, since it provides an incentive for risk selection: each fund will attempt to include people who are better off economically and in better health and exclude those with limited resources and more health problems. Smaller funds are more vulnerable to specific risks, such as illnesses that require more expensive treatment. This is why funds that cover a small number of people tend not to be economically viable in the long term ().

In the extreme case of an individual fund, such as health savings accounts (), in which the risk of disease is carried almost exclusively by one person, a costly episode of illness could lead to financial ruin. Furthermore, when the members of a fund share similar characteristics in terms of the social and environmental determinants of health to which they are exposed, the risk of health problems tends to be inefficiently diluted, implying a higher cost per person to treat episodes of illness than in funds that cover people with different characteristics. This is a powerful reason for advising against segmented funds for communities with limited resources.

The existence of numerous funds with their respective mechanisms for collecting and pooling resources and contracting services compromises the efficiency of the entire health system due to the administrative costs that it entails, as well as the cumulative superimposed transaction costs. Single large funds tend to be a more efficient type of organization than competing funds, as long as organizational and institutional incentives are adequate (). Economies of scale in the operation of these funds can generally be expected—not only in the collection and pooling of resources, but in the contracting of services for large numbers of people.

Pooled funds will contribute little to meeting the objective of equity if poor individuals and households must make a greater economic effort to finance them than the non poor. Flat contributions or fixed amounts that are equal for all are a highly regressive mechanism, since they represent a higher proportion of the income of poor households than non-poor households. In order to prevent this, contributions should be tied to the contributory capacity of households and individuals and should be progressive only when poor households must contribute a small percentage of their income. Moreover, solidarity-based risk sharing among a group of people means that the contribution to the fund must not be greater for those at higher risk of disease. Financially protecting households with young children, older persons, people with chronic diseases, and other groups likely to make greater use of the health services means not penalizing them with higher contributions.

Finally, in addition to increasing access to quality health services, financial protection is an important tool for fighting inequity and poverty, as it converges with policies for development and the social and economic protection of societies. In other words, it represents a specific contribution from the health sector to human development strategies.

Summary

The health financing situation in the Region is well defined. Public expenditure rose between 2010 and 2015 but did so very slowly, and out-of-pocket expenditure fell, but not fast enough. In this context, substantial progress was made in some cases, with sharp increases in public health expenditure in Uruguay, and sustainability of the goal in Canada, Costa Rica, Cuba, and the United States, all of which had met it earlier. Considering past levels of public expenditure, substantial increases are being observed in Bolivia, Ecuador, Nicaragua, and Peru, along with a clear trend toward the reduction of direct payments, as seen in Bolivia, Brazil, Colombia, El Salvador, and Peru. Tax policies could play an important role in enabling Bolivia, Brazil, Ecuador, and Nicaragua to reach the benchmark of 6% of GDP in the near future. However, health expenditure has not been accorded sufficient priority in many countries, even in the context of economic growth. Considering only the more populous countries in each subregion, this can be seen in Argentina, the Bahamas, Guatemala, Jamaica, Mexico, Panama, and Venezuela—countries with negative health expenditure elasticities with respect to GDP growth. Still, the countries report progress in terms of efficiency in the integration of care and the strengthening of primary care through different types of initiatives—in some cases with a high degree of success in their health indicators.

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Reference/Note:

1. According to WHO (), health financing functions consist of raising revenue, pooling it, and allocating economic resources (that is, spending). Revenue can be raised through taxation, contributions to the social security system, voluntary premiums, and direct payments. Pooling, in turn, involves collecting and managing resources to guarantee that the financial risk of losses stemming from an episode of illness is borne by all members of the common fund. Resource allocation, or spending, is the payment to health service providers, which includes the transfer of historic budgets to mixed payment mechanisms.

2. While this indicator is very important because it is a significant measurement of country efforts in health and because of its acceptance as a prerequisite and useful benchmark in the regional strategy for universal health, it cannot be interpreted in isolation, since individual variations can reflect movements within a country’s economic cycle (variations in GDP), for example, regardless of the resources allocated to the health sector.

3. By definition, insurance premiums (or any other form of prepayment) are not considered out-of-pocket expenditure; by convention, neither are the indirect costs associated with the use of services (transportation, meals, etc.).

4. European Union parameters are used as representative of the more advanced countries, even though development levels in some EU countries are considered similar to those of several countries in the Americas.

5. There is no absolute consensus regarding this threshold. For example, Wagstaff and van Dorslaer () examine threshold differences in the case of Vietnam. Knaul et al. () define a threshold of 30% of the non-subsistence expenditure or the total expenditure of a household once the international poverty line of US$ 1 per day is discounted.

6. PAHO. Estudio de gasto catastrófico y empobrecedor en salud en la Región de las Américas (forthcoming).

7. Cuba does not appear in the figure because it is not in the World Economic Outlook Database of the International Monetary Fund (IMF).

8. Simple average of the countries.

9. PAHO. Public and private expenditures on pharmaceutical products in Latin America and the Caribbean (unpublished).

10. Cid C, Matus M, Báscolo E. Fiscal space for health. Is economic growth enough for the Americas? Washington, D.C.: PAHO; September 2016 (unpublished).

11. Grossman’s human capital model () and Shultz’s human development model () laid the foundation for including health in neoclassical economic growth theories based on Solow (). In post-Keynesian theories, moreover, institutional distributive stimuli are critical for growth, in which equity is an important factor. Many economists, among them Nobel Prize winners such as Gary Becker and Amartya Sen, have also made important contributions-the former noting the importance of health in workforce productivity and the latter giving health a value in itself as a human capability.

Social determinants of health in the Americas

  • Introduction
  • Conceptual Foundation of the Social Determinants of Health
  • Setting the Scene
  • Core Regional Challenges
  • The Social Determinants of Health Approach to Core Regional Challenges
  • Advances Achieved in the Key Action Areas Identified by the Rio Declaration (2011)
  • Towards Sustainable Development
  • Conclusion
  • References
  • Full Article
Page 1 of 9

Introduction

The social determinants of health (SDH) are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (). These forces and systems include economic policies and systems, development agendas, social norms and policies, and political systems. These conditions can be highly inequitable and lead to differences in health outcomes. The experience of such conditions may simply be unavoidably different, in which case they are considered inequalities, or they may in fact be unnecessary and avoidable, in which case they are considered inequities and therefore appropriate targets for policies designed to increase equity.

In the Region of the Americas, evidence exists on how the SDH influence a wide range of health outcomes and efforts towards universal health, as reflected in both the development of the Millennium Development Goals (MDGs) and the ways in which they were pursued by countries. Analyzing these determinants is particularly relevant in the Americas, given that health inequity and health inequality continue to constitute the principle barriers to sustained development in the Region. Those living in the Region tend to be disproportionately affected by the poor conditions of daily life, which are shaped by structural and social factors (macroeconomics, ethnicity, cultural norms, income, education, occupation). These conditions and factors are responsible for pervasive and persistent health inequalities and inequities throughout the Americas.

The Pan American Health Organization’s Strategy for Universal Access to Health and Universal Health Coverage notes that recent improvements achieved in health throughout the Americas were due in part to advances in economic and social development of the countries, the consolidation of democratic processes, the strengthening of health systems, and the political commitment of countries to address the health needs of their populations (). The strategy recognizes that policies and interventions addressing the SDH and fostering the commitment of society as a whole to promote health and well-being, with an emphasis on groups in conditions of poverty and vulnerability, are essential requirements to advance toward universal access to health and universal health coverage. There is a clear need to continue efforts to overcome exclusion, inequity, and barriers to access and the timely use of comprehensive health services. Improved intersectoral action is required to impact policies, plans, legislation, regulations, and joint action beyond the health sector that address the SDH.

Conceptual foundation of the social determinants of health

The concept of the SDH incorporates a broad set of determinants extending beyond those that are only social in nature. The basic components of the SDH conceptual framework include (a) the socioeconomic and political context, (b) structural determinants, and (c) intermediary determinants (). Figure 1 outlines some of the key social, economic, cultural, and environmental aspects influencing health outcomes. Combined with individual behavior, genetic factors, and access to quality health care, these factors are thought to account for all, or virtually all, health outcomes (). It is critical to both distinguish between factors that mitigate risk concerning the extent to which they are modifiable–in other words, whether the differences in health outcomes they cause represent inequities or inequalities–and to consider the probable relationship between these factors and policies designed to influence them (). In considering the value, effectiveness, and appropriateness of policies in this regard, the SDHs offer the opportunity to position health as a public good, that is to say, having benefits for all of society that are not reduced by the marginal health gains of one individual but may in fact have exponentially positive effects on the health of other individuals ().

Figure 1.The social determinants of health conceptual framework

Source: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Geneva: World Health Organization; 2007. ().

The SDH approach is widely regarded as a highly effective means of addressing health inequities that promotes action across a range of factors that affect individual and population health outcomes, many of which are beyond the reach of the health sector. The approach has developed substantially over the past number of years, punctuated by two core calls to action. In 2005, the World Health Organization launched a Commission on the Social Determinants of Health (CSDH) and charged it with the responsibility of gathering evidence on inequities, as a way to understand the SDH and their impact on health equity, and issue recommendations for action (). The CSDH’s final report (2008) issued three recommendations for action: to improve daily living conditions; to tackle the inequitable distribution of money, power, and resources; and to measure and understand the problem and assess the impact of action (). The Rio Political Declaration on Social Determinants of Health (2011) also had substantial implications for this agenda in the Region. The Declaration emphasizes the need for an SDH approach and served as a call to action on interrelated principles addressing the SDH approach as well as broader, related concepts including equity and human development.

Clear emphasis has been placed on the importance of multisectoral action in addressing the SDH, the unacceptability of stark health inequities, and health as a human right. Grounded in equity, action on the SDH in the Region of the Americas requires recognition of the complex and often long-term causes of ill health and health inequity, through research in both social science and epidemiological disciplines. A growing body of evidence has led to intensified action across the global health spectrum with notable national-level engagement in the Region of the Americas. By addressing the fundamental “causes of the causes” of good and ill health, the SDH approach has the potential to remove some of the fundamental barriers that impact health and address some of most intractable health issues in the Region that are closely associated with dimensions of inequity, supporting the progressive transition towards universal health.

Setting the scene

The Region of the Americas has much to celebrate in terms of the progress in health over the past 5 years. As we reach the end of the era of the Millennium Development Goals (MDGs), it is valuable to briefly review progress made during this period in order to contextualize the current health landscape in the Region and address key areas where there is still much work to be done. Significant progress has been recorded in terms of reaching the health-related MDG, particularly in terms of overall levels of nutrition, life expectancy, poverty, under-5 mortality, HIV, malaria, and tuberculosis. Targeted efforts at the local, national, and regional levels in each of these areas have been facilitated by economic development, resulting, for example, in improved levels of nutrition and lower levels of associated child stunting.

At the same time, the review of progress made during this period combined with the assessment of the current health landscape in the Region highlights key areas where there is still much work to be done. Pursuit of the MDG contributed to improved outcomes in health for the Region; however, it also highlighted challenges with regard to equity of outcomes. While the achievements made during this time period can be lauded, other challenges have appeared in their place. In some areas, progress has stagnated. For example, despite reaching the MDG target of halving the rate of extreme poverty (), the reduction in rates in the Americas has slowed to a near halt in recent years (). This has severe implications for the Region as poverty has a direct impact on access to decent housing, services, education, transport, and other vital factors for overall health and well-being (). In fact, poverty is arguably the single largest determinant of health (). A recent publication from the World Bank Group on chronic poverty estimated that one in four people in Latin America and the Caribbean (LAC) are still living below the poverty line (). Compounding concerns over mobility, the United Nations Development Program (UNDP) estimates that over 200 million people in the Region subsist just above the poverty line of US$ 4 a day, outside of the middle classes not yet included in income classifications as poor (). These individuals are considered to be at high risk of falling into poverty should a financial crisis or natural disaster strike. This type of transient poverty (that is, poverty experienced as the result of a temporary fall in income or expenditure) generates variability and thus inequality in the poverty status of individuals ().

Additionally, the favorable trends that have been reflected in national and regional averages mask the gaps in progress that remain both within and between countries. A more nuanced look at the regional and national averages disaggregated by income and social strata reveals substantial gaps in equity between and within countries in the Region (). Most notably, in 2015, while the Region of the Americas had one of the highest reported average for life expectancy at birth (76.9) (), a closer look at country-specific data reveals that the difference in life expectancy at birth between countries was as great as 18 years (). The Region’s apparent success with regard to eradicating poverty also demonstrates the MDGs focus on national averages rather than on progress at subnational levels and across different population groups (). The Economic Commission for Latin America and the Caribbean (ECLAC) 2014 edition of Social Panorama of Latin America confirmed that not everyone in the Region has reaped the same benefits on this front as the downward trend in poverty over the last 15 years was greater among the wealthiest groups than among the most disadvantaged (). Many individuals categorized as chronically poor were unable to escape poverty during this time period. Labor income was a powerful driver behind the immense reduction in poverty over the last decade. The chronically poor face greater barriers to entering the labor force, reducing their opportunity for employment and exacerbating the cycle of chronic poverty. Poverty also continues to be concentrated within certain ethnic groups. In the Region of the Americas, indigenous peoples remain among the poorest and, in some areas, the income gap between them and other population groups has grown even wider ().

These findings highlight the concerns that programming to achieve the MDGs did not go far enough in terms of reaching less advantaged populations. Regional successes relate disproportionately to the “low-hanging fruit” of those already better served by public services. This paradox highlights the genuine limitations of the MDG-era achievements. While true success has been achieved in terms of global health indicators, many of these successes fall short when viewed through the equity lens.

Core regional challenges

Monitoring inequities and the factors that determine them is a challenge for existing information systems, requiring changes in the types of data the health sector collects. Information gathering entails choosing basic health indicators, stratifying criteria, and applying indices to measure both inequities and inequalities (). Conversely, it also offers the opportunity to measure multiple facets of health outcomes: who we are, how we live and die, and which events and circumstances play deciding or influential factors in determining these outcomes, at both the individual and population levels. Though numerous MDG targets were achieved, it must be noted that, almost universally, progress by wealthier, more privileged members of society exceeded that of the more disadvantaged. Furthermore, MDG targets that were not achieved indicate continuing Regional challenges in addressing health outcomes related to gender, sexual and reproductive health, communicable diseases, noncommunicable diseases, mental health, and access to care. This section examines the inequities and inequalities related to a sample of Region-specific issues in reproductive and maternal health, communicable and noncommunicable diseases, and mental health that will require more concerted action on the social determinants of health to improve health outcomes in these areas.

Reproductive and maternal health

The health of mothers can directly affect the health of their children. The cycle that is created from this dynamic potentially allows health inequalities to remain concentrated in certain populations for generations. While progress was made in terms of reducing the under-5 mortality rate during the MDGs era, on a global scale, maternal mortality remains incredibly high, reflecting the presence of inequities in access to health services, such as routine reproductive health care. A lack of access to basic services results in many unmet health care needs, such as contraceptive needs, unintended pregnancies, undiagnosed sexually transmitted infections, and undiagnosed cancers.

In order for barriers to be addressed and for progress to be made, it is imperative that social policies recognize the role of gender as a strong structural determinant of health. For example, women have higher health care costs than men due to their greater use of health care services. At the same time, women are more likely than men to be poor, unemployed, or engaged in work that does not provide health care benefits (). That said, gender alone does not account for all of the barriers women face in accessing care. Access to the necessary resources for health attainment is further restricted by the intersections between gender inequality and other important determinants of health such as income, education, age, ethnicity, and sexual orientation, leaving vulnerable populations at an especially high risk. For example, in Latin America and the Caribbean, women from the poorest quintile have greater unmet health needs, such as the need for contraception, compared to women from the wealthiest quintile (). Lower levels of income and ethnic background have been associated with early sexual initiation. Early sexual initiation is often associated with risks of both adolescent pregnancy among young women and adverse sexual health outcomes, such as sexually transmitted infections, thereby exposing less-advantaged populations to a double burden of infectious disease and barriers to women’s socioeconomic mobility (). Additionally, women in rural communities do not have equal access to convenient, affordable, or culturally appropriate reproductive health services and education. Women from racial/ethnic minorities frequently experience social and economic exclusion—yet another example of an unequal situation that produces health inequities at numerous moments throughout the life course, particularly during pregnancy and childbirth.

Within the Region of the Americas, reducing maternal mortality also remains a persistent challenge despite the fact that numerous Member States reported having adopted policies, programs, or plans for gender and health. This has troubling implications for the Region’s ability to meet the needs of women, despite the avowed political commitment. National and subnational inequalities in the maternal mortality rate are prominent (). Data from 2015 revealed stark differences between countries in the maternal mortality rate per 100,000 live births, with numerous countries reporting rates far below or far above the Regional average of 81 per 100,000 live births (Figure 2) (). These findings echo the point that has been made from a variety of Regional stakeholders, that the focus must remain on gaps in achievement of the MDGs, recognizing that however challenging the achievement of MDG targets was, there is still considerable work to be done to ensure that these targets are met on an equitable basis ().

Figure 2. Maternal mortality rate (per 100,000 live births), 2015

Source: World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank Group, United Nations Population Division.Trends in maternal mortality: 1990 to 2015. Geneva: WHO; 2015.
Available from: http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1.

Communicable diseases

The incidence of major infectious diseases has declined globally since 2000. Regardless, communicable diseases remain a prominent global challenge. For many years, the “big three” of HIV, tuberculosis, and malaria have overshadowed others, leading to the emergence of the “neglected diseases” category, also referred to as “neglected tropical diseases” (NTD). The SDG recognize NTD as a major global threat, with an estimated 1.7 billion people across 185 countries requiring treatment for NTD in 2014 (). The pressing concern of NTD, as well as other vector- and water-borne diseases, led to the adoption of the target 3.3 within the SDG, “by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.”

NTD encompass a group of pathologies that disproportionally impact resource-constrained areas of the world, subject to inadequate response systems, resources, and the ability to mitigate harm, in addition to the level of harmful environmental exposures. Numerous determinants affect the spread of communicable diseases. These determinants include, but are not limited to, water and sanitation, housing and population clustering, climate change, gender inequity, sociocultural factors, and poverty. The relationship between these determinants and health and equity is rather complex given that these determinants are often overlapping. For example, housing and population clustering can be viewed as an intermediary social determinant for NTD as it has direct links with poverty as a structural social determinant. It must be recognized that the spread of these diseases is often perpetuated by multiple environmental and social determinants coupled with a lack of resources for prevention and care, and due attention afforded to the issue by policymakers.

Noncommunicable diseases and mental health

Noncommunicable diseases (NCD) have been identified as a major challenge to sustainable development in the 21st century and are therefore central to the post-2015 development agenda (). The rise of NCD has been driven by primarily four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets. Efforts to address these risk factors have been met with numerous challenges, many of which are attributed to the prioritization of wealth over health by other sectors. There has been substantial growth in the provision of processed foods and products that are linked to higher levels of obesity, diabetes, and other diet-related chronic diseases ().

NCD represent a substantial disease burden in the Americas in terms of both mortality share and impact upon disability-adjusted life year (DALY) rates (). Looking at the proportional mortality in the Americas, the burden of NCD appears staggering, with the overall proportion of deaths attributed to NCD ranging from 60% to 89% (Figure 3) (). Moreover, not all social groups are affected by NCD in the same way. NCD risk factors are much higher among poor populations. In fact, substantial differences in DALYs across income levels exist in the Americas (). There is also a strong correlation between low education levels and high rates of NCD in low-, middle-, and high-income countries. Given this, there has been a shift towards interventions focused on risk factors and their related environmental, economic, social, and behavioral determinants. Additionally, differing characteristics of inequity and inequality within and between countries require country-specific contexts to be taken into consideration when addressing NCD. Changing demographics give cause for concern, as does the impact of increasing economic prosperity on individual health once a particular threshold is passed. For example, a 2016 study on socioeconomic status and health in adolescents found a positive correlation between socioeconomic status and sedentary behavior, which is associated with risk of NCD, suggesting that this group may respond to interventions that target this behavior (). In these cases, health does not always follow wealth, highlighting the complex nature of inequalities and the social determinants of health ().

Figure 3. Proportional mortality in the Americas by subregion, 2012

Source: Escamilla-Cejudo JA, Sanhueza A, Legetic B. The burden of noncommunicable diseases in the Americas and the social determinants of health. In: DCP3 Disease Control Priorities. Section 2: socioeconomic dimensions of the impact of NCD. 3rd ed. Seattle: Disease Control Priorities Network; 2013:13–22. ().

Mental health also has been inextricably linked to NCD and their outcomes. The prevalence and social distribution of mental health disorders has been well documented in high-income countries, but there is a growing recognition of the issue in low- and middle-income countries. Evidence suggests that social risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality, the higher the risk (). Accordingly, mental health disorders can be shaped by various social, economic, and physical environments () operating at different stages of life—not only in early life when there is a higher predisposition to develop a mental health disorder, but also at older ages, and during working and family-building years (). The impact of these social determinants on mental health can be accumulated over the life course (hence the importance of employing the “life course perspective” in considering fundamental causes of health and morbidity), increasing the severity of mental health disorders and/or the incidence of new ones.

Studies have shown that the more relevant SDH associated with mental health disorders include income, education level, gender, age, ethnicity, and geographic area of residence. For example, increased rates of depression and substance use are systematically associated with lower income levels (). The poor and disadvantaged suffer disproportionately from common mental disorders (depression, anxiety, suicide, etc.) and their adverse consequences (). In addition to household income, low educational attainment, material disadvantage, and unemployment are other factors leading to common mental disorders (). Gender is another important social determinant: certain mental health disorders are more prevalent in women than in men (), and, in fact, women frequently experience the impact of social, economic, and environmental determinants in different ways than men (). For example, women report more suicide attempts while men commit more fatal suicides (). Regarding substance abuse, though men are more likely to engage in risky behavior and develop drug-related problems, women suffering from addiction are less likely to seek treatment for substance abuse due to societal barriers in place ().

In the Region of the Americas, there is increasing interest in the relationship between working conditions and mental disorders, particularly depression and anxiety. Mental health disorders affect many employees in the Region, a fact that in the past has been overlooked because these disorders have tended to be hidden in the workplace. As a consequence, mental health disorders often go unrecognized and untreated, not only damaging an individual’s health and career but also reducing productivity at work ().

The social determinants of health approach to core Regional challenges

Given the close links between health equity and the underlying determinants of health, an integrated and systematic approach to address the underlying determinants of health is essential for reducing health inequities. The idea that health is created in the context of everyday life as opposed to being limited to health service-oriented settings was articulated in the 1986 Ottawa Charter for Health Promotion (). The Ottawa Charter drew strong links between the principles of health promotion and the SDH, both of which consider health to be an ecological phenomenon, created and modified by the wider system of factors that influence how individuals, as well as population groups, experience daily life and long-term trends throughout the life course. Taking into account the contextual determinants of health and health behaviors, a vigorous health promotion response is another essential component to addressing health challenges ().

Recently, health promotion in the Region has focused on the creation of healthy and supportive municipalities, workplaces, housing, schools, and universities. As part of this strategy, there has been a reactivation of the various health-promoting networks at the Regional level, namely Healthy Cities, Municipalities and Communities; Health-Promoting Universities; and Health-Promoting Schools. For example, while both Mexico and Cuba have maintained full coverage of Healthy Cities for over 20 years, numerous cities in the Region of the Americans have joined this movement in recent years. Prominent cities include Medellín, Cali, and Bogotá in Colombia; Curitiba, Guarulhos, and São Paulo in Brazil; La Granja, Chile; Cienfuegos, Cuba; and Buenos Aires, Argentina.

Building on the Declaration of Alma-Ata, the Ottawa Charter also highlighted the need for all sectors to invest in health and the need for the expansion of the concept of health determinants in order to “build healthy public policies.” Currently, a strategic approach to harness action across all sectors, known as Health in All Policies (HiAP), is being implemented in countries. The Helsinki Statement on Health in All Policies (2013), articulated HiAP as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve populations health and health equity” (). HiAP emerged from the increasing recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors. HiAP is known as the “operational arm” of the SDH approach precisely because many of the health inequities outlined have root causes in social, economic, structural, and environmental causes that do fall under the purview of sectors outside of health. In order to truly achieve equity in health, the “one size fits all” approach must be avoided. The various policy interests involved in the conditions that produce healthy (or unhealthy) outcomes require coordination, stewardship at the highest level of government, mutual appreciation for distinct priorities and capacities of different sectors, and skills in communication and negotiation that have not traditionally been part of the public health sphere. HiAP establishes a strategic approach that provides advocates and policy makers with guidance to address the “causes of the causes” of ill health and to develop intersectoral effective action.

In line with the Helsinki Statement, the HiAP approach promotes sustained collaboration among sectors whose policies and practices have significant influence on health outcomes such as those discussed (). It sets out concrete priorities and practices to support positive action on the SDH (). The approach has been well received in the Region of the Americas, the first WHO Region to establish a Regional Plan of Action on Health in All Policies (2014) (). The Regional Plan of Action on HiAP marks a significant milestone in the global acceptance of the HiAP approach to encourage collective and coordinated action for health. Progress since then in the Americas includes a series of guiding documentation and activity designed to support Member States in implementation, largely under the rubric of the aforementioned HiAP initiative and including the Road Map for the Plan of Action on Health in All Policies (), the creation of a Health in All Policies in the Sustainable Development Goals Task Force and Working Group, and the Commission on Equity and Health Inequalities in the Region of the Americas. Additionally, countries including Brazil, Chile, Mexico, and Suriname (see Box), have recently embarked on consolidating actions in this area through capacity building and planning that will ensure that health is firmly placed at the crux of national policy development and planning. Such action is being complemented by PAHO through the work of Commission on Equity and Health Inequalities in the Region of the Americas.

The Suriname experience—implementing health in all policies to address the social determinants of health

After hosting the subregion’s first HiAP training in Paramaribo, the government of Suriname began immediately moving towards implementation of the HiAP approach to address the social determinants of health. Under the leadership of the Ministry of Health and with support from PAHO, the Government of Suriname implemented a Quick Assessment of the Social Determinants of Health to understand the underlying causes of major health problems and associated health inequities. Results from the assessment of available data found that, in Suriname, the social determinants that are predominately related to the major diseases contributing to DALYS are geographical location, socioeconomic status, population group, and gender. These findings were used to establish eight country-specific areas of action for the implementation of HiAP. Suriname’s experience demonstrates the success of taking on a multisectoral approach to health and highlights the strong links between the social determinants of health and HiAP.

Source: Pan American Health Organization. Health in All Policies in the Americas. Health in All Policies approach: quick assessment of health inequities. [Internet]; 2015. Available from: http://saludentodaslaspoliticas.org/en/experiencia-amp.php?id=29.

Given the strong overlap of the goals, means, and priorities associated with the SDH approach, health promotion, and HiAP, progress made on one front has great potential to simultaneously advance the others. Additionally, the successful implementation of HiAP and health promotion throughout the Region demonstrates that the factors that affect health and well-being can be addressed through the establishment of sustainable public policies, the creation of intersectoral partnerships, the development of supportive environments, the active participation of local governments and communities, and the strengthening and sustainability of new and existing networks (). The focus on an inclusive and participatory approach and collaboration across sectors is echoed by the global community’s recent commitment to implement the 2030 Agenda and the Sustainable Development Goals (SDG).

Advances achieved in the key action areas identified by the Rio Declaration

Within the Americas, individual countries and Regional bodies have made considerable progress in implementing the SDH agenda. Practitioners, policymakers, and the public alike have been receptive to this equity-oriented approach, advancing a range of initiatives to address some of the gross health inequalities that feature nationally and regionally using SDH tools. The Rio Political Declaration on Social Determinants of Health continues to serve as a guiding principle for the successful implementation of the SDH approach. In line with the recommendations of the Commission on Social Determinants of Health (), the Rio Declaration established five key action areas on SDH at the global, national, and local levels (). These key areas optimize the potential of the approach to reduce inequities and achieve targets set by the Region and help build momentum within countries for the development of dedicated national action plans and strategies. Accordingly, a review of the advances and progress in addressing the SDH over the last 5 years, within the context of the Rio Declaration, is merited.

1. Key area: improve governance for health and development

Improving health means improving governance in health and development. The three main arguments supporting this assertion are as follows: (1) health is unevenly distributed, (2) many health determinants are dependent on political action, and (3) health is a critical dimension of human rights and citizenship (). Improved governance is therefore essential to advance human health and development. In this context, the term governance refers to the interaction between governments (including their different constituent sectors) and other social organizations, how governments and organizations relate to civil society, and how decisions are taken in a complex and globalized world ().

Improving governance for health and development and addressing the social determinants involves transparent and inclusive decision-making processes that give voice to all groups and sectors involved (). Actions within this area pertain to government structures and the development of social and environmental policies and programs that aim to reduce inequity in health. In order to provide guidance to countries, the following five principles of good governance have been identified to better address the SDH ():

  1. Legitimacy: Processes focused on the implementation of policies that impact the SDH must ensure legitimacy by providing a voice to all stakeholders involved, including those affected by the decisions.
  2. Direction: Work on the SDH requires a clear, strategic vision for promoting the SDH agenda.
  3. Performance: The mechanisms for decision-making on the SDH must be responsive to all stakeholders and encourage participation.
  4. Accountability: All actors must be held accountable for the decisions made in respect to the shared goals.
  5. Fairness: Decision-making should be fair and aim to reduce inequalities in health.

These principles demonstrate that effective governance requires a range of conditions, including the creation of conducive policy frameworks; accountability and ongoing participation of civil society and nontraditional partners; and emphasis on shared values, interests, and objectives among partners. Successful implementation of an SDH approach to improve health and well-being requires the establishment of governance mechanisms that delineate the individual and joint responsibilities of different actors and sectors in the pursuit of health and well-being.

A lack of coordination among different actors and conflicting interests can constitute a significant barrier to advancing development. This touches on another important concept, namely the commercial determinants of health, defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (). Historically, there has been criticism from the public health sector regarding the influence of the corporate sector on health and well-being. There are four main channels through which corporate influence is exerted: (1) marketing, (2) lobbying, (3) corporate social responsibility strategies, and (4) extensive supply chains. The focus on lifestyle choices has been extensively analyzed, particularly in regards to tobacco marketing and the marketing of unhealthy commodities towards children (). There is now a growing body of evidence to suggest that the tobacco, food, drink, and alcohol industries have on occasion employed tactics and strategies to undermine public health, and policymakers have faced difficulties to effectively mitigate against the impact of such strategies.

Action across all sectors—Regional approach to reducing traffic-related injuries and deaths

The Region’s progress in reducing traffic-related injuries and deaths is an example of collaboration and intersectoral action in practice. Intersectoral strategies include improving road infrastructure, updating transportation legislation, and promoting vehicle inspections and safety standards. Numerous countries within the Region have created national policies promoting sustainable and safe public transportation. Specific countries implementing safe transportation practices include Argentina, Cuba, Guatemala, Jamaica, Panama, Peru, and Uruguay. Additionally, 27 countries created road safety agencies between October 2011 and December 2014. Fifteen countries passed laws setting the blood alcohol limit for drivers, 32 countries approved laws making seatbelt use compulsory for all passengers in vehicles, and 30 countries passed laws on compulsory helmet use for all motorcycle passengers.

Source: Pan American Health Organization. Progress report on plan of action on road safety. 54th Directing Council of PAHO; 67th
Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 September 28-October 2 (CD54/INF/5)

An example of intersectoral action for health at work is Mexico’s National Agreement for Healthy Food (). This agreement is an intersectoral initiative to address the determinants of obesity, by regulating access to food and beverages and providing supportive environments for healthy lifestyles. The agreement received political support from the highest levels of the federal government, and has been implemented through several federal government agencies including finance, social development, education, economics, agriculture, rural development, workplace safety, and health. The program focuses on reducing inequity by giving particular attention to the prevalence of overweight and obesity in children, low-income populations, and indigenous communities. Under the agreement, the food and beverage industries were held accountable for their role in health outcomes, particularly those of children. The objective here was to work with the food and beverage industries to contribute to health more positively by incorporating health-promoting principles into their campaigns while at the same time limiting the marketing of unhealthy foods and beverages towards children. Since the program was first implemented, much progress has been made, particularly in terms of the regulation of media advertisements and the sale and distribution of unhealthy foods and beverages in schools ().

2. Key area: promote participation in policy-making and implementation

Successful action on the SDH requires the participation of communities and civil society groups in the creation of policies, and the monitoring and evaluation of their implementation. Civil society has a critical role to play in identifying priority areas for action, generating evidence for work on the SDH, and by holding policymakers and program implementers accountable for the actions they undertake and the commitments they make. Governments can play an active role in promoting participation by offering incentives, subsidizing costs, and ensuring legitimacy and transparency. Improving transparency in policy-making on the determinants of health is critical for the adoption and implementation of successful and inclusive policies.

A recent report from the World Bank and PAHO, Toward universal health coverage and equity in Latin America and the Caribbean evidence from selected countries, noted that governments have made progress in supporting and promoting the participation of civil society in the policy-making process (). Bolivia, Ecuador, and Venezuela, among other countries, have have inscribed social participation in their constitutions as a means of reducing social and economic inequality (). Additionally, as of 2014, nine countries and territories reported having specific mechanisms in place to engage communities and civil society in the policy development process across sectors.

Case Study: Ecuador’s National Plan of Good Living

Ecuador’s Plan nacional para el buen vivir (National Plan for Good Living, or NPGL) is an example of the successful involvement of civil society in policy-making and implementation. Ecuador’s countrywide action plan incorporates an SDH approach to health and policy and is committed to developing and implementing social policies. The plan was developed through consultation with diverse actors and recognizes citizen participation as a basic right. In order to identify specific needs within the policy, forums for dialogue were created to enable the participation of different groups, including women and men from different social-cultural backgrounds, of different ages and sexual orientation, to provide their opinion on the achievements of the previous National Development Plan. The feedback given was incorporated into the new plan. The NPGL consists of specific sectoral work plans consistent with national strategy and priorities, with one specific work plan being dedicated to health. The health sector work plan adopts the SDH approach and its goals are set through multiple sectors including health, education, and housing, among others. Ecuador’s NPGL serves as a concrete example of the successful use of the SDH approach in the development of new policies with the input and participation of citizens and different social groups.

Sources: National Secretariat of Planning and Development. Good living: a better life for everyone 2013–2017 [Internet]; 2013.
Available from:http://www.plani6cacion.gob.ec/wpcontent/
uploads/downloads/2013/12/Buen-Vivir-ingles-web-6nalcompleto.pdf.
.

Throughout the Region, efforts have also been made to engage previously excluded populations. As of 2014, 10 countries and territories reported having specific strategies in place to involve marginalized groups in policy discussions at the local, subnational, and national levels (). Actions are ongoing to promote mental health and well-being in indigenous populations. Indigenous populations are disproportionately affected by an array of common mental disorders. These groups have different ways of conceptualizing their health issues and of organizing care, as determined by historical, geographic, and cultural factors. Argentina, Brazil, Canada, and Chile, among others, have promoted fora for dialogue with the participation of indigenous practitioners, clinical health, public health, anthropology, and mental health specialists, where each of the actors share their knowledge and best practices spanning different indigenous communities.

3. Key area: further guide the health sector towards reducing health inequalities

Reducing health inequities and inequalities through transformation of the health system is core to PAHO’s Strategy for Universal Access to Health and Universal Health Coverage, adopted in 2014 (). The strategy expresses the commitment of PAHO Member States to strengthen health systems, expand access to comprehensive quality health services, provide financial protection, and adopt integrated, comprehensive policies to address the SDH and health inequities. It argues that “universal access to health and universal health coverage require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and provide a society-wide commitment to fostering health and well-being” (). The strategy makes the case that gender, ethnicity, age, and economic and social status are social determinants that have a positive or negative impact on health inequities, the reduction of which is a core objective of universal health.

In the Region, Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, Jamaica, Mexico, Peru, and Uruguay have implemented an array of policies to increase the scope and equity of health programs (). There has also been Regional progress in expanding health care services and resources to persons with disabilities. In October 2014, ministers of health throughout the Americas pledged to improve access to health and rehabilitation for people with disabilities and to safeguard their rights. To demonstrate this commitment, the Regional Plan of Action on Disabilities and Rehabilitation was approved by PAHO Member States in 2014. This plan calls for a stronger, more integrated health sector response in supporting persons with disabilities, their families, and caregivers. Countries that have demonstrated notable efforts towards a more integrated health sector response in supporting persons with disabilities, their families, and caregivers include Chile, Guyana, and Mexico ().

The strategies adopted by countries to transform the health system moving towards universal health are presented elsewhere in this chapter, specifically in the discussions relating to access to health services, improved health governance and stewardship, and health financing. Here, however, it is important to note that efforts to address health inequities, as they relate to the SDH, must vary depending on the context of the country, existing health inequities, and the structure of social and health systems. For example, in examining the health situation of women in La Paz, Bolivia, critical variations were found in several conditions: cancer (especially cervical-uterine cancer), maternal mortality, sexual and reproductive health, the impact of HIV/AIDS, and domestic and intrafamily violence. Women reported significantly lower health care coverage and minimal participation in the promotion and care of their own health. Evidence suggests that this was due to discrimination, mistreatment, and the lack of available services that address needs specific to women. The STAR Health Services initiative was developed by the health department in La Paz from 2004 to 2006 later focusing on the Pampahasi Bajo health services (). The initiative aimed to improve health conditions by strengthening the management of services, ensuring “quality with a focus on gender” and the development of processes that empower women in their community (primarily migrant Aymarans and those living in poor areas).

During the first phase of the initiative, gender considerations were successfully integrated into the primary health care framework. These adjustments included improvements in signs posted, the use of native language and curtains for privacy, easier scheduling,, more accessible and informative literature, the organization of health service teams, better treatment of patients, the monitoring of user satisfaction, and the development of a community education program that raised awareness and strengthened the respect for women’s health care rights. The initiative served to reestablish the role of the health team as an “agent of change” responsible for confronting gender-based issues and promoting gender sensitivity within the existing healthcare delivery system. It demonstrated the need for collaborative planning among health staff and community organizations to address differentiated needs and to respond appropriately to the inequities at hand.

4. Key area: strengthen global governance and collaboration

Ensuring political coherence requires action on the SDH both within countries and internationally. International collaboration towards the adoption of coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health is an important component in advancing an SDH approach. Reforming global governance for health is a necessary component for achieving global health with justice, as this goal requires international and domestic responsibilities that are centered on human rights (). For example, the Framework, was developed in response to the globalization of the tobacco epidemic to demonstrate the commitment of all countries to combating this health crisis. Thirty countries in the Region of the Americas are State Parties to the Convention (). Brazil was one of the first signatories of the WHO Framework Convention on Tobacco Control, and created an intersectoral commission called the National Commission for the Implementation of the Framework Convention on Tobacco Control and its Protocols. Tasked with developing and implementing policies to reduce tobacco consumption, 18 different governmental sectors collaborated to produce the National Policy for Tobacco Control (). They also passed other legislative changes to regulate tobacco product costs and marketing, and even to provide technical and financial support for small-scale tobacco farmers to diversify their crop production.

Some more recent prominent international conferences that address health and development include the Third International Conference on Financing for Development, the 2015 UN Summit (during which the Sustainable Development Goals were adopted), the 2015 UN Climate Change Conference, and the Seventh World Urban Forum, to name a few. These conferences have considered including commitments for advancing global health and its determinants (). For example, the Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects of climate change on health.

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The Paris Agreement for Climate Action: a global commitment

The Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects climate change has on health. The Paris Agreement is a global initiative to protect population health from harmful and unhealthy products and environments. In 2016, 31 PAHO Member States signed the Paris Agreement, including Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Canada, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, El Salvador, Granada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, the United States of America, Uruguay, and Venezuela.

Sources: UN Climate Change Newsroom. Paris Agreement signature ceremony [Internet]; 2015. Available from: http://newsroom.unfccc.int/media/632121/list-of-representatives-to-high-level-signature-ceremony.pdf. United Nations. Paris Agreement-status of ratification [Internet]; 2016. Available from: http://unfccc.int/paris_agreement/items/9444.php.

5. Key area: monitor progress and increase accountability

It is imperative that the implementation of policies that address the SDH be informed by evidence. The availability of data, or lack thereof, adversely impacts decision-making in policy development and public health action, and in shaping what research can or will be done. Building the evidence base for intersectoral action that addresses the SDH will be necessary to improve our understanding of populations that experience the greatest levels of inequality, and the interventions that are required to address inequities and disparities. This is particularly relevant for many low- and middle-income countries where there are significant limitations in the available data, namely, disaggregated data for socioeconomic status, ethnicity, and education levels as well as other important health determinants ().

As a result of the priorities established in the MDG agenda, there is a greater preponderance of data related to reproductive, maternal, and child health, allowing for a more detailed analysis of socioeconomic inequalities in these areas. However, countries are now being tasked with meeting SDG 17, which specifically calls for the “availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts.” The need to address this challenge is of particular relevance when developing monitoring mechanisms for SDG 3, to ensure healthy lives and promote well-being for all at all ages. The limited data associated with NCD as well as measures for universal health coverage means that countries will need to build capacity in assessing health inequalities as they relate to the SDH and these health priority areas. The Health Inequality Monitoring Framework developed by the WHO along with the Health Equity Monitor, as part of the Global Health Observatory, provides a guide and resource to countries when building monitoring capacity. Ensuring the comparability of data is essential for sharing successes and challenges when addressing health inequalities at the national level. The Region of the Americas has already taken action on this front through the inclusion of indicators measuring inequality in the 2014–2019 Strategic Plan of the Pan American Health Organization. Countries are responding to the challenge of generating disaggregated data by establishing observatories for the measurement of inequalities and health inequities. Already, Uruguay and Colombia have established national observatories that use the WHO Framework for monitoring inequalities, and Mexico is in the process of establishing its own health inequity monitoring system.

Monitoring the progress made during the MDG era has played an important role in identifying key areas for future action as well as core health issues that still remain to be addressed. The Region of the Americas has shown a strong commitment to identifying these key areas. Throughout the Region, countries have begun establishing national/regional networks of multisectoral working groups and stakeholders to evaluate the impact of government policies on health and health equity. As of 2014, six countries reported having these networks in place. Additionally, in May 2016, ECLAC presented a document, Horizons 2030: equality at the centre of sustainable development, which takes an in-depth look at the key challenges and opportunities for implementation of this approach in the Region (). The Member States of ECLAC also recently adopted resolution 700(XXXVI) establishing the Forum of the Countries of Latin America and the Caribbean on Sustainable Development, a body responsible for monitoring and reporting on implementation of the wider 2030 Agenda. A series of priorities has been articulated by ECLAC to support this approach, which both strengthens and reinforces the connections between the SDH, equality, and sustainable development, namely, strengthening the regional institutional architecture, enhancing analysis of the means of implementation of the 2030 Agenda at the Regional level, supporting the integration of the SDG into national development plans and budgets, and promoting the integration of the measurement processes to build SDG indicators into national and regional strategies for the development of statistics and statistics capacity (). Several of these components—particularly strengthening statistics capacity at the country level, which facilitates examination of the population groups benefiting most and least from certain policies and interventions—have profound implications for achieving equity and improving health.

Additionally, monitoring and surveillance systems have been identified as key to guiding the adoption of new programs and policies. Given the varying national contexts within the Region, programming must be sensitive to the landscape of social determinants within each country. Therefore, country-specific programming is required as opposed to a broad-brush Regional approach. A number of new surveillance initiatives have been developed in order to better understand the arising health needs that vary within and between countries. In 2013, UN-Habitat introduced a measure for prosperity, the City Prosperity Index, with the intention of helping decision-makers design appropriate policy interventions (). Since its creation, the City Prosperity Index has been applied in numerous cities in the Region, including Buenos Aires, Ciudad Obregón, Fortaleza, Guadalajara, Guayaquil, Guatemala City, Lima, Medellín, Mexico City, Montreal, New York, Panama City, Quito, São Paulo, and Toronto. Moving forward, the relationships between health outcomes and social stratification variables must be clearly established, and developing accountability mechanisms in policy-making will be essential.

Towards sustainable development

The 2030 Agenda for Sustainable Development named eradicating poverty, in all forms and dimensions, as one of the greatest challenges facing humanity as well as a core component to achieving sustainable development (). The 2030 Agenda and the 17 SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the population. Poverty is explicitly highlighted in Goal 1 of the SDGs, which calls for an end to poverty by 2030 (). Achieving this goal entails targeting the most vulnerable populations through poverty-reduction strategies. These strategies involve the development and use of cross-sectoral development frameworks that tackle the cause and effect of poverty in a country (). Based on the broad consensus of leading development agencies, successful poverty-reduction strategies must be results oriented, comprehensive, country specific, participatory, collaborative, and long term (). In the Region, a large number of countries have expanded coverage and noncontributory benefits to specific populations through poverty reduction strategies in the form of special plans and programs. In several countries, these programs have contributed to reducing poverty and extreme poverty, particularly in rural areas.

Conditional cash transfers (CCT), which are programs through which cash can be transferred to families in extreme poverty, have been recognized as evidence-based mechanisms for both reducing poverty and improving health. These programs also serve as important contributors to human development and social protection. CCT programs have a long-standing history throughout the Region. From the earliest transfer programs in the mid- to late 1990s in Mexico to the Federal District in Brazil, practically every country within the Region has deployed these types of programs. Positive outcomes are evident in significant, albeit modest, improvements in school enrollment, education outcomes, and overall early childhood development. Progress in health has been demonstrated across several indicators including infant mortality, maternal health, immunization, access to nutritious food, and quality of services accessed. As poverty often manifests itself in the form of hunger and malnutrition, the success of these interventions in regards to food and nutrition are particularly relevant for vulnerable groups and those living in extreme poverty. That said, contextual goals and benchmarks that respond appropriately to domestic priorities are critical to this process (). It is worth noting that the greatest advances in these trends have occurred in countries with modest welfare gaps such as Argentina, Brazil, Chile, Uruguay, and, to a lesser extent, Panama. However, Ecuador, Bolivia, El Salvador, and, to a lesser extent, Mexico, have positively escaped this generalization as these countries have enacted successful initiatives despite having very low fiscal commitment. As both poverty and growing inequality are detrimental to economic growth and undermine social cohesion, practical solutions such as these that pertain to the common challenges of human development will be crucial moving forward.

Conditional cash transfers: improving outcomes for the most vulnerable

The effects of poverty are particularly harmful in vulnerable populations such as infants and children. Many CCTs have therefore set their focus on maternal and child health. For example, Juntos (“Together”), a cash-transfer program in Peru, aims to lift children out of poverty and improve their education, health, and nutrition. While the program appeared to lead to modest improvements in school enrollment (a 4% increase), a recent evaluation found that Juntos has mitigated the problem of extreme chronic malnutrition among its child participants. The program has also successfully enhanced access to resources and services. Since 2012, Juntos has been managed by the Ministry of Social Development and Inclusion, in coordination with various ministries in charge of social affairs. This cooperation across sectors opened access to the variety of public services offered by each individual ministry.

The Uruguay Grows with You program outlines another platform for success, which runs highly focused activities targeting the most vulnerable citizens. The impact on those enrolled has been substantial thus far, reducing the level of depression in mothers and pregnant women from 31% to 16% since 2012. Other actions include the inclusion in social safety nets, such as family allowances and housing programs, and the construction of inclusive policies. The latter is especially important as the development of inclusive policies helps promote economic opportunities for the poor.

Both in Uruguay and Peru, contextual implementation was key, yet in each case, and elsewhere in the Region, integrating different institutional sectors into an overall strategy has allowed policymakers to create all-encompassing strategies to combat poverty in novel and effective manners.

Conclusion

As the Region transitions from the MDGs into the new 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs), addressing health inequities must be seen as priority. It is important to benefit from the lessons learned and address unfinished business through the new development agenda (). This new Agenda is the product of an unprecedented inclusive and collaborative process and is unique in that it integrates all three dimensions of sustainable development (economic, social, and environmental) around people, the planet, prosperity, peace, and partnership. The targets set by the SDGs seek to go beyond the scope of MDGs while addressing the most important social, economic, environmental, and governance challenges of our time. The SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the world’s population (). The implementation of the SDGs provides a unique opportunity to address the “causes of the causes” and shape health outcomes through a stronger focus on the differential distribution in access to health services. Whereas traditional approaches to public health and health promotion addressing risk factors centered around individual “risky” behavior remain relevant, increasingly (regionally and globally) attention is shifting to examine macroscale processes involving trade, global markets, and geopolitical relationships as determinants of health (). Surveillance systems will need to be enhanced for the wider social monitoring of the goals of SDH, the SDGs, and HiAP.

The Strategy for Universal Access to Health and Universal Health Coverage constitutes a call for action, for the health sector to progressively expand integrated quality health services, and beyond the health sector, in the implementation of health policies, plans, and programs that are equitable and efficient and that respect the differentiated needs of the population. Health is a key component of sustainable human development, and universal access to health and universal health coverage are essential for the achievement of better health outcomes in order to ensure healthy life and promote the well-being of all.

As countries continue to develop people-centered, robust, and resilient health systems, efforts must continue to intensify intersectoral action focusing on areas outside of the health sector to improve equity, health, and well-being, in accordance with the 2030 Agenda, for Sustainable Development and the Sustainable Development Goals and the SDGs. The breadth and ambition of the 2030 Agenda for Sustainable Development, and the interlinked nature of the 17 SDGs, require a national, regional, and global response that harnesses cooperative action across sectors. From the education of women and girls to taxation of nonnutritious foods, from healthy living spaces to health financing, universal health will only be achieved through a concerted effort to address the social determinants of health, and the development of key strategic partnerships involving actors well outside of the health sector.

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Reference/Note:

Access to comprehensive, equitable, and quality health services

  • Introduction
  • Expanding equitable access to comprehensive, quality services
  • Transforming the organization and management of health services through the development of health care models that focus on people and communities
  • Moving towards the design of comprehensive, quality, universal, and progressively expanded health services
  • Prioritizing investment in the first level of care
  • Increasing employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas
  • Improving the availability and rational use of the medicines (including vaccines) and other health technologies
  • Facilitating the empowerment of people and communities so that they are more knowledgeable about their health situation and their rights and obligations and can make informed decisions about their health
  • Conclusions
  • References
  • Full Article
Page 1 of 10

Introduction

The Region of the Americas remains one of the most inequitable regions in the world, with millions of people lacking access to comprehensive health services ().

The data for the Region indicate that between 2013 and 2014 more than 1.2 million deaths could have been prevented if health systems had offered accessible and timely services of good quality. Moreover, data for Argentina, Brazil, Colombia, and Peru show limited use of preventive health services, with only 15% to 21% of the population reporting at least one preventive care visit per year. The percentage is even smaller among the populations in the lowest income quintiles ().

The people most affected by lack of universal access to health and universal health coverage are those who live in conditions of greatest vulnerability. There continue to be differences between the poorest and richest populations in access to the health services needed to reduce maternal and child mortality and morbidity, and these inequalities have slowed the Region’s progress (). Data on economic inequalities in the coverage of maternal and child health services for Bolivia, Colombia, the Dominican Republic, Haiti, and Peru show that sizeable gaps continue to exist. In Peru, for example, the coverage rate for these services remains much lower for the poorest women, among whom the percentage who give birth in a health care institution is 69%, compared with 99% among the wealthiest women ().

Health care models in the countries of the Region often fail to adequately address the differentiated health needs of individuals and communities. Segmentation and fragmentation of health services, which exist in the majority of the countries of the Region, exacerbate difficulties in access to comprehensive, quality services, and low response capacity at the first level of care and result in inefficiencies. The available data indicate that only half of persons with noncommunicable chronic diseases are diagnosed and that only half of those who are diagnosed receive treatment, which is effective in only 1 of 10 cases (). The rate of hospitalization for conditions that could be managed in an outpatient setting is an indicator that reflects response capacity at the first level of care. Between 2001 and 2009, the hospitalization rate for such conditions in countries of the Region, including Argentina, Colombia, Costa Rica, Ecuador, Mexico, and Paraguay, ranged from 10.8% to 21.6%. Of these conditions, gastrointestinal infections accounted for the largest proportion of hospitalizations in Argentina, Ecuador, and Paraguay (33%, 27%, and 22%, respectively, of all reported cases of avoidable hospitalization). Most maternal deaths in the Region could also be prevented by delivering quality maternal health care services during pregnancy, childbirth, and the postpartum period. Approximately 81% of the maternal deaths in the Americas are attributable to direct causes, including hypertension, hemorrhage, abortion, and sepsis ().

The possibilities for expanding access by strengthening the first level through a primary health care (PHC) approach are hindered by differences in the availability and quality of human resources for health and the composition of the health workforce. For example, 10 countries of the Region have an absolute health worker deficit (fewer than 25 physicians and nurses per 10,000 population) or show severe inequalities between urban and rural areas in availability, which compounds access problems (). Countries such as Bolivia, El Salvador, Panama, Paraguay, and Peru continued to face challenges in both the availability and the distribution of health personnel in 2012 and 2013. Data from some countries in the Region, including Bolivia, Canada, Panama, and the United States, indicate that the availability of physicians in urban areas is as much as 80 percentage points greater than in rural areas ().

Other key challenges that the Region faces in expanding equitable access to health services are related to access to and rational use of medicines and health technologies. Progress in this area is very much influenced by lack of adequate financing and inefficient use of resources. Insufficient access to care and the existence of financial barriers are among the main causes of this problem ().

Barriers to access, exclusion, and changing needs are major challenges for health systems, which the reform and transformation processes undertaken in recent decades have not yet been able to fully surmount. In response to these problems, the Strategy for Universal Access to Health and Universal Health Coverage highlights the urgent need to expand equitable access to comprehensive, quality services in the Region (). Its first strategic line identifies the following key elements to guide the changes needed in the organization and management of health services in order to move towards universal health:

  • Strengthen or transform the organization and management of health services through integrated health services networks.
  • Move toward designing comprehensive, quality, universal, and progressively expanded health services.
  • Increase investment in the first level of care, as appropriate, in order to improve response capacity.
  • Increase employment options, especially at the first level of care.
  • Improve the availability and rational use of medicines (including vaccines) and other health technologies.
  • Facilitate the empowerment of people and communities.

This section describes the basic elements and orientations of each key area, as well as the progress made and the challenges for implementation.

Expanding equitable access to comprehensive, quality services

The available data show some significant improvements, although results vary from country to country. A comparison of data on health insurance coverage, use of preventive services, and barriers to access to health services for Chile, Colombia, Mexico, Peru, and the United States reveals gains in health service coverage and access in most of these countries of the Region, together with reductions in inequalities between income quintiles. Between 2014 and 2015, the level of health insurance coverage was quite high for these countries, with averages of approximately 98% in Chile, 95% in Colombia, 86% in the United States, 80% in Mexico, and 73% in Peru. Despite these high average percentages, however, insurance coverage among the poorest households was much lower than among the wealthiest ones, especially in the United States (–14 points) and Peru (-12 points). More importantly, these high insurance coverage levels did not always coincide with levels of health service use or with the percentage of households reporting access barriers, which demonstrates once again that coverage, particularly insurance coverage, does not in and of itself ensure access to services. For example, data on use of preventive care services between 2011 and 2015 show varying percentages of use among the five countries, with national averages of 98% in the United States, 75% in Colombia, 76% in Mexico, 24% in Chile, and 15% in Peru. Colombia and Mexico showed the greatest progress, with increases, respectively, from 60% to 75% between 2010 and 2015 and from 73% to 76% between 2012 and 2014. In Colombia, Mexico, and Peru, the use of preventive services was lower among the population in the lowest income quintiles. These inequalities were even more evident in Colombia, where the gap between the richest and the poorest households was almost 20 percentage points in 2015. In Chile, an inverse relationship was observed, while in the United States there was no clear pattern of disaggregation. The data for Canada, Colombia, and Peru also show marked geographic inequalities in the use of preventive services, with no noticeable improvements between 2005 to 2015. In 2015, the use of preventive services varied between 44.4% and 81.3% across the geographic subdivisions of Canada, between 17.45% and 83.49% in Colombia, and between 0.4% and 6.5% in Peru. With regard to the percentage of households that reported access barriers, the average between 2014 and 2015 was 37% in Peru, 19.9% in Mexico, 6.8% in Chile, 2.3% in Colombia, and 1.9% in the United States. The proportion of households that reported barriers was markedly higher among poorer households than among richer ones in Peru and Mexico, in particular. It is worth noting that inequalities have declined in the majority of these countries for all the indicators analyzed.

In contrast with the situation of preventive care, the majority of the countries in the Region have achieved universal coverage (100%) or near universal coverage (≥93%) of maternal and child health services (). Data disaggregated by income quintile for Bolivia, Colombia, the Dominican Republic, Haiti, and Peru show a downward trend in inequalities, although differences between the poor and the rich persist. For example, in Peru the difference in maternal care coverage among women in the highest income quintile and those in the lowest income quintile shrank from 60 to 12.8 percentage points for prenatal visits and from 80 to 30 percentage points for institutional births (). Nevertheless, the coverage of these services continues to be much lower among the poorest women. In Peru in the period 2005–2015, 69% of the poorest women gave birth in a health care institution, compared with 99% of the wealthiest women ().

As for access to immunization, major improvements have been recorded. The majority of countries have vaccination coverage rates of 93% to 100% for the diphtheria/pertussis/tetanus triple vaccine (DPT), with the exception of Ecuador, Guatemala, Haiti, and Panama, which have less than 80% coverage. Data on inequalities for Bolivia, the Dominican Republic, and Haiti show not only an increase in overall DPT vaccination coverage per year, but an even larger taking place in the poorest segments of the population, which is indicative of an improvement in equity of access ().

Data on the percentage of the population reporting barriers to health service access show marked geographic inequalities and limited improvements over time. In 2013, 16.9% of the population in Canada reported barriers to health service access, compared with 16% in 2005. The variation between geographic subdivisions was 11.48% to 20.6%. In Peru, it was 1.9% to 29.8% in 2015, while in Colombia, 11.5% of the population reported economic access barriers in 2011, compared with 42.3% in 2007. Data from the United States indicate that from 2010 to 2014 there was a reduction of 10% to 20% in the number of adults (19-64 years of age) who reported not having access to medical care because of its cost (). Data for the Region of the Americas indicate that avoidable mortality declined between 2010 and 2014 in Anguilla, Belize, Brazil, Costa Rica, Ecuador, Monserrat, Paraguay, Peru, and Suriname, although there were significant differences between countries.

Transforming the organization and management of health services through the development of health care models that focus on people and communities

The model of care provides the strategic orientation and general features of the organization of a health system, the purpose of which is to meet the needs of individuals, families, and communities. The model of care finds expression in several dimensions: the specification of what health services and benefits are guaranteed (the what), the way in which services are organized and managed in order to provide care (the how and where), and how the resources to finance the services are allocated. Accordingly, the model of care brings together the functions of the health system (Figure 1). It also incorporates the life-course, gender, human-rights, ethnic, and intercultural perspectives, and it promotes active social participation and extramural and intersectoral action.

Figure 1.Functions of the health system and the model of care

Source: Pan American Health Organization. Versión preliminar del informe Expandiendo el Acceso Equitativo a los Servicios de Salud: recomendaciones para la implementación y la acción. Washington, D.C.: PAHO; 2015.

The countries of the Region have moved forward in the development of a model of care with these characteristics (Table 1) and are in various stages of implementing the model. Nevertheless, the majority of countries continued to a biomedical model that should be no longer used.

Table 1. Overview of health care models with ethnic and intercultural perspectives

Country Structure Model of care or of program Standards and technical guides Reported experiences
Bolivia Vice-Ministry within the Ministry of Health and Sports SAFCI Program – family, community, and intercultural health model Strategic guidelines for traditional medicine and interculturalism in health Experience of Potosí
Chile Indigenous Health Care and Interculturalism Unit Comprehensive family and community health care model with an intercultural component Standards that include appropriate equipment, architectural modifications, protocols for referral and coordination between traditional and conventional medicine practitioners Makewe and Nueva Imperial hospitals, Boroa Filulawen center
Ecuador National Directorate for Intercultural Health within the Ministry of Health Comprehensive family, community, and intercultural health care model Guidelines that encourage health promotion from the perspective of diverse world views, culturally appropriate services, and coordination between the health system and traditional and ancestral wisdom Guamaní health area
Guatemala Indigenous care unit within the Ministry of Health Inclusive health model Standards developed in keeping with the inclusive model, including referral and counter-referral between different practices Municipal district of Nahuala
Mexico Directorate of Traditional Medicine and Intercultural Development Health and Nutrition for Indigenous Populations national action program Intercultural integration policies, use of traditional medicine Program for comprehensive hospitals with traditional medicine in the State of Puebla, health units under the national program
Peru National Center for Intercultural Health (CENSI), National Institute of Health/ Ministry of Health Comprehensive family- and community-based health care model Guidelines for intercultural action, including cultural diversity, traditional medicine, and integration into the system Culturally sensitive maternity care experience in in Ayacucho

In order to move towards a people- and community-centered care model, the strategy calls for an increase in the response capacity of the first level of care within an integrated health services network (IHSN) based on the primary health care strategy ().

PAHO has outlined the essential attributes and the domains that should be taken into account when designing and implementing such a network. Moving to an IHSN means that the work of health service providers must be guided by health priorities. Regulation and governance mechanisms are also needed to ensure coordination among the providers in the network and balance and linkage among national and local authorities, civil society organizations active in the area in question, and the population served by the network (see Chapter 1, Topic 4, Stewardship and Governance) ().

If a network of services is to operate efficiently, the services must be organized in a particular way. Disease prevention and health promotion services should be emphasized and ambulatory health care services should be given preference over hospital services. The first level of care should include groups of service providers who work in interdisciplinary teams and are linked to other institutions that provide specialized hospital-based and ambulatory care services. The first level should also have the capacity to coordinate care for users of the network of services. Evidence indicates that services are increasingly being transferred from hospitals to specialized ambulatory care or community-based services. It will not be possible to set up efficient networks without making changes in how health care processes are designed and delivered. Special attention should be paid to changes in the organization and management of hospitals so that they contribute efficiently to the objectives of the network, since hospitals, although they serve small segments of the population, are necessary for the delivery of highly complex and specialized services. Hospitals also account for the highest proportion of spending within health systems and are the focus of public attention and political concern. Current trends suggest that hospitals that function within an integrated network tend to need fewer beds, will make more intensive use of technologies and human capacities, and will orient their activities more towards ambulatory care. At the same time, efficiency and clinical outcomes will improve if high-complexity centers are developed ().

The problems currently besetting hospitals (such as excess demand in emergency rooms and long waits for elective procedures) will only worsen if changes are not made in the design and operation of the network as a whole, especially if the response capacity of the first level of care is not increased. In other words, it is impossible to have an IHSN without hospitals, but hospitals will not be sustainable if they are not part of an IHSN.

Higher priority must be attached to health promotion and disease prevention services that are oriented towards the coproduction of health, with a strong focus on ambulatory care and the incorporation of intercultural and gender features. It is also necessary to create opportunities for intersectoral action in the community and, sometimes, to seek opportunities for synergy between public and private actors ().

In order to put in place an efficient network, it is necessary to ensure the availability of human resources, medicines and health technologies, financing and incentives aligned with the objectives of the network, and capacities for leadership and governance. These elements will be examined in this and the following sections.

Internationally, there is evidence of the importance of reorienting health care services as described above (). In the Region, the key strategies being applied in the transformation of health care models include: investing in primary health care centers, establishing family health, developing the workforce for primary and community-based health care, developing multidisciplinary teams in the community, establishing community outreach services, investing in specialized care for older persons (including support for home care), integrating mental health care into primary care, and promoting the use of new technologies to provide treatment and manage care in remote communities.

The extent to which care models have been reoriented and transformed varies, however, ranging from reorganization of the entire network of services (Box 1) to a shift designed to address specific problems or diseases (for example, care for persons with chronic diseases and older adults and mental health care – see Box 2) or strengthen the first level of care without an IHSN approach ().

Box 1. Development of Integrated Health and Social Service Centers in Quebec, Canada ()

The Province of Quebec, Canada, has been applying a long-term strategy to overcome fragmentation in the way health care is organized and provided across its 17 administrative regions. To that end, it has established a modality of care that formally integrates the financing and delivery of health and social services. In 2004, health sector reforms reorganized the model of care into 90 integrated health and social services centers (CISSS, from the French Centres intégrés de santé et de services sociaux) that provide services to specific local populations. The emphasis has been placed on accessibility and continuity of preventive care, as well as on curative services for groups in more vulnerable conditions.

CISSSs provide PHC-based health and social assistance services through “autonomous” family medicine groups. They encourage a multidisciplinary approach, enhancing the role of nurses and public health workers and empowering community groups, including citizens committees and representatives of the community. Among the principal interventions carried out are the following:

  • Partnerships of community nurses with hospital emergency rooms to monitor and manage frequent users in community environments in order to reduce hospital readmissions;
  • Investment in education and training in comprehensive care to support joint action and serve vulnerable groups in the community; and
  • Interdisciplinary teams comprising health and municipal government personnel to support older persons in their homes through an approach emphasizing independent living and adapted dwellings.

The key challenges identified for the development of new approaches to care in Quebec included population aging and related new health problems, increased inequalities between social classes, difficulties in controlling expenses, and political issues related to financing of long-term public health care. Integration proved problematic because of competition among professional groups and autonomous service providers. Lack of preventive care remains a deficiency in the way in which care is provided.

Key lessons for the future of integrated health and social services centers in Quebec include:

  • Expand the functions of nurses at the clinical and community levels.
  • Integrate other health professionals to support family doctors in the clinical environment.
  • Ensure monitoring of the delivery and quality of private medical care, especially for the elderly.
  • Increase citizen participation in the management and organization of first-level care centers, and the participation of users in planning.
  • Improve the integration of curative and preventive approaches in the practice of family medicine.

Box 2. Improving the quality of care for chronic diseases in the Caribbean (Anguilla, Antigua and Barbuda, Barbados, Belize, Grenada, Guyana, Jamaica, Saint Lucia, Suriname, and Trinidad and Tobago) ()

Demonstration projects using the chronic care model have been carried out across the Caribbean in 142 health centers, with the participation of 40,000 patients. The goal of these projects is to boost the capacity and skills of local health teams to better manage care for people with diabetes. The specific focus of these projects is to encourage the participation of patients, their families, and the community through the introduction of the PAHO Chronic Care Passport. The aim is to support education on the disease itself and on self-management. The preliminary results show reductions in glycosylated hemoglobin (HbA1c) levels, a substantial increase in the number of people who receive preventive care (for example, nutritional counseling and examination of feet and vision), and improvements in quality-of-care indicators.

One of the non-delegable responsibilities of the network of services is to ensure the quality of services. Quality is an inherent attribute of–and a requirement for–universal health. In order to achieve equitable access to comprehensive quality services, a systemic approach is required, spearheaded by the health authority in the exercise of health system stewardship (see Chapter 1, Topic 4, Stewardship and Governance). At the health services network level, interventions are aimed at ensuring responsive care that meets people’s needs and expectations. Numerous initiatives have been launched In the Region to ensure quality in the delivery of services (Table 2).

Table 2.Summary of initiatives to address quality in health systems

Country Support structure National policy Experience reported
Ecuador National Department for Quality Assurance of Health Services, National Agency for Quality of Health Services and Prepaid Medicine (ACESS) Development of a culture of quality; quality control of services; support for users of the system and assurance of effective operation of health services Plan for accreditation of 44 hospitals
El Salvador National Quality Management Unit of the Comprehensive and Integrated Health Services Networks (RIISS) RIISS quality management system Specialized pharmacy project
Honduras Quality management unit of the Ministry of Health Saving Lives with Quality program Reduction of neonatal deaths at Mario Catarino Rivas Hospital Implementation of safe surgery
Mexico General Directorate for Health Quality and Education National Strategy for the Consolidation of Quality in Health Care Establishments and Services Evaluation of the implementation of the Comprehensive Health Quality System (SICALIDAD)
Peru General Directorate for Quality in Health, National Health Authority Health quality management system Protection of health rights in Peru: experiences arising from the oversight role of the National Health Authority

Moving towards the design of comprehensive, quality, universal, and progressively expanded health services

Health systems should be capable of defining the benefits that are going to be made available to the populations they serve. In so doing, they should seek to build in a dynamic process of progressive expansion aimed at ensuring that an increasing number of health problems can be resolved through the incorporation of new knowledge and resources, involving and making more innovative and creative use of public, private, and social security resources to reduce fragmentation, facilitate economies of scale and ensure an integrated response. This definition of benefits is key in order to realize the aspiration of ensuring equitable access to comprehensive, quality, people- and community-centered health services ().

In order to move forward in this area, one of the most essential tasks is to decide on a method for prioritizing services and benefits. The objective is to offer communities and populations a specific set of services designed to improve their health and well-being ().

The question of how to prioritize services, and thus design basic national packages of health services and benefits, has been widely debated for many years in the Region of the Americas (). Historically, the debate has centered around the strategic purchase of health services through a continuous search for the best interventions. The countries of the Region are currently at different stages of the process of specifying health services and benefits; they also differ in terms of the way the right to health is formulated (see Table 3 and Boxes 3 and 4).

Table 3. Specification of services and benefits in selected countries of the Region of the Americas ()

Country Name of benefit package Year implemented Population covered (%) Relevant legislation Regulatory entity Quantity and type of services
Argentina Compulsory Medical Program (PMO) 1995 52% Acts 23660 and 23661 Department of Health Services, Ministry of Health All levels of care

Broad and explicit list

Some criteria for coverage

Brazil National List of Health Services and Activities (RENASES) 2011 100% Act 8080
Act 8142 on the Unified Health System (SUS)
Ministry of Health, Health councils (national, state, and municipal) Primary care services

Urgent and emergency services

Psychosocial services

Specialized health care services

Public health surveillance services

Chile Explicit Health Guarantees (GES) 2005 100% Act 19966
Act 18933
Health authority, Ministry of Health Free first-level services

Secondary and tertiary level services for 80 health problems to date

Coverage guides and medicines list

Guyana Guaranteed Package of Public Health Services 2008 100% Ministry of Health All levels of care Includes medicines list
Peru Essential Health Insurance Plan (PEAS) 2009 Workers covered by Social Security and by public insurance Act 29344 on Universal Insurance Health authority, Ministry of Health First, second, and third level with care for 50 health problems selected on the basis of the burden of disease
Uruguay Comprehensive Health Care Plan (PIAS) 2008 100% Decree 465/008 of 10/2008 National Health Board (JUNASA), Ministry of Public Health Comprehensive health programs and catalog of benefits:

  1. Medical care modalities
  2. Medical specialties, other professionals, and technical personnel for the management and the recovery of health
  3. Diagnostic procedures
  4. Therapeutic and rehabilitative procedures
  5. Oral health
  6. Medicines and vaccines
  7. Medical transportation

Adapted from: Leguiza Fondos J, et al. Análisis comparativo de conjuntos de prestaciones que brindan los sistemas de salud en las Américas y el Caribe. (Comparative analysis of packages of services provided by health systems in the Americas and the Caribbean). Washington, D.C.: PAHO; June 2012 (unpublished document).

Box 3. Development of a Comprehensive Health Services Plan in Uruguay ()

Uruguay’s Comprehensive Health Care Plan establishes overall guarantees for an integrated national health system and has sought to strengthen governance and the regulatory process. Launched in 2007, the Plan’s key innovation was the creation of a catalog that sets out an exhaustive list of benefits, including 1,600 technical procedures related to diagnosis and nearly 3,000 procedures related to therapy and rehabilitation, oral health, vaccines, medicines, and means of transportation. In 2008, the Plan was expanded through the addition of a set of existing public health programs, such as support for self-care.

The list is updated on the basis of scientific evidence and changes in prevailing epidemiological conditions, with support from a group of experts. A rigorous process is followed that involves examining a set of impact criteria and the evidence base and determining whether improvements are justified in terms of healing and better quality of life. After the list is developed, a working group classifies and considers the efficacy of treatment and places the interventions in priority categories.

The catalog laid a foundation for establishing contracts for management of the model of care with public and private providers (a first round in 2008 and a second in 2012), including sanctions in the event of non-performance. The National Fund (which is income tax-based) negotiates rates and incentives with a view to promoting universality of access and quality of care, with professional incentives linked to changes in the model of care and quality. Payments are results-oriented, which allows for greater technical and administrative autonomy and flexibility for providers.

The main challenge to the Plan’s success has been to ensure sustainable care that is distributed in a fair and ethical manner. The strategy for communicating with citizens has been essential in order to help people understand that a country has limited resources and has demonstrated transparency in the development of its system of guarantees. The main principles guiding implementation include: transparency in decision-making, promotion and communication of results, management of public and professional opinion, and social participation.

Box 4. Implementation of Explicit Health Guarantees (AUGE) in Chile ()

The AUGE reforms in the Chilean health system have sought to support the development of a more integrated health system and to overcome problems related to financing, in particular high levels of private financing, and segmentation in the delivery of services. The reforms include new insurance schemes for low-income people (FONASA, which covers 7%, and ISAPRE). FONASA is geared towards reducing premiums and developing healthier populations among the poorest groups, while ISAPRE focuses on the higher-income brackets.

The basic principle guiding AUGE has been the integration of public and private financing in order to create a service with explicit guarantees, comprehensive regulation, and stronger management that promotes integrated models of care through integrated public and private networks. It includes 56 guarantees aimed at addressing chronic diseases and population aging, with a focus on strengthening primary health care, in terms of access, equity, quality, and financial protection. The latter is important in order to prevent the package of benefits from becoming a regressive tax.

The process of developing the AUGE reforms was reportedly highly political, but it took account of external consultation processes by the Ministry of Health aimed at reaching agreement on the basis for guarantees and implementation to be applied progressively. As a result, there was a large increase in financial coverage for people with insurance.

Curiously, AUGE has been insufficiently utilized, as people have maintained dual coverage, and prices of the previous coverage have declined. AUGE has improved diagnosis and treatment times, but has also been associated with an increase in administrative bureaucracy. The successes reported include more timely care and some progress in changing the model of care to promote public health and address chronic diseases. Unexpected negative impacts include “patient poaching” by providers prompted by payment system incentives. These problems should be addressed by switching to payment of incentives based on episodes of care, perhaps in the form of bundled payments. Chile continues to grapple with problems of segmentation and inequality, but has made important progress in promoting citizens’ health rights.

Prioritizing investment in the first level of care

In order to expand access to health services, it is necessary to prioritize investment in services at the first level of care in order to boost their response capacity. To do this, new resources are needed in the majority of the countries of the Region. Funding for such investment cannot be obtained only by seeking efficiencies or reallocating resources from hospitals to the first level of care, since, generally speaking, spending on public health remains insufficient (see Chapter 1, Topic 5, Health Financing in the Americas). Although most countries lack information systems that would make it possible to measure the increase in investment at the first level in financial terms, in recent years several countries have made significant progress in the development of their first level of care, as is evident from the information in Table 4.

Table 4. Experiences in primary health care as a means of moving towards universal health

Country Model of care and management Composition of the health team Functions Levels of system management
Bolivia “My Health” program within the framework of the government policy on family, community, and intercultural health (SAFCI). Operates through local health centers and higher-complexity centers that come under the responsibility of municipal governments Physician, nurse, nursing auxiliary Medical care at the local health center, family visits, and social management Ministry of Health-regulation and oversight of the entire system
 
Departmental governments and health services and municipal governments, which are responsible for the first and second levels of care
Brazil The Unified Health System (SUS) of Brazil includes health activities and services provided by public federal, state and municipal agencies or institutions. Territorial teams serving 800 to 1,000 families: general practitioner or family medicine specialist, nurse and nursing auxiliary, community health workers, dentist and oral health assistant Prevent and control diseases, injuries, and health risks; expand access to health services and health promotion and disease prevention interventions; management of health determinants; and strengthening management of the SUS at all levels of government Three levels of government (federal, state and municipal)
 
Complementary participation by private enterprise recognized
Costa Rica Costa Rican Social Security Fund (CCSS), public health insurance that includes comprehensive medical care, cash benefits and social services provided by decentralized institutions. The Ministry of Health oversees the performance of the essential public health functions and exercises sectoral leadership. National Council of the Health Sector. Basic comprehensive health care teams, distributed across 103 health areas (3,500-7,000 inhabitants): general practitioner, nursing auxiliary, medical records assistant, and comprehensive health service technician Disease prevention and health promotion, recovery, and maintenance; care for prevalent and emerging health conditions Ministry of Health, Costa Rican Social Security Fund, and decentralized institutions: National Insurance Institute, Costa Rican Institute of Water Supply Systems and Sewerage Systems, Alcoholism and Drug Dependency Institute, Costa Rican Institute for Research and Teaching on Nutrition and Health, National Health Council
Cuba Family Doctor and Nurse model, oriented towards health promotion, prevention and curing of disease, and rehabilitation at all health care levels Basic health teams: physician and nurse responsible for the health of the population they serve Comprehensive health care; educational research, managerial, and environmental activities Centralized system under the Ministry of Health, linked with government entities at the national and local level: National Assembly, Council of State, Council of Ministers, assemblies at the municipal and provincial level
Ecuador Comprehensive care model of the National Family, Community, and Intercultural Health System (MAIS-FCI) Basic health care teams: physician, nurse, psychologist, dentist, and auxiliary Promotion, prevention, treatment, rehabilitation, and home visits Integrated, decentralized, territorial, and participatory management, with transfer of competencies and resources according to MAIS-FCI requirements
 
Intersectoral coordination, integrated action at territorial level
 
Government results-based management (RBM) tool
El Salvador Comprehensive Basic Health Systems (SIBASIs), with interventions by public and private providers Health promotion, disease prevention and cure, and rehabilitation, focused on the individual, the family, the community and the environment 380 community family health teams and 28 specialized teams in 53% of low-income municipalities Comprehensive health care, decentralized management, delivery, and financing of health services and social participation Three levels:

  • Highest: Ministry, regulatory entity
  • Regional: regional directorates (SIBASI technical and administrative level), resource management
  • Local: SIBASI operational network and hospitals
Nicaragua Family and Community Health Model (MOSAFC), with three components: service delivery, management, and financing
 
Health networks include three levels of care and comprise community, public, and private establishments
Family and community health teams: physician, nurse, nursing auxiliary, basic sanitation technicians, and community health workers Comprehensive and integrated approach to education, promotion, prevention, treatment, and rehabilitation with emphasis on vulnerable groups and a life-course approach to care These actions are carried out through a network approach, actively involving community agents such as midwives, community health workers, and family, community, and life councils

Increasing employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas

The expansion of equitable access to comprehensive, quality services in order to advance towards universal health requires significant changes in the management of human resources for health. A key element, as is noted in the strategy, is the expansion of employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas. This intervention should be accompanied by the development of interdisciplinary teams at the first level of care. Interdisciplinary teams are needed to promote innovation, community participation and the empowerment of people with regard to health, intersectoral work, and the adaptation of specific work contexts to the health needs and preferences of communities.

An overall shared mission is imperative, with broad common goals and responsibilities, regulations for quality and safety of care, a mechanism for merit-based recruiting and hiring, and comparable labor conditions. Part of this mission should be to ensure the delivery of a set of services and programs and the existence of standards, work processes, treatment protocols, a management and coordination model, and accountability mechanisms.

Various countries have launched initiatives aimed at addressing the challenge of human resources for universal health. For example, in Peru, candidates for public positions, admission to second professional specialization programs, and government fellowships for basic or advanced studies are required to serve in rural or marginalized urban areas under a Ministry of Health initiative known as SERUMS (Servicio Rural y Urbano Marginal de la Salud). The initiative has boosted the number of physicians working in rural areas from 2,500 in 1999 to almost 9,000 in 2013 (). In Brazil, the Mais Médicos program is an initiative designed to improve the coverage of physicians at the first level of care, especially in rural and other underserved areas. The program includes medium- and long-term planning policies aimed at reorienting undergraduate education, a compensation policy with special incentives (for both Brazilian and foreign physicians), and an international collaboration agreement with the Government of Cuba. Thanks to an influx of 14,000 additional physicians at the first level of care during 2013, the program has improved the availability of medical professionals in the most underserved areas, especially rural areas. In Chile, the Health Careers System for physicians includes a training phase of up to 9 years in which the professionals are required to work at the first level of care in order to qualify for later specialization. Chile also has a remuneration policy that encourages health workers to work in rural and underserved areas. This policy provides special supplements for personnel who work in isolated areas or areas with high cost of living, with hardship pay for personnel working in very isolated or remote locations or performing difficult jobs at the first level of care in vulnerable or geographically isolated areas (). Uruguay is implementing its National Rural Health Program, which addresses three critical needs: better access to health services for rural populations, access to comprehensive health services (provided by a highly trained and committed interdisciplinary team), and assurance of continuity of care throughout the health care process. This program has made it possible to improve access to health care for residents of rural areas through interdisciplinary care teams ().

Improving the availability and rational use of medicines (including vaccines) and other health technologies

The aim in seeking to improve equitable and sustainable access to medicines and other safe, effective, high-quality, and cost-effective essential health technologies is to prevent, alleviate, diagnose, and treat health disorders, all of which are vital to progress towards access to universal health in the Region.

Access to medicines can be facilitated through solid and holistic management of the supply chain. Such management should ensure the integrity of the chain and the timely availability of products. A critical area is demand forecasting. Efficient supply management should include good procurement mechanisms, since such mechanisms have a significant impact on price. Procurement methods that favor competition and concentrate the purchasing power of public funds tend to reduce prices. By pooling demand across the public sector, national joint purchasing mechanisms are improving the ability of the public sector to negotiate and secure better prices. Similar results have been observed when demand is pooled at the international level. The most noteworthy examples are PAHO’s Revolving Fund for Vaccine Procurement and Regional Revolving Fund for Strategic Public Health Supplies, also known as the Strategic Fund. In 2016, 30 countries of the Region signed the agreement to participate in the PAHO Strategic Fund, through which they can access more than 150 essential and strategic products for their health programs. In 2015, purchasing through the fund exceeded US$ 70 million and yielded savings of 30% to 80% in drug costs to countries, thanks to procurement through international competitive bidding and economies of scale made possible by pooling demand from many countries. With regard to joint negotiating schemes, a noteworthy experience is the one being spearheaded by the MERCOSUR and UNASUR countries, which in 2015 formed a joint committee to negotiate with multinational pharmaceutical companies on the prices of a group of high-cost drugs. Through a transparent and collective mechanism shared among countries, and with technical support from PAHO and the use of the mechanism of the fund, countries have sought to improve the availability of essential medicines for the treatment of HIV/AIDS and hepatitis C. Sizeable reductions in the price of insert (for HIV/AIDS) have been achieved, as much as 83% in some countries. Countries continue to work jointly with PAHO to obtain better terms for the purchase of inputs for the management of hepatitis C.

With regard to the general availability of blood in a country, the rate of whole blood donation per 1,000 population is a good indicator. This rate is 32.1 donations per 1,000 population in high-income countries, 7.8 in middle-income countries, and 4.1 in low-income countries (). In 2014, the average donation rate in Latin America and the Caribbean was approximately 14.84 per 1,000 population; 45.39% of those donations came from unpaid volunteer donors, while 54.52% came from replacement donors. Although the donation rate per 1,000 population has fallen slightly in recent years (15.25 donations per 1,000 population in 2010, for example), the percentage of voluntary donations has risen steadily, climbing from 41.4% in 2010 to 45.39% in 2014. However, the high percentage of replacement donors represents an inequality that continues to affect blood availability.

Access to medical radiology services depends not only on the availability of appropriate, quality medical devices. It also depends on the effective integration of such services into the health services network and on their rational use.

Rapid technological progress is enabling the development of innovations in health care planning and delivery methods. There has been significant progress in the use of remote monitoring applications for the management of diseases such as diabetes and chronic obstructive pulmonary disease (COPD). This progress has been possible thanks to the availability of a growing number of mobile health applications. When effectively deployed, these approaches have shown that they can facilitate self-care and support continuous monitoring of symptoms in order to facilitate early intervention. E-health technology is now widely used in the Region as a means of increasing access to services, especially in rural and remote localities, and it can also be used by health care providers to facilitate coordination of care () (Box 5).

Box 5. Strengthening the first level of care through the use of new technologies in Panama ()

New technologies have been used strategically to strengthen the first level of care in Panama through the development of electronic health care records. These records serve as tools for decision-making about diagnosis, management of symptoms, and follow-up as part of the disease treatment and management process (Ministry of Health program). The synchronization of health records has helped to improve communication among health care professionals and providers. Information systems and the exchange of data facilitate clinical management, evaluation, and follow-up have helped to improve the allocation of limited resources in places where human resources or physical infrastructure were limited.

The development of telemedicine has also permitted remote management of patients (development of virtual hospitals in local communities), support for better management of symptoms, and promotion of self-care. Potential obstacles to their application include availability of human and financial resources to support the development of telemedicine, as well as cost and availability of the technological infrastructure itself. Both health professionals and service users have shown resistance to such changes. New skills are required, which means that new education and certification programs may be needed.

Facilitating the empowerment of people and communities so that they are more knowledgeable about their health situation and their rights and obligations and can make informed decisions about their health

The active participation of individuals and communities has been a fundamental principle in the successive strategies of WHO and PAHO, which have long emphasized people-centered care. The Alma-Ata Declaration, for example, recognized community participation as a key ingredient for strengthening health systems based on primary health care ().

In order to advance towards universal health, health systems must develop programs, interventions, and strategies to support both processes that empower people and processes that strengthen community participation in health.

A review of the evidence suggests the following four key strategies for involving individuals, their families, and caregivers:

  1. Self-management of health and health conditions: Includes support for the development of knowledge, abilities, and confidence to manage one’s own health (self-care), care for specific disorders, and recovery from an episode of ill health.
  2. Shared decision-making: Includes support to enable individuals to make decisions about their health, so that they can weigh various options (including the option not to take any action), think about risks and benefits, and consider how the available options mesh with their values and preferences.
  3. Actions among equals: Support for people in giving and receiving assistance from other people in similar circumstances, on a basis of mutual and shared understanding.
  4. Support for families and caregivers. The aim is to develop knowledge, skills, and actions so that people can take care of themselves and others (). Caregivers play a fundamental role in community health. Caregiving is considered a capacity for service and a human ability to care for the health of the community. It is therefore work that should be socially recognized and measured and valued in the health system. It should also be well paid if it is to cease to be considered an inescapable duty to be performed by women ().

Community participation in planning and goal-setting can help communities examine the factors underlying health problems and raise community awareness and can lead to community-led approaches to key challenges. For example, in Peru, community awareness-raising has been used as a strategy for promoting multisectoral collaboration and involving marginalized communities in decision-making about their health care ().

Community awareness-raising through education and participation in learning encounters and activities can help build stronger social networks and foster greater integration. Such measures work well when they focus on a specific health problem of mutual interest and when conversations and activities are culturally sensitive, as in the example described in Box 6.

Box 6. Promotion of health education and community participation in the city of Tunia, Colombia ()

In Colombia, 50% of families with young children live in the country’s poorest areas. Living in poverty generates a negative cycle of illness, poor mental health, lack of educational achievement, and reduced ability to work. Investing in early childhood development was therefore essential. However, traditional assistance programs tended to be paternalistic, charity-based, and ultimately unsustainable.

The city of Tunia, Colombia, has introduced a public policy on child health that aims to create a culture of care and protection for children from the moment of conception to the age of 5 years, upholding their rights and nurturing their development in order to assure them of a better future. A key part of the approach is promotion of community engagement and involvement, health education, and a new approach to health care among the residents of the city.

The approach includes the training of administrators to support activities relating to health education and nutritional counseling, family life, parenting, and promotion of community leadership. The approach to families and family life has encouraged the development of work skills, continued learning, and wise use of family finances. Approximately 355 family leaders have received training from 710 agents, which has had an impact on 4,289 vulnerable families with young children. The results have made a real difference, as can be seen from the changes reported between 2012 and 2014:

  • The proportion of pregnant women with appropriate weight and health rose from 33% to 86%.
  • The proportion of children weighing 3,000 g or more at birth increased from 60% to 65%.
  • The proportion of young children with chronic malnutrition decreased from 15% to 5%.
  • The proportion of fathers present at the birth of their children rose from 92% to 96%.

Care provided by the community through the collaboration of volunteers or community health workers as partners in care can achieve numerous objectives, including enhancing the legitimacy of and fostering trust in health care services, helping to strengthen the first level of care, encouraging learning among equals, and bolstering access to care and local support. For example, the development of “customer ownership” in the health system of Nuka, Alaska, led to investments that promoted universal access to community health associations and to the development of community partnerships that have had a profound and lasting impact on the improvement of population health ().

Organized groups of people who represent the opinions of people at the local or national level offer the opportunity to develop democratic responsibility among health services and the local communities, strengthening governance and promoting advocacy. For example, in Colombia the New Paradigm project encouraged people with spinal cord injuries to get together regularly to discuss their health care issues in collaboration with health professionals. This approach has enabled learning among peers and helped to encourage and build trust ().

The development of community empowerment strategies helps protect people’s right to health and promotes responsibility-sharing between the population and health care providers. Through the creation of transparent, respectful, and responsible relationships among communities, providers, and decision-makers, this approach helps to generate the necessary conditions for people to take more responsibility for their health and lifestyle decisions and better address the social determinants of health. This contributes to informed decision-making, better knowledge of health, promotion of self-determination, and greater involvement by people in decision-making and in influencing matters that affect their lives and the lives of their communities ().

Conclusions

This topic has explored various necessary and complementary elements for advancing towards access to comprehensive, equitable, and good quality health services. The agreements adopted by PAHO, the volume of available evidence, and technical cooperation tools constitute a solid support for the efforts of the health systems in our countries to achieve their objectives. In the preceding pages, we have endeavored to summarize each of these elements and to highlight some examples of progress in the countries of the Americas in recent years. While progress has been made, numerous challenges remain, and not all countries are advancing at the same rate. PAHO is convinced that access to comprehensive, equitable, quality health services can be achieved by following the recommendations in the universal health strategy and the technical documents that complement it.

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Reference/Note:

1 Estimate by the authors on the basis of available information from 38 countries of the Region that submitted reports in 2013 and 2014 to PAHO’s Health Information Platform for the Americas (PLISA).

2 Sources: Bolivia: Segunda Medición de Metas Regionales en Recursos Humanos, 2013; United States: Primary Care Workforce Facts and Stats No. 3, content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD; Canada: Scott’s Medical Database, 2015, Canadian Institute for Health Information. Note: the data for the United States are for physicians working at the primary care level.

3 Authors’ calculations based on data from Chile’s Ministerio de Desarrollo Social, Encuesta de Caracterización Socioeconómica Nacional, 2013 and 2015, data file and documentation: http://observatorio.ministeriodesarrollosocial.gob.cl/casen/basededatos_historico.php; Colombia’s Departamento Administrativo Nacional de Estadística (DANE), Encuesta Nacional de Calidad de Vida, 2010-2015, data file and documentation: http://formularios.dane.gov.co/Anda_4_1/index.php/catalog; Mexico’s Instituto Nacional de Estadística y Geografía (INEGI), Encuesta Nacional de Ingresos y Gastos de los Hogares, 2012 and 2014, data file and documentation: http://www.inegi.org.mx/est/contenidos/espanol/proyectos/metadatos/encuestas/enigh_211.asp?c=10748; Peru’s Instituto Nacional de Estadística e Informática del Perú, Encuesta Nacional de Hogares, 2010-2015, data file and documentation: http://iinei.inei.gob.pe/microdatos/; and the United States’ Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2014, data file and documentation: https://meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp?topicid=1Z-1. Data retrieved 21 Nov. 2016.

4 Based on calculations by the authors using data from Colombia’s Departamento Administrativo Nacional de Estadística (DANE), Encuesta Nacional de Calidad de Vida, 2012, 2014, and 2015, data file and documentation: http://formularios.dane.gov.co/Anda_4_1/index.php/catalog; Canada’s Statistics Canada, Canadian Community Health Survey, 2006-2013, data file and documentation: http://www.statcan.gc.ca/eng/survey/household/3226; and Peru’s Instituto Nacional de Estadística e Informática, Encuesta Nacional de Hogares, 2006, 2010, and 2011, data file and documentation: http://iinei.inei.gob.pe/microdatos.

5 Refers to the percentage of the population that had health problems and did not receive medical care due to lack of money, distance, time, difficulty in getting a medical appointment, or preference. Cultural, economic, geographical, and availability barriers are considered barriers to access.

6 Based on calculations by the authors using data from Statistics Canada, Canadian Community Health Survey (CCHS), 2005-2013.

7 Based on calculations by the authors using data from Colombia’s Encuesta Nacional de Calidad de Vida (ECD, 2012, 2014, 2015) and Peru’s Encuesta Nacional de Hogares, 2006, 2010, and 2011.

8 Calculations by the authors on the basis of available information for 38 countries and territories of the Region that reported data to the Health Information Platform for the Americas (PLISA) in 2010 and 2014.

9 Specialized ambulatory care services concentrate cost-effective technology and trained health personnel in specific areas for the management of complex cases and highly complex diagnostic and therapeutic procedures, such as imaging, endoscopy and laparoscopy, major outpatient surgery, dialysis, chemotherapy, etc. They also provide services for long-stay rehabilitation patients and services for community-based management of specific situations, such as care for mental health patients, care for dependent elderly persons, and initiatives for the care of other populations in conditions of vulnerability.

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